Emergency imaging assessment of deep neck space infections

Clinical diagnosis and outcome of cervicofacial cellulitis in pyrexic rabbits: six cases (2014-2021)

OBJECTIVES

To assess the signalment, history, exam findings, diagnostics, treatment and outcome of rabbits diagnosed with pyrexia and concurrent cervicofacial cellulitis.

MATERIALS AND METHODS

Retrospective evaluation of medical records of rabbits diagnosed with cervicofacial cellulitis and pyrexia based on physical exam, contrast-enhanced CT, clinicopathology and microbiology findings.

RESULTS

Six out of 1588 rabbits met the study inclusion criteria. Rabbits presented with a median age of 6 years (range, 8 months to 8 years) with a presenting complaint of anorexia or hyporexia. All rabbits had a rectal temperature >40.2°C (104.4°F). Physical exam and contrast-enhanced CT revealed unilateral submandibular and ipsilateral cervical diffuse soft tissue swelling in five of six rabbits. No antemortem evidence of periodontal or dental disease was found on physical exam or CT. Leucopenia was present in five of six rabbits. A left shift with marked toxic changes was present in all four rabbits, for which blood smears were reviewed. Bacterial cultures of the aspirated subcutaneous soft tissue swelling cultured Escherichia coli, Pasteurella multocida, Granulicatella adiacens, Streptococcus species, Haemophilus species and Bacteroides species. Treatment was pursued in five rabbits, where all rabbits received supportive care and four of five rabbits received systemic antibiotics. One rabbit was euthanased following a diagnosis of cervicofacial cellulitis. Three out of five rabbits continued to decline clinically despite medical management, and thus, euthanasia was pursued within 24 hours of starting treatment. Two rabbits responded to initial treatment and developed subsequent multi-focal abscessation. One rabbit was euthanased due to client cost constraints, and one rabbit died shortly after achieving clinical resolution of cervicofacial cellulitis.

CLINICAL SIGNIFICANCE

Cervicofacial cellulitis should be considered a differential diagnosis in pyrexic rabbits with facial or cervical swelling with medical and surgical management pursued for therapy.

Deep odontogenic infections - Computed tomography imaging-based spreading routes and risk for airway obstruction

PURPOSE

This study aimed to evaluate deep odontogenic infection (DOI) spread and features utilizing head and neck computed tomography (CT) imaging.

MATERIAL AND METHODS

Patients with acute DOI and preoperative contrast-enhanced CT-imaging were included in the study. Infection spaces, radiological features of these infections, CT imaging-based compromised airway and patients' background factors were evaluated and associations between these and need for postoperative mechanical ventilation (MV) were reported.

RESULTS

Altogether 262 hospitalized patients were included in the final analysis. Typically affected spaces were submandibular (74%), mandibular buccal/vestibular (37%), and sublingual (26%). Retropharyngeal (1%), mediastinal (1%) and danger space (1%) involvements were unusual. The infections were quite evenly distributed between multispace abscesses (53%) and other infections (47%). In multivariate analysis, CT-based compromised airway (OR 5.6, CI 95%, 2.9-10.9, P <0.001), midline crossing (OR 3.3, CI 95%, 1.2-8.8, P = 0.018) and extension at the level or below hyoid body (OR 2.4, CI 95% 1.2-5.1, P = 0.016) predicted the need for MV. Other radiological findings and patients' background variables remained statistically non-significant for MV.

CONCLUSION

Anterolateral and superior spread to the neck is typical in DOIs, whereas caudal progression is rare. Postoperative need for MV can be well recognized from CT.

Pancreatitis with infected pseudocyst presenting as a prevertebral abscess with spontaneous rupture into the oesophagus

The development of a prevertebral abscess due to an infected pancreatic pseudocyst and its spontaneous rupture into the oesophagus is a rare complication. We report a man who presented with odynophagia, dyspnoea and abdominal pain. Contrast-enhanced CT showed evidence of pancreatitis and a prevertebral space abscess communicating with the pancreas through the oesophageal hiatus. The patient was diagnosed to have a prevertebral abscess with chronic pancreatitis. Surgical drainage was planned, but the patient died of spontaneous drainage of the prevertebral abscess into the oesophagus and aspiration of the collection into the lungs.

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.

Advanced imaging of head and neck infections

When head and neck infection is suspected, appropriate imaging contributes to treatment decisions and prognosis. While contrast-enhanced CT is the standard imaging modality for evaluating head and neck infections, MRI can better characterize the skull base, intracranial involvement, and osteomyelitis, implying that these are complementary techniques for a comprehensive assessment. Both CT and MRI are useful in the evaluation of abscesses and thrombophlebitis, while MRI is especially useful in the evaluation of intracranial inflammatory spread/abscess formation, differentiation of abscess from other conditions, evaluation of the presence and activity of inflammation and osteomyelitis, evaluation of mastoid extension in middle ear cholesteatoma, and evaluation of facial neuritis and labyrinthitis. Apparent diffusion coefficient derived from diffusion-weighted imaging is useful for differential diagnosis and treatment response of head and neck infections in various anatomical sites. Dynamic contrast-enhanced MRI perfusion may be useful in assessing the activity of skull base osteomyelitis. MR bone imaging may be of additional value in evaluating bony structures of the skull base and jaw. Dual-energy CT is helpful in reducing metal artifacts, evaluating deep neck abscess, and detecting salivary stones. Subtraction CT techniques are used to detect progressive bone-destructive changes and to reduce dental amalgam artifacts. This article provides a region-based approach to the imaging evaluation of head and neck infections, using both conventional and advanced imaging techniques.

Effects of Crest Morphology on Lingual Concavity in Mandibular Molar Region: an Observational Study

Objectives

The aim of this radiological study is to evaluate the lingual concavity dimensions and possible implant length in each posterior tooth region according to posterior crest type classification by using cone-beam computed tomography.

Material and Methods

According to inclusion criteria, 836 molar teeth regions from 209 cone-beam computed tomography images were evaluated. Posterior crest type (concave, parallel, or convex), possible implant length, lingual concavity angle, width, and depth were recorded.

Results

In each posterior tooth region, concave (U-type) crest was detected most frequently while convex (C-type) was the lowest. Possible implant length values were higher in second molar regions than first molars. Lingual concavity width and depth were decreasing from second molars to first molars for both sides. Additionally, lingual concavity angle showed higher values in second molar sites than first molars. In all molar teeth regions, lingual concavity width values were the highest in concave (U-type) crest type while they were the lowest in convex (C-type) crest type (P < 0.05). Lingual concavity angle values were recorded as the highest in concave (U-type) and the lowest in convex (C-type) crest type at the left first molar and right molars (P < 0.05).

Conclusions

The lingual concavity dimensions and possible implant length may vary according to crest type and edentulous tooth region. Due to this effect, the surgeons should examine crest type clinically and radiologically. All parameters in the present study are decreasing while moving from anterior to posterior as well as from concave (U-type) to convex (C-type) morphologies.

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.

A comparison of patients with neck abscesses caused by esophageal foreign body impaction vs. inflammatory disease: a retrospective study

OBJECTIVES

During clinical practice, we have detected a few cases of neck abscesses in patients diagnosed with esophageal foreign body impaction (EFB) but without the primary inflammatory disease. However, we do not know if neck abscesses caused by an inflammatory source are more like to be associated with a more severe progression or poorer prognosis. In this study, we aimed to identify differences between these two groups of patients by comparing progression and prognosis.

MATERIALS AND METHODS

We retrospectively reviewed all patients who underwent neck abscess incisions between January 2011 and March 2022 and divided these patients into two groups: an EFB group and an inflammation group. Data were described by percentages, means, and standard deviations (SDs). Fisher's precision probability test was used to compare differences between the EFB and inflammation groups. Categorical variables were analyzed by Pearson's Chi-squared test. In addition, three factors including hospital days, intensive care unit (ICU) stay, and drainage-tube removal time were used for multivariate analysis to identify independent correlations separately.

RESULTS

We enrolled a total of 33 patients with neck abscesses who received surgical incisions; the EFB group included 14 (42%) cases, while the inflammatory group included 19 (58%) cases. No significant differences were identified between the two groups in terms of surgery type (with or without mediastinotomy) and postoperative management (negative pressure drainage or postoperative irrigation). There were no significant differences between the two groups in terms of hospital stay, the timing of drainage-tube removal, the risk of ICU admission, and the probability of receiving intubation and tracheotomy. The incidence rate of esophageal perforation differed significantly between the two groups (p < 0.001). However, there were no significant differences in terms of other preoperative or postoperative comorbidities. The multivariate analysis revealed that the application of mediastinotomy (HR = 0.216 [0.049, 0.963]; p = 0.044) was correlated with a longer stay in the hospital. The time from symptoms to surgery was associated with a longer drainage tube removal time (HR = 0.392 [0.159, 0.967]; P = 0.042) and longer ICU stay (OR = 79.754[1.513, 4203.182]; P = 0.03).

CONCLUSION

Patients with neck abscesses associated with EFB and inflammation received the same therapeutic management, and there were no significant differences between these two groups in terms of prognosis. Furthermore, esophageal perforation was found to be irrelevant to the aggravation of neck abscesses, and there was no need for additional surgery to repair a perforated esophagus in patients with neck abscesses.

LEVEL OF EVIDENCE

Retrospective cohort (2b).

Computed tomography analysis of fascial space involvement demonstrates correlations with laboratory tests, length of hospital stays and admission to the intensive care unit in odontogenic infections

OBJECTIVES

Odontogenic infections are frequent and can spread, leading to complications such as sepsis and the need for admission to an Intensive Care Unit (ICU). The purpose of this study was to perform a computed tomography analysis of the fascial space involvement and correlate with personal data, laboratory tests, length of hospital stays and admission to the ICU in patients with odontogenic infections who required hospitalization.

METHODS

Patients with odontogenic infections admitted between June 2017 and May 2018 were prospectively evaluated. The fascial spaces involved were studied using computed tomography with contrast. The possible correlations of tomographic findings with comorbidities, nutritional status, the causative tooth, laboratory tests, length of hospital stays and admission to the ICU were analyzed.

RESULTS

We identified 66 cases of odontogenic infections which were admitted in the period analyzed. The involvement of primary spaces (86.7%) predominated, followed by secondary ones (8.7%), and cervical (4.6%). The most frequently involved fascial spaces were submandibular (27.1%), buccal (20.8%), sublingual (18.3%), submental (16.7%), and others (17.1%). There were significant differences between laboratory tests (p < 0.001), mean hospital stays (p < 0.001), and admissions to the ICU (p < 0.001) depending on the number of fascial spaces involved. There was no influence of comorbidities, nutritional status, or causative tooth on fascial space involvement.

CONCLUSION

There was a relationship between greater involvement of fascial spaces assessed by computed tomography and higher values of laboratory tests, more extended hospitalization stays and admission to the ICU.

LEVEL OF EVIDENCE

Level 2b.

Parapharyngeal and floor‐of‐mouth abscess secondary to tonsillar phlegmon: A rare and unusual cause of Ludwig's angina

We present an unusual case of Ludwig's angina secondary to a left tonsillar phlegmon in a previously fit and well 50‐year‐old woman. This tonsillar phlegmon spread along the peritonsillar/parapharyngeal plane to cause a diffuse cellulitis and collection in the submental, sublingual, and submandibular spaces despite empirical intravenous antibiotic therapy.

Should preoperative computed tomography be routine examination for cervicofacial space infections?

Background

Cervicofacial space infections are potentially life-threatening, which require accurate diagnosis, early incision, and adequate drainage. The utilization of computed tomography (CT) in cervicofacial space infections has significantly increased for its advantages in the evaluation of abscesses, its availability, and low cost. However, the clinical value of preoperative CT imaging in cervicofacial space infections remains controversial for its poor specificity, radiation exposure, potential complications, and extra cost. We, therefore, investigated whether CT examination should be used as a routine examination in the treatment of patients with cervicofacial space infections.

Methods

A retrospective study of all patients affected by cervicofacial space infections that received incision and drainage surgery from Jan 2016 to Dec 2020 was performed at West China Hospital of Stomatology at Sichuan University. Patients were divided into two groups: the group with preoperative CT and without preoperative CT. Outcomes, including reoperation rate, missed diagnosis rate, days of symptom relief, length of stay, duration of surgery, and total cost of hospitalization, were analyzed.

Results

Out of n = 153 patients, 108 patients underwent surgery with preoperative CT and 45 patients without preoperative CT. The reoperation rate in the preoperative CT group (6/108, 5.6%) was significantly lower (P = 0.00) than that in the group without preoperative CT (10/45, 22.2%). Significant reduction of missed diagnosis rate (P = 0.00), days of symptom relief (P = 0.01), length of stay(P = 0.03), and duration of surgery (P = 0.01) were detected in the preoperative CT group. The results demonstrated that the utilization of preoperative CT can reduce the missed diagnosis rate and repeated surgery complications.

Conclusions

We recommend preoperative CT as a routine examination in cervicofacial space infections.

Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses

Deep neck infections (DNIs) include all the infections sited in the potential spaces and fascial planes of the neck within the limits of the deep layer of the cervical fascia. Parapharyngeal and retropharyngeal infections leading to parapharyngeal abscess (PPA) and retropharyngeal abscess (RPA) are the most common. DNIs remain an important health problem, especially in children. The aim of this narrative review is to describe the management of peritonsillar, retropharyngeal and parapharyngeal abscesses in pediatric age. Despite relatively uncommon, pediatric DNIs deserve particular attention as they can have a very severe course and lead to hospitalization, admission to the intensive care unit and, although very rarely, death. They generally follow a mild upper respiratory infection and can initially present with signs and symptoms that could be underestimated. A definite diagnosis can be made using imaging techniques. Pus collection from the site of infection, when possible, is strongly recommended for definition of diseases etiology. Blood tests that measure the inflammatory response of the patient may contribute to monitor disease evolution. The therapeutic approach should be targeted toward the individual patient. Regardless of the surgical treatment, antibiotics are critical for pediatric DNI prognosis. The diagnostic-therapeutic procedure to be followed in the individual patient is not universally shared because it has not been established which is the most valid radiological approach and which are the criteria to be followed for the differentiation of cases to be treated only with antibiotics and those in which surgery is mandatory. Further studies are needed to ensure the best possible care for all children with DNIs, especially in this era of increased antimicrobial resistance.

Odontogenic Infection Pathway to the Parapharyngeal Space: CT Imaging Assessment

Introduction

Parapharyngeal space infection may lead to severe and potentially life-threatening complications. The aim of this study was to assess the odontogenic infection pathway to the parapharyngeal space using CT imaging.

Materials and Methods

Nineteen patients in mandibular odontogenic infections with abscess who underwent contrast-enhanced CT were evaluated in this study. We reviewed the location of abscess and spread of odontogenic infections to the different components of the buccal space, submandibular space, sublingual space, masticator space and parapharyngeal space using CT imaging. The location of abscess and spread of odontogenic infections were analyzed with the Pearson Chi-square test.

Results

Regarding the odontogenic infection pathway to parapharyngeal space, the masticator space (100%) was the most frequent, followed by the buccal space (85.7%), submandibular space (85.7%) and sublingual space (57.1%), while those without parapharyngeal space, the submandibular space (83.3%) was the most frequent, followed by the buccal space (75.0%), masticator space (58.3%) and sublingual space (33.3%). The masticator space was significant space in patients with/without parapharyngeal space infection (P = 0.047).

Conclusion

CT imaging could be an effective method in assessment of odontogenic infection pathway to the parapharyngeal space. The odontogenic infection in masticator space tends to display spread of parapharyngeal space.

Deep Neck Abscesses in Children: An Italian Retrospective Study

BACKGROUND

Retropharyngeal and parapharyngeal abscesses (RPAs, PPAs) usually affect young children. Surgical drainage and/or antibiotic therapy are treatment of choice, but no specific guidelines exist. In order to reduce the risk of severe complications, appropriate diagnosis and therapy are necessary. The aims of the study were to review diagnosis and management of children with RPAs/PPAs and to compare surgical versus medical approach.

METHODS

This is a multicenter retrospective study including all patients younger than 15 years admitted at 4 Italian pediatric hospitals of Florence, Padua, Rome, and Treviso, with International Classification of Diseases, Ninth Revision discharge diagnosis code of RPAs and PPAs, from January 1, 2008, to December 31, 2016.

RESULTS

One hundred fifty-three children were included. The median age was 4.4 years, with overall male predominance. Heterogeneous signs and symptoms (fever, neck cervical, lymphadenopathy, pain, and stiff neck most frequently) and a large mixture of bacteria from pus cultures were detected. Computer tomography (66.7%) and magnetic resonance imaging (27.5%) were performed to confirm the presence of abscess. Fifty-one percent of abscesses were greater than 3 cm. Eighty-seven patients (56.9%) underwent surgery, and 66 (43.1%) were treated with antibiotics alone (mostly ceftriaxone, metronidazole, amikacin, and clindamycin) with median days of therapy of 26.5 days and length of therapy of 16.0 days of median. Median length of stay was 11 days. None had severe complications. Multivariate analysis indicated as independent predictive factors of surgery abscess of 3 cm or greater, high white blood cell count, and-most of all-the hospital of admission.

CONCLUSIONS

Deep neck abscesses mostly affect patients in early childhood, with a combination of nonspecific signs and symptoms, and it still emerges as a heterogeneous approach in diagnosis and management of these infections. Thus, common shared protocols represent an essential tool in order to standardize care and improve patients' outcomes.

Update on Antimicrobial Therapy in Management of Acute Odontogenic Infection in Oral and Maxillofacial Surgery

This article focuses on the antimicrobial therapy of head and neck infections from odontogenic origin. Odontogenic infections are among the most common infections of the oral cavity. They are sourced primarily from dental caries and periodontal disease (gingivitis and periodontitis). Many odontogenic infections are self-limiting and may drain spontaneously. However, these infections may drain into the anatomic spaces adjacent to the oral cavity and spread along the contiguous facial planes, leading to more serious infections. Antibiotics are an important aspect of care of the patient with an acute odontogenic infection. Antibiotics are not a substitute for definitive surgical management.

Deep Neck Infections: decisional algorithm for patients with multiple spaces involvement

BACKGROUND

Deep Neck Infections (DNIs) spread along fascial planes and involve neck spaces. Recently, their incidence has decreased due to the introduction of antibiotics; nevertheless, complications related to DNIs are often life-threatening.

OBJECTIVE

The purpose of this article is focused on the identification of predisposing factors of these complications, as well as on the development of a reliable therapeutic algorithm.

METHOD

Sixty patients with DNIs were enrolled from 2006 to 2019 for a retrospective study. The exclusion criteria for the present study was cellulitis, small abscesses responding to empiric or specific antibiotic therapy or with involvement of only one deep neck space. During the analysis the following parameters of interest have been evaluated: gender, age, site of origin, pathways of spread, comorbidities, clinical features, bacteriology data, type of surgical approach required, complications, duration of hospitalization and mortality rate. On admission, microbial swab analysis was performed.

RESULTS

Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), iron deficiency anemia and the involvement of multiple spaces have been associated with a significantly higher risk of developing complications. Most of our patients had polymicrobial infections. All patients underwent surgical drainage. The complication rate had occurred in 56.6% of patients, while death in 18.3%.

CONCLUSION

DNIs represent a medical and surgical emergency with potential serious complications, thus avoiding diagnostic delay is mandatory. Our preliminary data suggest the importance of evaluating the extent of infections because the involvement of multiple spaces requires timely surgery due to the higher risk of complications and mortality.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Emergency neck MRI: feasibility and diagnostic accuracy in cases of neck infection

Background

Computed tomography (CT) has traditionally been the first-line imaging method in neck emergencies such as deep neck infections. Due to superior soft-tissue contrast, magnetic resonance imaging (MRI) may be an alternative to CT, also in emergency situations.

Purpose

To characterize the use of routine MRI in neck emergencies, with an emphasis on clinical feasibility and diagnostic accuracy in cases of neck infection.

Material and Methods

We conducted a retrospective cohort study of all primary neck MRI scans performed using a 3-T MRI device during a five-year follow-up period in a tertiary emergency radiology department. Imaging data were compared with final clinical diagnosis and surgical findings as reference standards.

Results

The search identified 461 primary neck MRI scans, of which 334 (72%) were performed on the basis of clinical suspicion of infection. Radiological evidence of infection was observed in 95% of these scans, and at least one abscess was detected in 229 cases (72% of confirmed infection). MRI had an overall technical success rate of 95% and had high positive predictive value for both infection (0.98) and detection of abscess (0.95).

Conclusion

We found that emergency neck MRI can be successfully performed on most patients, and that MRI detects neck infection with a high accuracy. These results suggest that MRI may be an alternative to CT as the first or only imaging modality in neck emergencies.

Tongue protrusion as the presenting symptom of parapharyngeal abscess

Deep neck space infections are commonly seen in the pediatric population. The diagnosis, however, can be challenging to make and requires a high degree of suspicion because of developmental and age-related factors in children and non-specific presenting symptoms. Diagnosis becomes further complicated in patients whose comorbid conditions mask some of the more severe systemic symptoms. We present a case of a 2-year-old female with Trisomy 21 who presented with a chief concern of "tongue swelling" per parents. After initially failing treatment for presumed angioedema caused by an angiotensin-converting enzyme inhibitor, she was ultimately diagnosed with a parapharyngeal abscess with extension and mass effect causing tongue protrusion. This case represents a novel early presentation of a common infection and highlights the challenges of diagnosing deep neck space infections in children.

Odontogenic Head and Neck Region Infections Requiring Hospitalization: An 18-Month Retrospective Analysis

The aim of this study was to comprehensively review our experience with odontogenic infections in the head and neck region requiring treatment at a national referral center. We retrospectively reviewed 85 patients treated at the Chair and Clinic of Maxillofacial Surgery of the University Hospital in Wrocław between January 2018 and June 2019. We excluded patients with nonondontogenic infections or other than purulent clinical forms of dentivitis in the head and neck region. Several demographic, clinicopathological, and treatment variables were assessed. The majority of patients were men who were referred for inpatient treatment by a dentist or family doctor, presented to the Hospital Emergency Ward (SOR) by themselves, or transported to the SOR by paramedics SOR from their home or another hospital. All patients were treated in accordance with the current guidelines for head and neck region odontogenic infections. An incision was made and the abscess was drained. The odontogenic cause was removed followed by the collection of tissue for microbiological examination. The course of infection was monitored by means of laboratory parameters such as leukocyte counts and c-reactive protein levels. Odontogenic infections in the head and neck region are a persistent and common problem. Rapid, accurate diagnosis and treatment minimizes the risk of life-threatening complications, shortens the hospitalization period, and lowers treatment costs.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

The many faces of periapical inflammation

Dental periapical inflammation is common and can present with a wide variety of symptoms and signs. These include jaw pain and local soft-tissue inflammation, which may be obviously dental in origin; however, the presentation may also be with a painless mass or draining cutaneous sinus, with facial or ear pain or with symptoms of sinusitis, when the dental cause is not clinically obvious. Radiologists are often the first to recognise the dental source of symptoms in these cases. This recognition requires an awareness of the varied manifestations of periapical sepsis and careful systematic review of the teeth and jaws. The causative periapical lesion may be small and subtle, and there is not always a macroscopic defect in the cortical bone between the lesion and surrounding soft-tissue inflammation. The origin of the referral and the initial imaging technique used can vary. Dental periapical inflammation can also be an incidental finding on imaging. In these cases, it should not be mistaken for more sinister pathology and its presence should be conveyed to the referrer so that appropriate dental treatment can be initiated: this is especially important in patients with malignancy in whom radiotherapy is planned. In cases of severe odontogenic soft-tissue sepsis, a review of the airway and major blood vessels is important. We present cases to illustrate the wide range of clinical and radiological manifestations of periapical inflammatory pathology.

Sialolithiasis with abscess: An uncommon presentation of a Ludwig's angina mimic

Sialolithiasis represents the most common issue of the salivary gland, ranging from asymptomatic to airway compromising. In rapidly progressing, completely obstructive salivary stones, the presentation can mimic emergent oropharyngeal diseases, primarily Ludwig's angina. We present a case of a large and obstructive sialolith with abscess whose initial presentation was concerning for Ludwig's angina with impending airway compromise. While a common complaint, emergency providers should be aware of the nefarious presentation of an everyday complaint.

Fatal complications in a patient with severe multi-space infections in the oral and maxillofacial head and neck regions: A case report

BACKGROUND

Odontogenic infection is one of the common infectious diseases in oral and maxillofacial head and neck regions. Clinically, if early odontogenic infections such as acute periapical periodontitis, alveolar abscess, and pericoronitis of wisdom teeth are not treated timely, effectively and correctly, the infected tissue may spread up to the skull and brain, down to the thoracic cavity, abdominal cavity and other areas through the natural potential fascial space in the oral and maxillofacial head and neck. Severe multi-space infections are formed and can eventually lead to life-threatening complications (LTCs), such as intracranial infection, pleural effusion, empyema, sepsis and even death.

CASE SUMMARY

We report a rare case of death in a 41-year-old man with severe odontogenic multi-space infections in the oral and maxillofacial head and neck regions. One week before admission, due to pain in the right lower posterior teeth, the patient placed a cigarette butt dipped in the pesticide "Miehailin" into the "dental cavity" to relieve the pain. Within a week, the infection gradually spread bilaterally to the floor of the mouth, submandibular space, neck, chest, waist, back, temporal and other areas. The patient had difficulty breathing, swallowing and eating, and was transferred to our hospital as an emergency admission. Following admission, oral and maxillofacial surgeons immediately organized consultations with doctors in otolaryngology, thoracic surgery, general surgery, hematology, anesthesia and the intensive care unit to assist with treatment. The patient was treated with the highest level of antibiotics (vancomycin) and extensive abscess incision and drainage in the oral, maxillofacial, head and neck, chest and back regions. Unfortunately, the patient died of septic shock and multiple organ failure on the third day after admission.

CONCLUSION

Odontogenic infection can cause serious multi-space infections in the oral and maxillofacial head and neck regions, which can result in multiple LTCs. The management and treatment of LTCs such as multi-space infections should be multidisciplinary led by oral and maxillofacial surgeons.

CT of the Neck: Image Analysis and Reporting in the Emergency Setting

Interpreting findings seen at CT of the neck is challenging owing to the complex and nuanced anatomy of the neck, which contains multiple organ systems in a relatively small area. In the emergency department setting, CT is performed to investigate acute infectious or inflammatory symptoms and chronic processes. With few exceptions, neck CT should be performed with intravenous contrast material, which accentuates abnormally enhancing phlegmonous and neoplastic tissues and can be used to delineate any abscesses or necrotic areas. As part of the evaluation, the vascular structures and aerodigestive tract must be scrutinized, particularly for patency. Furthermore, although the patient may present because of symptoms that suggest non-life-threatening conditions involving structures such as the teeth or salivary glands, there may be serious implications for other areas, such as the orbits, brain, and spinal cord, that also may be revealed at the examination. With a focus on the emergency setting, the authors propose using an approach to interpreting neck CT findings whereby 12 areas are systematically evaluated and reported on: the cutaneous and subcutaneous soft tissues, aerodigestive tract and adjacent soft tissues, teeth and periodontal tissues, thyroid gland, salivary glands, lymph nodes, vascular structures, bony airspaces, cervical spine, orbits and imaged brain, lung apices, and superior mediastinum. The use of a systematic approach to interpreting neck CT findings is essential for identifying all salient findings, recognizing and synthesizing the implications of these findings to formulate the correct diagnosis, and reporting the findings and impressions in a complete, clear, and logical manner.Online supplemental material is available for this article.^©RSNA, 2019.

Transoral Point-of-Care Ultrasound in the Diagnosis of Parapharyngeal Space Abscess

BACKGROUND

Parapharyngeal space abscesses (PPSA) are deep-space neck infections that are associated with significant morbidity and, rarely, mortality if not promptly diagnosed and treated. The diagnosis is often difficult, as the clinical presentation can mimic peritonsillar abscesses (PTA). Transoral point-of-care ultrasound (POCUS) may be a useful tool to help distinguish PTAs from other deep-space infections such as PPSAs.

CASE REPORT

A woman presented to the Emergency Department (ED) with fever, sore throat, trismus, and unilateral tonsillar swelling from a walk-in clinic with a preliminary diagnosis of PTA for drainage. A POCUS performed by the emergency medicine resident in the ED demonstrated normal tonsils. However, it revealed evidence of a PPSA. A computed tomography scan was performed, which confirmed the diagnosis. The patient was admitted to the otolaryngology service for antibiotics and steroids, with subsequent improvement and discharge home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case, the use of POCUS in the ED avoided an unnecessary invasive procedure, and facilitated the correct diagnosis of an uncommon condition.

Emergency Imaging of the Nontraumatic Pediatric Head and Neck

Pediatric patients present emergently with a wide variety of infectious, inflammatory, congenital, traumatic, and neoplastic conditions. Imaging plays a crucial role in distinguishing among the potential diagnoses, as often, history and physical exam is limited in these young sick patients. Understanding the imaging appearance of the range of conditions which are commonly encountered and their potential complications, facilitates appropriate and expedient management. The radiologist must recognize the benefits of the various imaging modalities available and help the clinician choose among the possibilities depending on the clinical status of the patient.

Infections and foreign bodies in ENT

Infections of the ear, nose and throat are common. The majority of these infections are managed by the primary care physicians and they settle with conservative and medical management. However, a small group can progress to become troublesome and develop complications to the extent that they may require surgical intervention. Some of the infections can lead to life-threatening complications therefore awareness and correct diagnosis along with appropriate management is paramount. Foreign bodies in the ear, nose and throat are commonly encountered. The location and type of foreign body can have an implication on the urgency of action and the possible complications. In this article the common ENT infections and foreign bodies and their management are discussed.

Confluent Retropharyngeal, Lateral Pharyngeal, and Peritonsilar MRSA Abscess in an Infant

Neck abscesses such as retropharyngeal, peritonsilar, and lateral pharyngeal are well described, typically cause a characteristic illness, and have a known epidemiology. We present a rare occurrence of case of confluent, mixed retropharyngeal, lateral pharyngeal, and peritonsilar abscess in a 9-month-old female infant. The symptoms at presentation were very mild and not expected in association with this extensive an abscess. The causative organism was methicillin-resistant Staphylococcus aureus.

Increasing Use of Intensive Care Unit for Odontogenic Infection Over One Decade: Incidence and Predictors

PURPOSE

To determine whether intensive care unit (ICU) admissions for odontogenic infections have increased during the past decade and whether certain clinical features are associated with a greater rate of ICU admission.

MATERIALS AND METHODS

The data from patients undergoing surgery for odontogenic infections at the Royal Brisbane and Women's Hospital in the 24 month from January 2003 to December 2004 were compared with those from patients treated from January 2013 to December 2014. A χ² analysis was used to compare the demographic, admission, and clinical patient data in each cohort. A multiple logistic regression model was used to determine which clinical features were associated with greater rates of ICU admission.

RESULTS

The rate of ICU admission increased significantly from 7 to 24% during the decade (χ² = 12.74; P = .000), although the clinical presentation of patients admitted to the ICU was similar in both cohorts. The mean number of days spent in the ICU increased significantly from 1.7 ± 0.5 to 3.24 ± 2.5 days (t = -3.63; P = .001), and the overall length of stay increased from 1.7 ± 0.5 to 3.5 ± 4.1 days (t = 2.99; P = .004). The use of preoperative computed tomography (CT) increased significantly from 42.9 to 93.3% (χ² = 13.25; P = .000). The most significant predictors of ICU admission were lower third molar involvement (P = .026), dysphagia (P = .020), and C-reactive protein (CRP) levels exceeding 150 mg/L (P = .039).

CONCLUSIONS

The use of the ICU in the management of odontogenic infection has increased significantly at the Royal Brisbane and Women's Hospital over 1 decade. The demographic data and clinical presentation of the patients admitted to the ICU did not change significantly. However, the length of ICU stay and the total length of stay have both increased. A significant increase in CT usage for odontogenic infections also occurred. Third molar infections, dysphagia, and elevated CRP might be relevant clinical predictors of a more complicated course of care requiring ICU admission. More judicious use of CT scanning, combined with prompt surgical consultation and intervention, might reduce the rate of ICU admissions for odontogenic infections.

Diagnostic work-up in obstructive and inflammatory salivary gland disorders

Inflammatory and obstructive disorders of the salivary glands are caused by very different pathological conditions affecting the gland tissue and/or the excretory system. The clinical setting is essential to address the appropriate diagnostic imaging work-up. According to history and physical examination, four main clinical scenarios can be recognised: (1) acute generalised swelling of major salivary glands; (2) acute swelling of a single major salivary gland; (3) chronic generalised swelling of major salivary glands, associated or not with "dry mouth"; (4) chronic or prolonged swelling of a single major salivary gland. The algorithm for imaging salivary glands depends on the scenario with which the patient presents to the clinician. Imaging is essential to confirm clinical diagnosis, define the extent of the disease and identify complications. Imaging techniques include ultrasound (US), computed tomography (CT) and magnetic resonance (MR) with MR sialography.

A severe deep neck odontogenic infection not prioritised by the emergency department triage system and National Early Warning Score

A 62-year-old man with a background of type 2 diabetes mellitus presented to the emergency department (ED) with a 5-day history of dental pain, progressive right facial swelling, trismus, dysphagia and voice changes. The oropharynx could not be directly examined completely due to trismus. The patient had a National Early Warning Score of 0 and so was triaged into the ‘minors’ section of ED. Following assessment by the on-call oral and maxillofacial surgeon, an urgent contrast-enhanced CT demonstrated a large parapharyngeal collection, which required urgent anaesthetic and surgical intervention. The patient developed pulmonary complications postoperatively, but eventually made a full recovery.

Association between deep neck space abscesses and internal carotid artery narrowing in pediatric patients

Background/aim: Our aim was to interpret the effects of deep neck space abscesses on the adjacent carotid artery according to abscess location, as well as to determine narrowing by calculating the mean stenosis ratios.Materials and methods: Neck computed tomography scans and clinical data of 45 children with neck abscesses were evaluated retrospectively for abscess location and internal carotid artery narrowing. The lumen areas of the carotid arteries were measured from standard levels, and stenosis ratios were calculated with two different techniques. The mean stenosis ratios of each group according to abscess location were then compared with the control group.Results: Among the 45 abscesses included in the study, 51.1% (n = 23/45) were located in the peritonsillar region, 37.8% (n = 17/45) were located in the parapharyngeal-lateral retropharyngeal space, and 11.1% (n = 5/45) were in the midline retropharyngeal space. We found a statistically significant difference between the mean stenosis ratios of the ipsilateral side of the parapharyngeal-lateral retropharyngeal abscesses and the control group (P < 0.01).Conclusion: The children with parapharyngeal-lateral retropharyngeal abscesses all had narrowing in the adjacent carotid lumen to some degree. Although most of the patients had no clinical symptoms, radiologists have to be aware of this arterial complication to prevent further progress and fatal complications.

Univariate and multivariate models for the prediction of life-threatening complications in 586 cases of deep neck space infections: retrospective multi-institutional study

OBJECTIVE

To identify deep neck infection factors related to life-threatening complications.

METHODS

This retrospective multi-institutional study comprised 586 patients treated for deep neck infections between 2002 and 2012. The statistical significance of variables associated with life-threatening complications of deep neck infections was assessed.

RESULTS

During treatment, life-threatening complications occurred in 60 out of 586 cases. On univariate analysis, life-threatening complications were linked to: dyspnoea, neck movement disturbance and dysphonia (all p < 0.001); and parapharyngeal, anterior visceral or pretracheal deep neck involvement (all p < 0.002). Aetiology was significantly linked to tonsils (p < 0.001). Regarding infection type, fasciitis was a significant factor (p < 0.001). Candida albicans was a significant bacterial culture (p < 0.001). A multivariate step-wise model disclosed fewer significant variables: retropharyngeal space (p = 0.005) and major blood vessels area (p = 0.006) involvement, and bacterial culture C albicans (p < 0.001).

CONCLUSION

It can be predicted that patients with deep neck infections, with neck movement disturbances, dysphonia, dyspnoea and swelling of the external neck, accompanied by severe pain, and inflammatory changes in the retropharyngeal space and large vessel areas, with culture-confirmed infection of C albicans, are likely to develop life-threatening complications.

Nontraumatic head and neck injuries: a clinical approach. Part 2

Nontraumatic emergencies of the head and neck represent a challenge in the field of neuroradiology for two reasons. As explained in the first part of this update, these entities affect an area where the thorax joins the cranial cavity and can thus compromise both structures; second, they are uncommon, so they are not well known. Maintaining the same approach as in the first part, focusing on the clinical presentations in the emergency department rather than on the anatomic regions affected, we will study the entities that present with two patterns: those that present with a combination of cervical numbness, dysphagia, and dyspnea and those that present with acute sensory deficits. In the latter group, we will specifically focus on visual deficits, because this is the most common symptom that calls for urgent imaging studies.

Evaluation of ultrasonography as a diagnostic tool in the management of head and neck facial space infections: A clinical study

Introduction:

Superficial facial space infections represent a significant amount of the dental problems that present to hospital. Determining whether an odontogenic swelling is a cellulitis or abscess is difficult, but important as both may require different treatments. The use of an ultrasound may aid in differentiating cellulitis and abscess. This study was done to compare the accuracy of clinical examination alone versus ultrasonography (USG) in the diagnosis of cellulitis and abscess in symptomatic patients with a diagnosis of superficial facial space infection.

Materials and Methods:

Twenty patients (1870 years) diagnosed as superficial facial space infections by clinical and radiographic examinations were included in the study and patients with significant medical conditions were excluded. The provisional clinical diagnosis was made after a thorough history was taken and clinical examination was performed to determine if the swelling was a cellulitis or abscess. Swelling was then evaluated using the ultrasonic transducer which was placed over the swelling to aid the diagnosis which was again recorded. An incision and drainage procedure was performed after the administration of local anesthesia. The success of the ultrasound intervention versus clinical examination was based on whether frank exudation was detected during incision and drainage of such swellings.

Results:

The statistical analysis found that USG is a valuable diagnostic aid for detection of abscess or cellulitis in head and neck facial space infections.

Interpretation and Conclusion:

The findings of this prospective analysis indicate that there was statistical difference between clinical examination alone and USG in making the correct diagnosis. The sensitivity, specificity, positive predictive, negative predictive, and accuracy were not similar for all methods tested. From the results of this study, ultrasound is recommended as an adjunct to clinical examination in differentiating between cellulitis and abscess.

Infectious arteritis of the internal carotid artery complicating retropharyngeal abscess

INTRODUCTION

Retropharyngeal abscess is a well-known entity in children, but can also occur in adults. The two main vascular complications are vascular compression and pseudoaneurysm, while infectious arteritis of the internal carotid artery is exceptional.

CASE REPORT

The authors describe a case of a retropharyngeal abscess in an adult woman complicated by infectious arteritis of the internal carotid artery. This rare complication was treated by endovascular occlusion of the internal carotid artery and incision and drainage of the abscess in combination with antibiotic and anticoagulant therapy. The patient did not present any neurological sequelae and follow-up MRI did not reveal any signs of vascular or neurological complications.

DISCUSSION

This case highlights the importance of thorough examination of imaging performed in the context of deep neck space abscess to detect signs of vascular involvement. Treatment must be aggressive in view of the life-threatening risk of arterial rupture or septic embolism. This is the first reported case of infectious arteritis involving the internal carotid artery complicating retropharyngeal abscess.

Face and Neck Infections: What the Emergency Radiologist Needs to Know

An overview of the imaging of face and neck infections is presented. Most of the imaging presented is contrast-enhanced computed tomography. The emphasis of this presentation is to enable the emergency radiologist to accurately diagnose face and neck infections, to effectively communicate the imaging findings with emergency physicians, and to function as part of a team offering the best care to patients.

The value of early intervention and a multidisciplinary approach in the management of necrotizing fasciitis of the neck and anterior mediastinum of odontogenic origin

Necrotizing fasciitis (NF) is a serious clinical condition, which, if diagnosed late, invariably leads to a fatal outcome. A high index of suspicion of the presenting clinical signs and symptoms, supported by knowledge of the clinicopathologic processes that underlie its aggressive nature, should prompt early surgical intervention. Ultimately, the success of treatment requires a robust clinical pathway in which all members of the health care team are aligned by their skill sets and competencies to manage NF. This report describes the management of a case of a young man with aggressive NF of odontogenic origin affecting the neck and anterior mediastinum. A multidisciplinary approach brought about early recognition of the disease and surgical intervention, the use of frozen section biopsies to determine the extent of fascial spread, and aggressive debridement of the affected tissue. Teamwork, critical thinking, and situational awareness ensured that the patient received optimum care in a timely manner. The psychological, clinical, radiologic, pathologic, and microbiological aspects of the patient's care are presented with a literature review.

Diagnosis and management of deep neck infections in children: the experience of an Italian paediatric centre

Deep neck infection (DNI) is a severe occurrence in children. We've examined the presenting signs and symptoms, the value of single diagnostic procedures, the rate of complications and the impact of the therapeutic options on the final outcome, in children with a DNI. We retrospectively evaluated patients, aged 0-18 years, who were admitted for a DNI, from January 2006 through December 2012, at Regina Margherita Children's Hospital, Turin, Italy. We subdivided them on the basis of type of treatment: pharmacological treatment alone or antimicrobial treatment plus surgery. An univariate analysis has been performed to examine the differences between the two groups. Sixty patients (32 males, 28 females) with diagnosis of DNI were enrolled; 33 children only received medical treatment (group 1), whereas 27 patients underwent also surgical interventions (group 2). The mean abscess size was significantly higher in group 2 than in group 1 (p = 0.01). The predominant organisms were Streptococcus sp. (11 cases, 52.4%, mostly Streptococcus pyogenes). The most frequent antibiotic regimen was a β lactam alone (either III generation cephalosporin or amoxicillin/clavulanate). The duration of intravenous antibiotic varied between the two groups, without statistical significance (p = 0.052); whereas the oral antibiotic administration was significantly shorter in group 1 than in group 2 (p = 0.0003). Three patients (5%) developed complications. This research confirms that the medical approach, with high doses of intravenous antibiotics for a minimum of 5 days, could be a tolerable and safe option for the treatment of patients with stable condition and/or small DNIs.