The Importance of Etiology on the Clinical Course of Neck Abscesses

Deep neck infections with and without mediastinal involvement: treatment and outcome in 218 patients

Purpose

Infections of the deep neck, although becoming scarcer due to the widespread use of antibiotics, still represent a dangerous and possibly deadly disease, especially when descending into the mediastinum. Due to the different specialities involved in the treatment and the heterogenous presentation of the disease, therapeutic standard is still controversial. This study analyzes treatment and outcome in these patients based on a large retrospective review and proposes a therapeutic algorithm.

Methods

The cases of 218 adult patients treated with deep neck abscesses over a 10-year period at a tertiary university hospital were analyzed retrospectively. Clinical, radiological, microbiological and laboratory findings were compared between patients with and without mediastinal involvement.

Results

Forty-five patients (20.64%) presented with abscess formation descending into the mediastinum. Those patients had significantly (all items p < 0.0001) higher rates of surgical interventions (4.27 vs. 1.11) and tracheotomies (82% vs. 3.4%), higher markers of inflammation (CRP 26.09 vs. 10.41 mg/dl), required more CT-scans (3.58 vs. 0.85), longer hospitalization (39.78 vs 9.79 days) and more frequently needed a change in antibiotic therapy (44.44% vs. 6.40%). Multi-resistant pathogens were found in 6.67% vs. 1.16%. Overall mortality rate was low with 1.83%.

Conclusion

Despite of the high percentage of mediastinal involvement in the present patient collective, the proposed therapeutic algorithm resulted in a low mortality rate. Frequent CT-scans, regular planned surgical revisions with local drainage and lavage, as well as an early tracheotomy seem to be most beneficial regarding the outcome.

Gastric perforation after accidental esophageal intubation in a patient with deep neck infection

Deep neck infection with airway obstruction may complicate endotracheal intubation with limited neck motion, pharyngeal swelling, and prominent secretion. Unrecognized esophageal intubation (EI) may unduly overinflate the stomach to inhibit effective ventilation, increase the incidence of hypoxia, and produce a ruptured visceral organ. We report an 81-year-old female patient with deep neck infection and impending respiratory failure who suffered gastric perforation after accidental EI in the intensive care unit. After failed attempts of intubation, EI was recognized rapidly as the culprit, although roughly audible bilateral breathing sounds were present but not gastric bubble sounds. A catastrophic complication of gastric rupture occurred due to ambu-bagging and mechanical ventilation. Surgical intervention was performed immediately. Possible mechanisms are discussed.

Management of odontogenic space infection with microbiology study

INTRODUCTION

Dental infection has plagued humankind for as long as our civilization has been a fight against microorganisms by man dates back to ancient civilization. The discoveries of antibiotics are encouraging trends towards conquest of the microbial infection.

MATERIALS AND METHODS

This study emphasizes the detection of pathogenic microorganisms by microbiological examination and culture of specimens representative of the infection, importance of early and correct diagnosis of infections, prompt treatment and supportive care.

RESULTS

The age group most commonly involved was in the third and fourth decades of life. Extraction followed by incision and drainage was done. The most commonly involved space was submandibular followed by buccal space. Thirty isolates were obtained. 43 % of the strains were strict anaerobes and 39 % were aerobes, with mixed growth was seen in 18.52 %. Amongst aerobes alpha hemolytic Streptococcus aureus and Peptostreptococcus as anaerobes were the most predominant followed by Bacteroides and Prevotella. Mixed aerobic and anaerobic isolates were obtained from 18.52 % of total cases. Overall resistance to Penicillin was 22 %, amongst aerobes.

CONCLUSION

Amoxicillin and Clavulanic acid combination performed better, as 100 % strains were sensitive to it. The results of this study saw a changing trend in terms of predominance of anaerobic bacteria over aerobic ones.

Emergency imaging assessment of deep neck space infections

Deep neck space infection may lead to severe and potentially life-threatening complications, such as airway obstruction, mediastinitis, septic embolization, dural sinus thrombosis, and intracranial abscess. The clinical presentation is widely variable, and often early symptoms do not reflect the disease severity. The complication risk depends on the extent and anatomical site: diseases that transgress fascial boundaries and spread along vertically oriented spaces (parapharyngeal, retropharyngeal, and paravertebral space) have a higher risk of complications and require a more aggressive treatment compared with those confined within a nonvertically oriented space (peritonsillar, sublingual, submandibular, parotid, and masticator space). Imaging has 5 crucial roles: (1) confirm the suspected clinical diagnosis, (2) define the precise extent of the disease, (3) identify complications, (4) distinguish between drainable abscesses and cellulitis, and (5) monitor deep neck space infection progression. Ultrasonography is the gold standard to differentiate abscesses from cellulitis, for the diagnosis of lymphadenitis. and to identify internal jugular thrombophlebitis in the infrahyoid neck. However, field-of-view limitation and poor anatomical information confine the use of ultrasonography to the evaluation of superficial lesions and to image-guided aspiration or drainage. Computed tomography (CT) combines fast image acquisition and precise anatomical information without field-of-view limitations. For these reasons, it is the most reliable technique for the evaluation of deep and multicompartment lesions and for the identification of mediastinal and intracranial complications. Contrast agent administration enhances the capability to differentiate fluid collections from cellulitis and allows the detection of vascular complications. Magnetic resonance imaging is more time-consuming than CT, limiting its use to selected indications. It is the technique of choice for assessing the epidural space involvement in pre- and paravertebral space infections and complements CT in the evaluation of the infections reaching the skull base.

Determinants of cutaneous injection-related infection care at a supervised injecting facility

PURPOSE

To evaluate the factors associated with receiving cutaneous injection-related infection (CIRI) care among a representative cohort of supervised injecting facility (SIF) users.

METHODS

Data were collected biannually as part of a prospective cohort, the Scientific Evaluation of Supervised Injection study. Kaplan-Meier methods and Cox proportional hazards regression with recurrent events were used to examine incidence and factors associated with CIRI care, respectively.

RESULTS

One thousand eighty individuals were recruited between December 1, 2003 and January 31, 2008. The incidence density of participants receiving CIRI care was 22.0 per 100 person-years (95% confidence interval [CI]: 19.6-24.6). In the adjusted Cox proportional hazard model, female sex (adjusted hazard ratio [AHR]=1.87 [95% CI: 1.32-2.64]), unstable housing (AHR=1.39 [95% CI: 1.02-1.88]), and daily heroin injection (AHR=1.52 [95% CI: 1.13-2.04]) were independently associated with receiving CIRI care at the SIF.

CONCLUSIONS

These results describe who is more likely to receive CIRI care, which is of use to those engaged with policy and practice of treatment regimens involving this population.

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.