Is ultrasonography-guided drainage a safe and effective alternative to incision and drainage for deep neck space abscesses?

The assessment and management of deep neck space infections in adults: A systematic review and qualitative evidence synthesis

OBJECTIVES

To summarise current practices in the diagnosis and management of deep neck space infections (DNSIs). To inform future studies in developing a framework in the management of DNSIs.

DESIGN

This review was registered on PROSPERO (CRD42021226449) and reported in line with PRISMA guidelines. All studies from 2000 that reported the investigation or management of DNSI were included. The search was limited to English language only. Databases searched included AMED, Embase, Medline and HMIC. Quantitative analysis was undertaken with descriptive statistics and frequency synthesis with two independent reviewers. A qualitative narrative synthesis was conducted using a thematic analysis approach.

SETTING

Secondary or tertiary care centres that undertook management of DNSIs.

PARTICIPANTS

All adult patients with a DNSI.

MAIN OUTCOME MEASURES

The role of imaging, radiologically guided aspiration and surgical drainage in DNSIs.

RESULTS

Sixty studies were reviewed. Thirty-one studies reported on imaging modality, 51 studies reported treatment modality. Aside from a single randomised controlled trial, all other studies were observational (n = 25) or case series (n = 36). Computer tomography (CT) was used to diagnose DNSI in 78% of patients. The mean percentage of management with open surgical drainage was 81% and 29.4% for radiologically guided aspiration, respectively. Qualitative analysis identified seven major themes on DNSI.

CONCLUSIONS

There are limited methodologically rigorous studies investigating DNSIs. CT imaging was the most used imaging modality. Surgical drainage was commonest treatment choice. Areas of further research on epidemiology, reporting guidelines and management are required.

Imaging assessment of deep neck spaces infections: an anatomical approach

Despite the widespread use of antibiotics, deep neck infections are still a relevant clinical problem and can cause severe and potentially life-threatening complications. Imaging plays a pivotal role into the clinical management of deep neck infections, allowing identification of the source of infections, definition of the precise extension of the disease and early diagnosis of local or distant complications. The complex anatomy of deep neck spaces may hide the actual extent of disease: the knowledge of neck anatomy enables radiologists to rapidly evaluate expected routes of spread of infections and to effectively communicate crucial information to surgeons. Computed Tomography is the most used imaging modality for assessing primary site of infection, extent of disease and local complications. Magnetic resonance imaging may be used as a second level imaging modality for individuating intracranial or spinal complications. The present work aims to review the imaging of deep neck spaces infections, focusing on relevant anatomy and clinical scenarios, underlining practical teaching points for each of them. Familiarity with deep neck spaces anatomy and knowledge of most common routes of spread of infections allow the radiologist to make a prompt diagnosis and to look for early signs of potential complications.

Ultrasound-Guided Needle Aspiration vs. Surgical Incision of Parotid Abscesses

OBJECTIVE

Standard treatment of parotideal abscesses consists of surgical drainage. This often has to be carried out in general anesthesia and carries the risk of iatrogenic injury of the facial nerve. Ultrasound-guided needle aspiration is an alternative therapy. Up until now a lack of systematic data concerning this subject exists. The study at hand aims to answer the question whether needle aspiration is a viable alternative for surgical drainage.

METHODS

All patients who had been treated surgically (n = 39) or via ultrasound-guided needle aspiration (n = 18) at our clinic were included into this monocentric retrospective analysis.

RESULTS

There was no statistically significant difference (p = 0.142) regarding the mean abscess volume in both groups (5.7 vs. 10.1 mL). Therapy of the abscesses on average required 1.88 (1-5) ultrasound-guided needle aspirations or 1.10 (1-4) surgical interventions. There was a trend to a shorter inpatient treatment period (5.88 vs. 7.33 days) after ultrasound-guided needle aspiration. This trend did not reach statistical significance (p = 0.301). Facial nerve alterations did not occur in any of the patients. Postoperative bleeding did never occur after needle aspirations but in 2% of the patients after surgical abscess revision.

CONCLUSION

Ultrasound-guided needle aspiration is safe and effective in the treatment of parotid abscesses.

Surgeon-performed ultrasound-guided head and neck procedures during COVID-19 pandemic

Background

The ultrasonographic procedure is a common diagnostic and therapeutic method in daily medical practice. Surgeon-performed ultrasound (SUS) has been gaining popularity, especially during this COVID-19 pandemic.

Methods

Two ENT surgeons performed US-guided diagnostic or therapeutic procedures in the outpatient clinic. A successful SUS is defined as the diagnostic procedure's ability to facilitate the final histopathological diagnosis that can guide the subsequent treatment and disease resolution following the therapeutic procedure without the need for more invasive open surgical intervention.

Results

Out of 10 participants, 6 are males, and 4 are females. There were no complications noted. All subjects had successful tissue sampling or intervention on the first attempt for diagnostic and therapeutic SUS.

Conclusions

With COVID-19, there has been a significant shift in ordinary medical practice. SUS is proven to be a safe and effective method to facilitate the management of head and neck pathologies.

Lessons learnt from the global iodinated contrast media shortage in head and neck imaging

A recent shortage in the global supply of iodinated contrast media (ICM) has required health service providers to review their contrast administration policies and implement strategies to conserve inventory. This article will review the current best practices in head and neck imaging for a variety of common presentations and provide examples where alternative imaging can be considered due to the recent ICM shortage. Ultrasound and MRI techniques can feature heavily in many diagnostic processes in head and neck pathology, and a variety of common presentations can be appropriately investigated through clinical evaluation or naso-endoscopy. In many instances, for the routine assessment of non-acute adult and paediatric head and neck presentations, the use of contrast-enhanced CT can be safely minimised to conserve ICM if required.

Deep neck space infection extending to the mediastinum that was treated conservatively

Deep neck space infections (DNSIs) are challenging to diagnose and manage. A female ex-smoker presented with difficulty breathing and chest pain. She was initially treated for exacerbation of emphysema with intravenous antibiotics. The ear, nose and throat team were later asked to review the patient for left submandibular swelling and odynophagia. CT of the neck was performed 10 days later, due to limited availability during COVID-19. It showed an extensive retropharyngeal collection from the level of the vallecula to just above the carina. Normally, a DNSI extending to the mediastinum would require prompt surgical management. However, the patient was clinically well once imaged, so the abscess was managed conservatively with intravenous antibiotics.

Treatment for parotid abscess: a systematic review

A parotid abscess is a dangerous complication of parotitis. In this study, we aimed to define current treatment concepts for parotid abscess, focusing on different management options. The authors performed a PRISMA-compliant systematic review across multiple databases including all original studies published until January 2021 focusing on treatment of parotid abscess. Studies specifying treatment modalities and treatment success rates were included based on abstract and full-text selection. The authors assessed study quality, demographics, success rates, management modalities and adverse events. Among 1,318 citations, 18 studies met our inclusion criteria. Twelve studies relied only on incision and drainage with antibiotic therapy; the remaining 6 compared different treatment modalities (incision and drainage versus exclusive medical therapy or ultrasound-guided drainage). Heterogeneity between studies precluded meta-analysis of data. The review showed that antibiotics remain the mainstay of treatment for parotid abscess. Conversely, the role of incision and drainage, and aspiration should be studied further. The higher rate of complications following incision and drainage suggests a more conservative approach is needed. Incision and drainage remain the main salvage option for conservative treatment failures.

The treatment of congenital pyriform sinus fistula: a single-center experience

PURPOSE

Congenital pyriform sinus fistula (CPSF) often presents diagnosis and treatment challenges. This study aimed to explore the treatment principles and to evaluate the effectiveness of the hypothermia plasma cauterization with suspension laryngoscopy for CPSF.

METHODS

The medical records of 56 patients with CPSF from January 2000 to December 2019 were retrospectively reviewed.

RESULTS

Of the 56 cases, the lesions were predominantly located on the left side (95%), and the accuracy of the first diagnosis was 30%. Ultrasound showed an abnormal rate of 86%, while CT or MRI displayed an abnormal anatomic lesion of 92%. The 3D visual reconstruction enabled the analysis of morphological characteristics of CPSF. The positive predictive value of barium esophagography was 89%, whereas the positive rate of the internal opening in CPSF under local anesthesia laryngoscopy was 33%. Nine cases of sinus type underwent open resection, and the recurrence rate was 33%. Interestingly, ten patients with sinus type underwent hypothermia plasma cauterization with suspension laryngoscopy, leading to a success rate of 100% without apparent complications.

CONCLUSIONS

Hypothermia plasma cauterization with suspension laryngoscopy alongside 3D imaging is both minimally invasive and repeatable with neglectable complications, which has the potential to serve as the first-line treatment for CPSF in the future.

Wisdom Tooth's Revenge: Retropharyngeal Abscess and Mediastinitis after Molar Tooth Extraction

Retropharyngeal abscess is potentially associated with high morbidity and mortality as a result of its direct anatomical connection with the mediastinum. Therefore, knowledge of the relevant anatomy is essential for recognizing the presence and extent of disease in a timely manner. In this case report, we aim to review the pertinent anatomy and patterns of spread of infection from a full blown deep neck space infection to result in mediastinitis and empyema.

The Factors Contributing to Efficiency in Surgical Management of Purulent Infections of Deep Neck Spaces

Deep neck infections (DNIs) are still emergency conditions in otorhinolaryngology. Due to rapid disease progression and life-threatening complications, the accurate surgical and medical treatment must be promptly applied. In the present study, we analyzed treatment protocols of 46 adults to assess efficacy of the treatment and search for prognostic factors of the outcomes. We performed retrospective analysis of medical data of 46 patients, who underwent surgical treatment in our department due to purulent DNI in the period from 2009 to 2017. Data investigated included age, sex, hospitalization time, duration of symptoms before drainage, comorbidities, selected laboratory tests results, location and the number of abscesses, results of microbiological cultures, and antibiotic treatment options. The study group consisted of 33 (71.7%) men and 13 (28.3%) women. Patients age ranged from 18 to 82 years. The mean duration of hospital stay was 13.2 ± 8.4 days. The most common site involved was submandibular space (43.5%), followed by parapharyngeal space (28.3%). The majority of patients had single abscess (81.2%), the multiple abscesses were revealed in 8 (18.8%) cases. The mean size of the abscesses was 42 mm. C-reactive protein level was increased in 96.7% patients (mean level 155.5  ±  146.7  mg/L), but the white blood cell count exceeded the normal in 60.9% cases (mean level 16.89  ±  5.59   ×  10⁹/L). Staphylococcus aureus (20.7%) and Peptostreptococcus (20.7%) were the most common species cultured from swabs. The antibiotic treatment included most commonly a combined ceftriaxone and metronidazole (n = 23). Two patients died due to complications. The correlation between different variables and the duration of hospitalization revealed only the hemoglobin level below 12.5 g/dL, a significant predictor of longer hospitalization (16.23 days vs 12.09 days, P = .017). Patients with purulent DNIs and decreased hemoglobin level are predisposed to prolonged recovery following the surgical drainage.