Life-threatening Deep Fascial Space Infections of the Head and Neck

A Perspective of Clinical Behaviour and Management of Deep Neck Space Infections (DNSI): The Clinical Conundrum

The diagnosis and management of deep neck space infections remain a challenging task for otolaryngologists. A retrospective observational analysis of 137 cases of deep neck infections at a tertiary care centre was reviewed. We present 137 treated cases of DNSIs in a retrospective 5 years clinical study conducted in the department of otolaryngology at a tertiary care center from January 2012 to December 2016. Demographic information, Socio-economic data, etiopathogenesis, clinical presentation, spaces involved, diagnosis, and treatment strategies, associated morbidities, course and complications were analysed and compared with past experiences. Odontogenic and salivary gland infections causes were the most common source of DNIs. Major complication observed was skin defect. In this study, submandibular space infection was found to be the most common space involved in DNSI. Pain (100%) was the most common clinical complaint followed by neck swelling (65.69%). Staphylococcus aureus (38 cases) was the most common micro-organism isolated. Surgical intervention was the main modality of treatment and there was one mortality. DNSIs are fairly common challenging and potentially lethal entities which can lead to severe complications in a very short time, should there be delay in its prompt diagnosis and management. Computerized Tomography Scan (CT scan) with contrast is the investigation of choice in diagnosing DNSIs. Assessment of airway control must take precedence.

Computed tomography-guided navigation assisted drainage for inaccessible deep neck abscess: A case report

RATIONALE

Deep neck infections (DNIs) in the head and neck area are difficult to treat due to the anatomical complexity of the cervical region. Since inflammation causes changes in anatomy, it is often difficult to find the exact location of the abscess, which leads to failed surgical drainage.

PATIENT CONCERN

A 76-year-old female patient was referred to our clinic with trismus and right-side facial swelling. After extraction of her lower third molar 2 weeks ago, due to chronic periodontitis, her trismus had aggravated and her maximal mouth opening was 20 mm.

DIAGNOSES

Computed tomography (CT) revealed an approximately 2.5 cm-sized abscess pocket with cellulitis in the right pterygomandibular space.

INTERVENTIONS

Since the first surgical drainage attempt using the intraoral approach under general anesthesia had failed and conservative antibiotic treatment was also ineffective, a second surgical procedure with a CT-guided navigation system was performed and the pus was successfully evacuated.

OUTCOMES

After drainage with CT-guided navigation, the clinical symptoms and septic conditions of the patient showed remarkable improvement, and there was no recurrence of infection within a year after the procedure.

LESSONS

Drainage with CT-guided navigation can be used as a successful surgical tool to aid in the surgery of patients with DNI when it is difficult to accurately target the abscess due to inflammation.

A Study on Deep Neck Space Infections

Deep neck space infections (DNSI) are serious diseases that involve several spaces in the neck. These are commonly seen in low socioeconomic group with poor oral hygiene, and nutritional disorders. These are bacterial infections originating from the upper aerodigestive tract. The incidence of this disease was relatively high before the advent of antibiotics. Treatment of DNSI includes antibiotic therapy, airway management and surgical intervention. Management of DNSI is traditionally based on prompt surgical drainage of the abscess followed by antibiotics or nonsurgical treatment using appropriate antibiotics in the case of cellulitis. This study was conducted to investigate the age and gender, clinical symptoms, site involved, etiology, co-morbidities, bacteriology, complications and outcomes in the patients of DNSI. A prospective study of deep neck space infections was conducted during the period July 2017 to July 2018 on the patients who attended the outpatient department and were admitted as inpatient in Safdarjung hospital, New Delhi. 40 Cases with DNSI all ages and both genders were included in the study. Patients who didn't require surgical intervention to drain pus were excluded. All parameters including age, gender, co-morbidities, presentation, site, bacteriology, complications, and investigations were studied. Due to advent of antibiotics, deep neck space infections are in decreasing trend. The common age group found to be affected is in 2nd and 3rd decade in our study. Out of all deep neck space infections, submandibular space infections were common (37.5%) followed by peritonsillar infections (12.5%). Infection of deep neck space remains fairly common and challenging disease for clinicians. Prompt recognition and treatment of DNSI are essential for an improved prognosis. Odontogenic and tonsillopharyngitis are the commonest cause. Key elements for improved results are the prompt recognition and early intervention. Special attention is required to high-risk groups such as diabetics, the elderly and patients with underlying systemic diseases as the condition may progress to life-threatening complications.

Upper Respiratory Tract Infections in the Critically I11

A review of severe upper respiratory tract infections that present in the critically ill (supraglottitis [epi glottitis], deep neck infections, and sinusitis) is pre sented with attention to pathogenesis, pathophysiology, diagnosis, differential diagnosis, and treatment. Supra glottitis is increasingly diagnosed in adults and, as with children, early recognition is crucial to limit mortality. To aid in diagnosis and treatment, a management al gorithm is used. Deep cervical infections, usually exten sions of upper airway infections, can spread along fascial planes with fatal results. Knowledge of the interconnec tions between anatomical spaces is a prerequisite to diagnosis and treatment. Sinusitis will present in the critically ill as orbital or intracranial complications or as a nosocomial infection. Discussions of acute and chronic community-acquired sinusitis in general, noso comial sinusitis, and sphenoid sinusitis as a separate en tity highlight differences in clinical presentation and bacteriology that are important to diagnosis and treat ment.

The Importance of Etiology on the Clinical Course of Neck Abscesses

OBJECTIVE: Formation of neck abscesses from injecting illicit drugs continues to be a common problem in the United States. We sought to determine whether neck abscesses resulting from direct inoculation differ in their clinical course and severity from those that arise from direct spread through inflamed tissue, as in pharyngitis or odontogenic infections.

STUDY DESIGN AND SETTING: Patients were separated based on the cause of their neck abscess into either an injection drug use group or a noninjection drug use group. We retrospectively compared both groups of patients by examining multiple clinical endpoints, including the number of operations, length of hospital stay, and requirement for emergent airway intervention.

RESULTS: Injection drug use was the most common cause of neck abscess. Only 1 of these patients needed more than 1 drainage procedure, and no patients required emergent airway intervention or an intensive care unit (ICU) stay. The majority of the patients in the noninjection drug group had a neck abscess as a result of unknown causes; nearly one half required an emergent operation for airway management and the mean ICU stay was 2.5 days.

CONCLUSION: Neck abscesses formed by direct inoculation have a relatively more benign clinical course than those resulting from spread through inflamed tissue. The latter require a longer hospital stay, more days in the ICU, and more emergent intervention.

Extracranial head and neck infections

This article outlines infections in the submandibular, lateral pharyngeal, retropharyngeal, danger, and prevertebral spaces, in conjunction with infections of the sinuses and mediastinum. By understanding the anatomy and pathophysiology, the reader will gain insight into the rationale for various therapeutic options.

Comparison of preoperative computed tomography and surgical findings in maxillofacial infections

PURPOSE

To examine the accuracy of computed tomography (CT) in predicting the presence of surgically confirmed abscess in patients presenting with deep maxillofacial infections (DMIs).

MATERIALS AND METHODS

The medical records of 36 patients with clinically suspected DMI were reviewed. All patients underwent preoperative CT scan to determine whether abscess or cellulitis was present. The operative reports of all patients were compared with their preoperative CT scan findings.

RESULTS

Of 36 patients, 30 had abscess predicted by preoperative CT scan. The positive predictive value for DMI based on CT findings interpreted by an oral surgeon and confirmed as an abscess at operation was 90%, whereas the negative predictive value was 33%. When findings were interpreted by a radiologist, the positive predictive value was 94.1% whereas the negative predictive value was 26.3%. Thirty patients had abscess predicted by preoperative CT scan when interpreted by an oral surgeon, whereas seventeen had abscess predicted by a radiologist. At operation, 3 of 30 patients had cellulitis whereas 27 had abscess, for a false-positive rate of 60% and false-negative rate of 12.9%. On the basis of preoperative radiography, 1 of 17 patients had cellulitis whereas 16 had abscess, for a false-positive rate of 16.7% and a false-negative rate of 46.7%. The agreement between CT and operative findings in predicting abscess by an oral surgeon was 80.6% and by a radiologist was 58.3%.

CONCLUSION

CT yielded high sensitivity for the detection of DMI abscess but poor specificity, likely because of the paucity of cellulitis.

Atypical locations of retropharyngeal abscess: beware of the normal lateral soft tissue neck X-ray

Retropharyngeal abscesses (RPA) are uncommon but potentially lethal deep neck space infections, over 95% of which occur in children under six years of age. Without a high index of suspicion, early recognition and prompt intervention, catastrophic consequences can ensue, and mortality can be as high as 60% if jugular vein thrombosis or mediastinitis occurs. While older children may have specific complaints referable to the pharynx, infants and young children may present with vague symptoms. To date, a lot of emphasis continues to be placed on the importance of lateral soft tissue neck X-ray in the diagnosis and management of patients with suspected retropharyngeal abscesses; and lateral neck X-ray has been cited as the most useful radiological view of the laryngopharynx. While we recognise the role of lateral neck X-rays in retropharyngeal and other upper airway pathologies, we present three case series in which lateral neck X-rays were normal and diagnosis was made only after CT scanning. These three cases were unusual as the abscesses were located high in the naso-pharynx making them impossible to detect on the lateral soft tissue neck X-rays and this underscores the need for high index of suspicion and prompt CT or MRI scanning, in any child with symptoms or signs suggestive of a possible retropharyngeal abscess.

Deep neck infection - analysis of 80 cases

Deep neck infections are serious diseases that involve several spaces in the neck. The most dreadful complication is descending necrotizing fasciitis, which needs early diagnosis and aggressive treatment.

Aim

To analyze 80 treated cases of deep neck infection and propose a schematic guideline for managing this disease.

Method

The authors present a retrospective analysis of 80 treated cases of deep neck infection, from June 1997 to June 2003.

Results

Odontogenic and tonsilar causes were the more frequent ones. Submandibular and parapharyngeal spaces were the most frequent location of deep neck infection. Staphylococcus aureus and Streptococcus sp were the microorganisms more commonly isolated.

Conclusions

Airway control should be priority in managing deep neck infections and if the patient has to be submitted to surgery special care should be taken at the moment of intubation - when curare must never be used. CT scan is the gold-standard imaging evaluation for the diagnosis of deep neck infection. Morbi-mortality is high when associated with septic shock and mediastinitis. Our mortality rate was 11.2% and only one, in five patients with mediastinitis, survived.

Human infection with Fusobacterium necrophorum (Necrobacillosis), with a focus on Lemierre's syndrome

Human infection with Fusobacterium necrophorum usually involves F. necrophorum subsp. funduliforme rather than F. necrophorum subsp. necrophorum, which is a common pathogen in animals. Lemierre's syndrome, or postanginal sepsis, is the most common life-threatening manifestation. Tonsillitis is followed by septic thrombophlebitis of the internal jugular vein and then a septicemia with septic emboli in lungs and other sites. Recent evidence suggests that F. necrophorum can be limited to the throat and cause persistent or recurrent tonsillitis. F. necrophorum is unique among non-spore-forming anaerobes, first for its virulence and association with Lemierre's syndrome as a monomicrobial infection and second because it seems probable that it is an exogenously acquired infection. The source of infection is unclear; suggestions include acquisition from animals or human-to-human transmission. Approximately 10% of published cases are associated with infectious mononucleosis, which may facilitate invasion. Recent work suggests that underlying thrombophilia may predispose to internal jugular vein thrombophlebitis. Lemierre's syndrome was relatively common in the preantibiotic era but seemed to virtually disappear with widespread use of antibiotics for upper respiratory tract infection. In the last 15 years there has been a rise in incidence, possibly related to restriction in antibiotic use for sore throat.

Life-threatening infections of the peripharyngeal and deep fascial spaces of the head and neck

This article reviews life-threatening infections of the head and neck. It discusses the anatomic boundaries, pathophysiologic processes, clinical manifestations, potential complications, and suggested therapies of infections of the submandibular, lateral pharyngeal, retropharyngeal, prevertebral, and danger spaces.

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.

History of possible foreign body ingestion in children: don??t forget the rarities

Foreign body ingestion in children is a common presenting complaint to the emergency department. Although the majority of ingested foreign bodies pass through the gastrointestinal tract unaided, some children will require either non-surgical or surgical intervention. Retained oesophageal foreign bodies may cause a multitude of problems, including mucosal ulceration, inflammation or infection, and more seriously paraoesophageal or retropharyngeal abscess formation, mediastinitis, empyema, oesophageal perforation and aorta-oesophageal fistula formation. We present a case of a 12-month-old child in whom delayed diagnosis of glass ingestion resulted in the development of a retropharyngeal abscess, oesophageal perforation and mediastinitis. Such complications following foreign body ingestion in children are rare but potentially fatal. A high index of suspicion must be maintained in young children presenting with a possible history of foreign body ingestion as a delayed diagnosis may lead to significant morbidity and mortality. We review the literature surrounding paediatric retropharyngeal abscesses and mediastinitis.

A five-year retrospective study of odontogenic maxillofacial infections in a large urban public hospital

The aim of this study was to analyze the etiology, presentation, management and outcome of odontogenic maxillofacial infections seen in an urban population that has only one major public hospital, which is also the only level I trauma center. All patients admitted to the Oral and Maxillofacial Surgery Service of San Francisco General Hospital with odontogenic infections over a 5-year period were included. Age, gender, site of infection, investigations performed, treatment carried out and outcomes were studied. Length of hospital stay and any readmissions were also noted. A total of 250 patients were admitted with maxillofacial infections, and in 157 cases the infection was odontogenic in origin. Males outnumbered females (102:55). Children had a preponderance of maxillary buccal infections whilst adults had more mandibular infections. Hospital stays ranged from 1 to 23 days, and only one patient required re-admission. A wide range of antibiotics were prescribed and 122 patients required dental extractions. Odontogenic maxillofacial infections are a public and personal health issue with potential life-threatening complications. This study identifies potential risk factors and suggests that early dental extraction, incision and drainage, coupled with intravenous antibiotic therapy, is the most effective treatment. Antibiotic therapy can be empirical since in no case where cultures were performed did this alter the antibiotic management.

Deep Fascial Space Infection of the Neck: A Continuing Challenge

We present our clinical experience with two complex cases of deep fascial space infections of the neck. The first was a case of cervical necrotizing fasciitis involving the submental space. The second was an infection beginning at the soft palate and extending to the anterior mediastinum. Both infections emanated from an oral source in patients with diabetes mellitus, and both patients required multiple surgical debridements and endotracheal intubation for airway protection. Despite the declining incidence of deep space neck infections, our cases illustrate the challenging diagnostic and treatment dilemmas for the clinician managing patients with diabetes.

CT and MR imaging evaluation of neck infections with clinical correlations

Infection of the neck is a common clinical problem in all age groups, especially children and young adults. The clinical symptoms and signs are often suggestive of the diagnosis. Imaging studies including CT and MR imaging are frequently required to confirm the diagnosis but more importantly to localize the infectious process and search for and delineate an abscess cavity. Ultrasound has also been used in the evaluation of superficial neck infections, especially to determine fluid accumulation. Conventional films consisting of an anteroposterior and lateral view were the examination before the introduction of CT in 1972. Conventional films can still be used for a preliminary survey, especially of the retropharyngeal space when there is a question of a retropharyngeal phlegmon or abscess.

Descending necrotizing mediastinitis due to odontogenic infections

OBJECTIVE

Acute purulent mediastinitis caused by oropharyngeal infection is termed descending necrotizing mediastinitis. Such infections usually have a fulminate course, leading to sepsis and frequently to death. The purpose of this study is to show the importance of early diagnosis, aggressive surgical intervention, and optimal antibiotics chemotherapy in controlling this fatal infectious disease.

STUDY DESIGN

Two patients with descending necrotizing mediastinitis due to odontogenic infection who were treated at our institution are described.

RESULTS

Both patients survived.

CONCLUSIONS

From the patients, 23 different aerobic and anaerobic bacteria were isolated. All of the isolates were susceptible to carbapenem. Early evaluation by means of cervicothoracic computed tomography scanning was extremely useful for diagnosis and surgical planning. Knowledge of anatomic pathways from the mouth to the mediastinum is essential. We believe that tracheostomy is not always necessary. In both of the cases presented, mediastinal drainage was completed through use of a transcervical approach. However, a more aggressive drainage including tracheostomy might be necessary when the infection extends below the carina.

Deep neck infections in children: a new approach to diagnosis and treatment

Forty-seven children presented with the diagnosis of a deep neck infection--either cellulitis or abscess--between January 1991 and July 1996. Forty-four (94%) had contrast-enhanced computed tomography (CT) imaging consistent with this diagnosis. Three patients with no CT scan had confirmation of an abscess at surgical drainage. Parenteral antibiotics alone were effective in the treatment of 24 of 47 infections (51%): seven parapharyngeal, one retropharyngeal, and 16 combined. By CT scan these infections represented cellulitis in 17 of 24 (71%), an abscess in three of 24 (13%), and incomplete abscess in four of 24 (17%). The average duration of hospitalization for this group was 4.8 days, with symptomatic improvement usually seen within 24 hours. Surgical drainage was performed on 23 of 47 infections (49%): three parapharyngeal, 17 combined, and three of unknown specific location. In 22 of these 23 children (96%), transoral drainage of the abscess was used as the primary surgical approach. In 21 of these 22 (95%) there was complete resolution without complications or recurrence; one abscess required a subsequent external approach. CT scanning with contrast revealed that all deep neck infections were located medial (usually anteromedial) to the great vessels. Abscesses with volumes estimated to be greater than 2000 mm3 were more likely to undergo surgery, but these differences were not statistically significant. The use of contrast-enhanced CT scanning provides information regarding abscess size, location, and relative position of the great vessels for safe and successful transoral drainage. Thus we recommend CT-assisted transoral drainage for combined retropharyngeal/parapharyngeal abscesses and selected isolated parapharyngeal abscesses that do not respond to parenteral antibiotics.

Descending necrotizing mediastinitis: complication of a simple dental infection

Descending necrotizing mediastinitis (DNM) is a rare complication of periodontic infection. The delay in diagnosis of DNM is believed to contribute to its high mortality rate. We report the case of a healthy 23-year-old man who was seen in the urgent care center, given the diagnosis of dental infection, prescribed penicillin, and sent home. He returned 48 hours later complaining of myalgias, purulent drainage from around his teeth, chest pain, and dyspnea. DNM was diagnosed, and aggressive treatment comprising thoracotomy, cervical incision and drainage, and antibiotics was begun. The patient responded well to treatment and was discharged from the hospital on postoperative day 20. Prompt diagnosis and immediate therapy are imperative for this rare condition.

Characterization and management of deep neck infections

A retrospective review was conducted of 91 patients with deep neck infections to determine the pattern of clinical disease and formulate a management plan. The spaces involved, as determined by clinical, radiologic, and operative findings, were the peritonsillar space (72 patients), parapharyngeal space (eight patients) submandibular space (seven patients), retropharyngeal space (one patient) superficial space (one patient), anterior visceral space (one patient), and visceral vascular space (one patient). Of the 19 patients who did not have a peritonsillar space infection the origin of the infection was found in eight; four of these were odontogenic. Thirty-eight patients required surgical drainage of the abscess. Five patients underwent tracheotomy due to increasing dyspnea. One patient with diabetes mellitus and a past history of myocardial infarction died of unknown cause. All other patients had an uneventful recovery without major complications. The combination of early radiologic diagnosis, effective antimicrobial therapy, and intensive surgical management contributed to the good prognosis.

Supraglottic airway infections

Supraglottic infections are included among the more serious pediatric infections, although they are less common than other pediatric respiratory infections. Supraglottic infections include epiglottis (supraglottitis), retropharyngeal cellulitis, retropharyngeal abscess, and peritonsillar abscess. A high index of suspicion combined with rapid diagnosis and treatment are crucial to reducing the morbidity and mortality associated with these infections. A review of these infections, including diagnosis and treatment, is presented.

Space-occupying and life-threatening infections of the head, neck, and thorax

Infections of the deep structures of the head and neck are polymicrobial, rapidly progressive, and frequently life-threatening. The bacteriology, clinical presentation, and the need for multidisciplinary management of these infections are stressed. In addition, this article discusses selected head and neck infections of immunocompromised hosts and postexposure prophylaxis for serious infections of the pharynx.

Comparison of computed tomography and surgical findings in deep neck infections

Computed tomography is routinely used in the evaluation of patients suspected to have deep neck infections. This 10-year retrospective study compares preoperative computed tomography scan reports with intraoperative findings in 38 patients who underwent surgical exploration of the parapharyngeal or retropharyngeal space within 48 hours of their radiographic assessment. Overall, intraoperative findings confirmed computed tomography scan interpretation in 76.3% of the patients. The false-positive rate was 13.2%, and the false-negative rate was 10.5%. The sensitivity of computed tomography scan for detection of parapharyngeal space or retropharyngeal space abscess was 87.9%. This study's documentation of false-positive computed tomography scans in the evaluation of deep neck infections emphasizes the importance of correlating radiologic interpretation with clinical examination before surgical intervention.

Management of maxillofacial infections: a review of 50 cases

Maxillofacial infections often place the oral and maxillofacial surgeon in situations where timely decisions have to be made. These decisions can be life-saving. This study reviews 50 infections treated over a 3-year period. The results reveal rapid resolution of the infections by adhering to fundamental principles in their management: recognition of airway compromise, surgical intervention, and the administration of the appropriate antibiotic. A protocol for the management of maxillofacial infections is described.

Retropharyngeal abscess in an afebrile child

A case of retropharyngeal abscess in a child is reported. The patient was nontoxic appearing, afebrile, and had minimal symptoms. The case is used to highlight the high index of suspicion that may be necessary to diagnose the condition. Diagnostic approaches, emergency treatment, and disposition of patients are discussed.

Parapharyngeal soft-tissue infection with Aeromonas hydrophila

Parapharyngeal soft tissue infections may be rapidly progressive and life-threatening. Prompt institution of appropriate antimicrobial therapy is of paramount importance. This report highlights the potential virulence of Aeromonas hydrophila in infection of the head and neck and the need to consider this organism in selected patients.

Retropharyngeal space infections in a community hospital

The emergency physician often has to deal with infectious disease emergencies. The authors have seen four cases of retropharyngeal infection of potentially life-threatening severity in less than 1 year, all were admitted through the emergency department (ED). Reporting these cases is important to increase awareness among emergency physicians of this classic disease entity. The characteristics of the patients are discussed including initial diagnostic approaches and the use of computed tomography (CT) scanning of the neck and mediastinum. One case of retropharyngeal space infection caused by Neisseria meningitidis serotype W-135 is described. This is the first such reported case. The recommendations are that, in the absence of overt focal infection, a non-surgical approach to the treatment of these patients is indicated. This should include suitable neck roentgenograms, CT scanning, and high-dose, intravenous, beta-lactamase-resistant antibiotics.