Deep neck infection: Analysis of 185 cases

Deep space neck infection: principles of surgical management

Knowledge of the management of infections of the deep spaces of the neck is essential to the daily practice of oral and maxillofacial surgery. Timely decisions must be made through the acute course of the disease. Interventions must be performed with the appropriate surgical skill. The surgeon must decide on medical and surgical management, including antibiotic selection, how to employ supportive resuscitative care, when to operate, what procedures to perform, and how to secure the airway. To make these decisions the surgeon must understand the anatomy of the region and the etiology of infection, appropriate diagnostic workup, and medical and surgical management. This article provides a review of these pertinent topics.

Analysis of systemic and local odontogenic infection complications requiring hospital care

OBJECTIVE

Analysis of systemic and local odontogenic infection complications requiring hospital care.

METHODS

All cases of odontogenic infections requiring hospital care, which were adjudicated in the Finnish Patient Insurance Centre during 2000-2003, were analysed. Patient characteristics, and the course and outcome of infection were reviewed.

RESULTS

The study material consisted of 35 patient cases; 15 male, 20 female; mean age 38.4 (16-67) years. The mean length of hospital stay was 14.8 (2-81) days. Nine patients required intensive care for mean 6.2 (2-19) days. Twenty-five (71%) patients developed local infection complications with cellulitis and abscess formation, and 10 (29%) patients a generalised or metastatic infection complication. The length of hospital stay among patients with systemic complications was longer than with local complications, 30.2 (2-81) days vs. 8.0 (2-34) days (p=0.0144). All patients with local complications survived but three of the 10 patients with systemic complications died. Medically compromised patients with underlying disease developed more often systemic infection complications than previously healthy patients (p=0.0028).

CONCLUSIONS

Medically compromised patients appear more susceptible to systemic rather than local infection complications with a need for significantly longer hospital stay and with an increased risk for fatal complications.

Descending necrotizing mediastinitis: a 10-year surgical experience in a single institution

OBJECTIVE

Early diagnosis and aggressive surgical drainage are very important for successful treatment of descending necrotizing mediastinitis. However, the surgical techniques used for this condition remain controversial. We report our 10-year experience of managing this devastating disease, focusing on the multidisciplinary, minimally invasive operative procedures and the unique bacteriologic factors in Taiwan.

METHODS

Between January 1997 and January 2007, we retrospectively reviewed 18 patients with descending necrotizing mediastinitis who were treated in the National Taiwan University Hospital. Diagnosis and Endo classification were confirmed by computed tomography of the neck and chest.

RESULTS

Eight women and 10 men were included in this study. The mean age was 57.8 +/- 15.2 years. Cervical drainage was performed in the involved area in all patients. The methods for mediastinal drainage included transcervical (n = 10), video-assisted thoracic surgical drainage (n = 6), subxiphoid drainage (n = 1), and mediastinoscopy-assisted drainage (n = 1). We could not rescue 3 patients because of uncontrolled sepsis before surgery, for a mortality rate of 16.7%. Klebsiella pneumoniae uniquely represents the most common pathogen in diabetic patients (P = .01), leading to more complicated courses in older patients (P =.04) and requiring more surgical interventions (P =.05) than other pathogens.

CONCLUSION

Transcervical mediastinal drainage is first justified in patients with limited disease in the upper mediastinum. For those with involvement of the lower anterior mediastinum, an additional subxiphoid approach is suggested. Cervicotomy with video-assisted mediastinal drainage is an excellent combination for involvement of the posterior mediastinum and pleural space. Klebsiella pneumoniae uniquely represents the most important and threatening causative pathogen for diabetic patients with descending necrotizing mediastinitis.

Use of peripherally inserted central catheters in the management of recalcitrant maxillofacial infection

PURPOSE

The most common short-term method for the delivery of parenteral antimicrobial therapy in an acute hospitalized patient has traditionally been via a short peripherally inserted intravenous cannula. This approach, however, has significant limitations, particularly in patients who require prolonged, uninterrupted intravenous access. In this article, we report on our experience with an alternative method used to establish and maintain medium- to long-term intravenous access utilizing a peripherally inserted central catheter (PICC) to treat patients presenting with aggressive or recalcitrant maxillofacial head and neck infections.

MATERIALS AND METHODS

We undertook a retrospective review of the medical records of 100 consecutive patients admitted to a tertiary referral teaching hospital, during the period February 2006 to February 2007, with a primary diagnosis of infection in the oral and maxillofacial region. We identified 6 patients in whom a PICC was used in the treatment of the condition. We also analyzed data obtained from an audit conducted by our infectious diseases unit. This audit recorded the outcome of 849 nurse-placed PICCs in the department's ambulatory intravenous therapy service. Using this data, we also performed a PICC line survival analysis and in so doing, calculated the complication rates.

RESULTS

In our series, the delivery of PICC-based therapy accounted for 6% of the treatment provided for all cases of maxillofacial sepsis. This included 3 cases of actinomycosis, 2 cases of odontogenic osteomyelitis, and 1 case of a zoonotic facial abscess/cellulitis. In this series of patients, catheters remained in situ for an average of 33 days (range 12-42 days). The audit data demonstrated that more than 75% of nurse-placed PICCs are functional without complication at 60 days. The most common complication was phlebitis (1 per 1,000 catheter days). Infection was rare (0.2 per 1,000 catheter days).

CONCLUSIONS

PICC is a safe and most reliable means of administering medium- to long-term intravenous antibiotics. We feel PICC-based therapy should be considered in the management of select patients with aggressive or recalcitrant maxillofacial head and neck sepsis.

Deep neck infection with dental origin: analysis of 85 consecutive cases (2000-2006)

CONCLUSIONS

Diagnostic work-up should include contrast-enhanced computed tomography (CT) and mandible orthopantogram. When a dental origin of deep neck infection is suspected, the intravenous antibiotic regimen has to be active against gram-positive bacteria, both aerobes and anaerobes. Surgical exploration and drainage may be mandatory at presentation, or in cases not responding to medical therapy within the first 24 h.

OBJECTIVES

Deep neck infections are still associated with significant morbidity and mortality rates when complications occur. Despite worldwide improvement in dental care and oral hygiene, a significant prevalence of deep neck infections caused by dental infections has been described recently (> 40%).

PATIENTS AND METHODS

We analysed retrospectively 85 cases of deep neck infection with dental origin out of 206 consecutive cases of deep neck infection diagnosed in our institution between 2000 and 2006.

RESULTS

The most frequent dental source was a periapical infection of the first mandibular molar, followed by second and third molar, respectively. Submandibular space infection involvement was diagnosed in 73 of 85 patients (85.9%), masticatory space infection in 28 (32.9%); in 56 patients (65.9%) the infection involved more than one space. Twenty-four patients (28.2%) were treated only with intravenous antibiotic therapy; 61 patients (71.8%) required both medical and surgical procedures.

Increased prevalence of infectious endocarditis in patients with type II diabetes mellitus

BACKGROUND

Patients with diabetes mellitus (DM) are at increased risk of infection. However, there are controversial reports about DM association with infectious endocarditis (IE). We evaluated the occurrence of IE in DM patients compared to a matched control.

METHOD

Treatment files of inpatients' admission that contained discharge diagnosis (ICD-9 codes) from Veterans Health Administration hospitals were used for this study. ICD-9 codes for DM (n=293,124) and a control group with ICD-9 codes for hypertension without DM (n=552,623) were utilized for comparison. The prevalence of IE was studied using ICD-9 codes for IE. Multivariate analysis was performed adjusting for chronic and acute renal failure and aortic and mitral valve disease. Continuous variables were analyzed by unpaired t tests. Binary variables were analyzed using the chi-square test and Fisher's Exact Tests.

RESULTS

IE was present in 1340 (0.5%) DM patients versus 1412 (0.3%) patients from the control group (relative increase of 40%). Using multivariate analysis adjusting for renal failure and valvular abnormalities, DM remained independently associated with IE (odds ratio=1.9; 95% confidence interval=1.8-2.1; P<.0001).

CONCLUSION

Patients with type II DM have significantly higher prevalence of IE independent of renal failure or valvular abnormalities consistent with increased vulnerability of DM patients for infections.

Challenging airways in deep neck space infections

Skilful airway management is critical in deep neck space infections. Although relatively uncommon, this spectrum of disease presents a clinical challenge for otolaryngologists and anesthetists. There is currently no universal agreement on the ideal method of airway control for these patients because this depends on various factors including available local expertise and equipment. We review the literature and discuss the available options of airway management in these head and neck emergencies. Special consideration is given to awake fiberoptic intubation and tracheotomy under local anesthesia. Relevant anatomy, route of spread and microbiology of deep neck space infections are also briefly discussed.

Death from overwhelming odontogenic sepsis: a case report

A case of fatal Ludwig's angina from an odontogenic origin complicated by chronic lymphocytic leukaemia is presented. This case highlights that death from odontogenic infection is a reality, particularly in those with systemic disease causing immunocompromise. Early surgical intervention, aggressive intravenous antimicrobial therapy and supportive care is imperative.

Effects of bacterial lipopolysaccharide on the pharmacokinetics of metformin in rats

It was reported that the hepatic microsomal cytochrome P450 (CYP) 2C11, 2D1, and 3A1 (not via the CYP1A2, 2B1/2, and 2E1) were involved in the metabolism of metformin in rats. It was also reported that the expressions of CYP2C11 and 3A2 decreased in rats pretreated with Klebsiella pneumoniae lipopolysaccharide (KPLPS). Therefore, the pharmacokinetic parameters of metformin could be changed in rats pretreated with KPLPS. Hence, the pharmacokinetic parameters of metformin were compared after both intravenous and oral administration of the drug at a dose of 100mg/kg to control rats and rats pretreated with KPLPS. After intravenous administration of metformin to rats pretreated with KPLPS, the total area under the plasma concentration-time curve from time 0 to infinity (AUC) of the drug was significantly greater (40.5% increase) than the controls due to significantly smaller CL value (27.7% decrease) than the controls. The significantly smaller CL value could be due to significantly smaller both the CL(R) and CL(NR) values (34.0% and 18.1% decrease, respectively) than the controls. The significantly smaller CL(NR) value could be due to decrease in the expressions of CYP2C11 and 3A2 in rats pretreated with KPLPS. After oral administration of metformin, the AUC of the drug was not significantly different between two groups of rats, and this may be at least partly due to decrease in absorption from the gastrointestinal tract compared with the controls.

Vascular and Parameningeal Infections of the Head and Neck

Vascular and parameningeal infections of the head and neck are rare but frequently life threatening. These infections include intracranial and extracranial septic venous thrombophlebitis, arterial mycotic aneurysms and erosions, subdural empyema, and epidural abscesses. They usually arise as complications of otogenic, oropharyngeal, or paranasal sinus infections, and management involves an aggressive combined medical-surgical approach.

Predisposing factors of complicated deep neck infection: an analysis of 158 cases

Both the introduction of antibiotics and improvements in oral hygiene have made deep neck infections occur less frequently today than in the past. Nevertheless, the complications from these infections are often life-threatening. The purpose of this article was to review the clinical findings of deep neck infections and identify the predisposing factors of these complications. The present study reviewed 158 cases of deep neck infections between the years of 1995 to 2004, 23 of which had life-threatening complications. Cases were excluded if they had peritonsillar abscesses, superficial infections, infections related to external neck wounds, or head and neck tumors. The authors used multiple linear regression and the logistic regression analysis in order to determine the clinical parameters that are associated with longer hospitalizations and complicated deep neck infections, respectively. The multiple linear regression showed that patients with a large number of involved spaces, diabetes mellitus, and complications required longer hospitalizations (p < 0.05). The logistic regression showed that patients with more than two involved spaces were more likely to have complicated deep neck infections (p < 0.05). Patients with odontogenic causes had negative correlation (p < 0.05). We recommend that high-risk groups, such as diabetic patients and/or patients with more than two involved spaces, should be more closely monitored throughout their hospitalization.

Cricothyrotomie préhospitalière: à propos d'un cas

Case report of a patient with tonsillitis treated with anti-inflammatory. The patient presented a dyspnoea and finally a cardiac arrest. The oral intubation was impossible and cricothyrotomy had to be performed with a catheter over needle technique. We found a total airway obstruction due to an epiglottis abscess. The patient died few days later of sepsis. We recommend having wire-guided cricothyrotomy technique or catheter-over-needle technique in all prehospital emergency unit and having emergency physician trained to the cricothyrotomy technique.

Identification of bacteria associated with spreading odontogenic infections by 16S rRNA gene sequencing

OBJECTIVE

To determine the bacterial species associated with spreading odontogenic infections (SOIs).

STUDY DESIGN

Pus samples from 4 cases of SOI were analyzed by microbiological culture methods for the presence of bacteria, and by polymerase chain reaction (PCR) amplification, cloning, and sequencing of bacterial 16S rRNA genes.

RESULTS

Culture methods identified species from the genera Prevotella, Streptococcus, and Fusobacterium, as well as anaerobic streptococci. Molecular detection methods identified a far more diverse microflora. The predominant genus detected was Prevotella, representing 102 (50.2%) of 203 clones analyzed. Prevotella oris was the most abundant species identified, representing 45 (22.2%) of 203 clones analyzed. Twelve clones (5.9%) represented uncultivable species, namely Prevotella PUS9.180, an uncultured Peptostreptococcus species, and an uncultured bacterium belonging to the Bacteroidetes phylum.

CONCLUSIONS

Prevotella species may play an important role in SOIs, and further work to examine in more detail the pathogenicity determinants of these organisms and associated host responses is warranted.

Parapharyngeal Abscess: Comprehensive Management Protocol

Parapharyngeal infections are rare, but they cause serious morbidity and mortality. Therefore, until now, the recommended treatment of parapharyngeal abscess has been early open surgical drainage. The purpose of this study is to review the clinical course and outcome of treatment in parapharyngeal abscess according to method of treatment. A prospective study was designed for parapharyngeal abscess in patients admitted for deep neck infection. During an 8-year period, from June 1994 to January 2003, 34 patients were enrolled. All had contrast-enhanced computed tomography (CT) imaging and confirmation of an abscess in the parapharyngeal space. All patients were treated with intravenous antibiotics. We treated 19 cases (conservative group) with antibiotics only or needle aspiration and 15 (surgical group) with intraoral or external drainage. The mean duration of hospitalization was 8.2 days in the conservative group and 11.6 days in the surgical group. There was no complication except mediastinitis in 1 case of the conservative group. Because of severe dyspnea, 5 patients required tracheotomy. Neck CT scan is a useful diagnostic tool to detect and establish the treatment plan of parapharyngeal abscess. Parapharyngeal abscess may, in some cases, respond to antibiotics, become localized to the parapharyngeal space and be treated conservatively with no need for early open surgical drainage.

Cervical infection with descending mediastinitis: a review of six cases

The aim of this study was to retrospectively review cases of cervical infection with descending mediastinitis, and to analyse the clinical character, diagnosis and treatment of this infection. Six patients were identified from December 1998 to June 2005. Their aetiology, associated systemic diseases, bacteriology, radiology, treatments and outcomes were reviewed. Four cases resulted from odontogenic infection, one from upper airway infection, and one had an unknown cause. Diffuse swelling in face and neck, chest distress, tachypnea, and fever were the main symptoms. Chest radiography showed a widening of the upper mediastinal shadow in four patients. Four patients underwent computed tomographic scanning that confirmed the diagnosis of descending mediastinitis, which suggests that routine use of this scan be highly recommended for early detection. Six different pathogens were identified through pus and blood culture. All patients underwent surgical drainage. Three patients received a tracheotomy. Of the six patients, four achieved good results, and there were two deaths. Early surgical drainage remains the main treatment for cervical infection with descending mediastinitis. Delayed diagnosis, inadequate drainage and multidrug-resistant bacterial infection were responsible for the deaths.

Deep Neck Infections: A Constant Challenge

BACKGROUND

Although the advent of antibiotics and improved dental care decreased the incidence and mortality, deep neck infections (DNIs) are not uncommon and present a challenging problem due to the complex anatomy and potentially lethal complications that may arise.

OBJECTIVES

This study reviews our experience with DNIs and tries to identify the predisposing factors of life-threatening complications.

METHODS

A retrospective review was conducted of patients who were diagnosed as having DNIs in the Department of Otolaryngology and in the Department of Infectious Diseases at Treviso Regional Hospital from 1995 to 2003. Associations between life-threatening complications and other factors were determined by chi(2) test, Fisher's exact test and Student's t test as appropriate.

RESULTS

One hundred sixty-seven charts were recorded; 95 (56.9%) were men, and 72 (43.1%) were women, with a mean age of 49.6 +/- 20.4 years (range: 2-96). There were 39 patients (23.4%) who had associated systemic diseases, with 53.8% (21/39) of those having diabetes mellitus. The lateral pharyngeal and submandibular spaces were the most commonly involved spaces. Upper airway infections and odontogenic infections were the two most common causes of DNIs (47.5 and 27.9% of the known causes, respectively). The pathogenesis remained unknown in 45 patients (26.9%). Coagulase-negative staphylococcus (36.9%) and Streptococcusviridans (28.8%) were the most common organisms, identified through cultures. Of the abscess group (77 patients), 42 patients (54.5%) underwent surgical drainage under general anesthesia. Thirty-one patients (18.6%) developed life-threatening complications: airway obstruction (n = 18), descending mediastinitis (n = 6), jugular vein thrombosis (n = 4), and pneumonia (n = 3). Compared with other patients, the unique features of patients with life-threatening complications were as follows: older age (p = 0.04), a higher white blood cell count (p = 0.01), abscess formation (p = 0.02), associated systemic disease (p < 0.001), diabetes mellitus (p < 0.001), anterior visceral space involvement (p < 0.001), and multiple-space involvement (p < 0.001).

CONCLUSIONS

DNIs continue to occur and these are associated with significant morbidity and mortality even in this era of antibiotics. Furthermore, the widespread and inappropriate use of antibiotics may change the clinical presentation and course of these infections, making them more elusive and less predictable also in complicated cases. The clinical assessment of patients who are older, with abscess formation, underlying systemic diseases, diabetes mellitus, visceral anterior space or multiple-space involvement requires careful consideration of potential complications.

Severe odontogenic infections, part 1: prospective report

PURPOSE

The purpose of this study was to prospectively evaluate a series of patients with severe odontogenic infections (OI).

PATIENTS AND METHODS

In this study, 37 consecutive hospitalized patients with odontogenic infection were treated with intravenous penicillin (PCN) (unless allergic), and prompt incision and drainage. Standardized data collection included demographic, preadmission, time-related, preoperative, anatomic, treatment, microbiologic, and complications information. Appropriate descriptive statistics were computed.

RESULTS

The sample consisted of 37 subjects (38% female) with a mean age of 34.9 years. Three subjects (8%) had immunocompromising diseases. Caries was the most frequent dental disease (65%) and the lower third molar was the most frequently involved tooth (68%). Trismus and dysphagia were present on admission in over 70% of cases. The masticator, perimandibular (submandibular, submental, and/or sublingual), and peripharyngeal (lateral pharyngeal, retropharyngeal, and/or pretracheal) spaces were infected in 78%, 60%, and 43% of cases, respectively. Abscess was found in 76% of cases. PCN-resistant organisms were identified in 19% of all strains isolated and in 54% of patients with sensitivity data. PCN therapeutic failure occurred in 21% of cases and reoperation was required in 8%. Length of hospital stay was 5.1 +/- 3.0 days. No deaths occurred.

CONCLUSIONS

This study indicated that PCN resistance, resulting in PCN therapeutic failure, was unacceptably high in this sample. Alternative antibiotics, such as clindamycin, should be considered in hospitalized patients with OI. Masticator space infection occurred much more frequently than previously reported. Trismus and dysphagia should be appreciated as significant indicators of severe OI.

Severe odontogenic infections, part 2: prospective outcomes study

PURPOSE

The purpose of this study was to identify significant predictors of 4 outcomes in patients with severe odontogenic infections: abscess formation, penicillin therapeutic failure (PTF), length of hospital stay (LOS), and need for reoperation.

PATIENTS AND METHODS

We used a prospective case series study design and enrolled 37 consecutive patients admitted for severe odontogenic infection between March 1996 and June 1999. Treatment consisted of intravenous penicillin (PCN) or clindamycin in PCN-allergic patients, surgical incision and drainage, and extraction(s) as soon as possible. Study variables were categorized as demographic, preadmission, time-related, preoperative, anatomic, treatment, microbiologic, and complications. The primary outcome variables were abscess formation, PTF, LOS, and reoperation. Multivariate linear and logistic regression techniques were used to measure associations between study variables and the outcome variables.

RESULTS

The sample consisted of 37 subjects (23 male, 14 female) with a mean age of 34.9 +/- 15.8 years. Multivariate analyses, controlling for confounding variables, indicated that culture of Peptostreptococci was a negative predictor of abscess formation. LOS was predicted by the number of infected spaces and duration of operation. There was no significant predictor of PTF or reoperation on multivariate analysis, although PCN-resistant organisms were isolated in all cases of PTF.

CONCLUSION

Increased LOS in severe odontogenic infections is predicted by the anatomic extent and severity of the infection and the occurrence of complications such as PTF and the need for reoperation. PTF is significantly associated with later identification of PCN-resistant organisms. The role of Peptostreptococci in abscess formation warrants further investigation.

Factors affecting the bacteriology of deep neck infection: a retrospective study of 128 patients

CONCLUSIONS

Broad-spectrum antibiotics are advocated for treating deep neck infection. Anaerobic coverage is necessary, especially in odontogenic cases. The presence of diabetes, infection of the parotid space and an obvious odontogenic source of infection can aid in determining the causative organisms.

OBJECTIVES

This study aimed to analyze the bacteriology in deep neck infections and identify the factors that influenced the causative pathogens.

MATERIALS AND METHODS

The records of 212 patients who were diagnosed as having deep neck infections at the National Taiwan University Hospital between 1997 and 2003 were reviewed; 128 patients with bacterial isolation from their pus cultures were enrolled.

RESULTS

The cultures of 46 patients (35.9%) were polymicrobial. Viridans Streptococcus was the most commonly isolated organism (38.3%), followed by Klebsiella pneumoniae (32.0%) and Peptostreptococcus (17.2%). The most common organism in 44 diabetic patients was K. pneumoniae (54.5%), versus viridans streptococcus (48.8%) in 84 nondiabetic patients. In patients with dental sources of infections, the culture rate of anaerobes was 59.3%; in upper airway infections and other sources of infections they were 22.7% and 21.5%, respectively (Chi(2) test, p = 0.0008). The differences in age, sex, and climate did not show any significant changes in the common causative pathogens. Common pathogens in the infection of parapharyngeal, submandibular, and extended spaces were the same as viridans streptococcus, but in the parotid space K. pneumoniae was the most common pathogen.

Severe odontogenic infections

BACKGROUND

Severe odontogenic infections are serious potentially lethal conditions. Following the death of a patient in the authors' institution this study was initiated to determine the risk factors, management and outcome of a consecutive series of patients.

METHODS

All patients admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with odontogenic infections in calendar year 2003 were investigated. Detailed information relative to their pre-presentation history, surgical and anaesthetic management and outcome was obtained and analysed.

RESULTS

Forty-eight patients, 32M, 16F, average age 34.5, range 19 to 88 years were treated. All presented with pain and swelling, with 21 (44 per cent) having trismus. Forty-four (92 per cent) were as a result of dental neglect and four (8 per cent) were regular dental patients having endodontic treatment which failed. Of those known to have been treated prior to presentation, most had been on antibiotics. Most patients had aggressive surgical treatment with extraction, surgical drainage, high dose intravenous antibiotics and rehydration. The hospital stay was 3.3 (range 1-16) days. Patients requiring prolonged intubation and high dependency or intensive care (40 per cent) had longer hospitalization. No patient died and all fully recovered.

CONCLUSION

Severe odontogenic infections are a serious risk to the patient's health and life. Management is primarily surgical with skilled anaesthetic airway management. Antibiotics are required in high intravenous doses as an adjunct and not as a primary treatment.