A prospective, blinded comparison of clinical examination and computed tomography in deep neck infections

Submandibular Sialolithiasis Mimicking Ludwig's Angina: A Case Report and Brief Clinical Review

The "double tongue sign" is a characteristic finding in patients with Ludwig's angina, a potentially life-threatening infection due to airway compromise. Management primarily focuses on early airway protection and antibiotic administration. Submandibular sialolithiasis, on the other hand, could present with the double tongue sign without symptoms suggestive of airway involvement. Unlike Ludwig's angina, conservative treatment is usually the first-line approach for sialolithiasis. The importance of rapidly recognizing and distinguishing between the 2 conditions is emphasized through effective triage and risk stratification, particularly in rural areas where physicians are not readily available.

Diagnostic accuracy of contrast-enhanced CT for neck abscesses: A systematic review and meta-analysis of positive predictive value

OBJECTIVES

To review the diagnostic accuracy of contrast-enhanced computed tomography (CT) in differentiating abscesses from cellulitis in patients with neck infections, using surgical findings as the reference standard.

MATERIALS AND METHODS

Previous studies in the last 32 years were searched from PubMed and Embase. Because of partial verification bias (only positive abscess findings are usually verified surgically), sensitivity and specificity estimates are unreliable, and we focused on positive predictive value (PPV). For all studies, PPV was calculated as the proportion of true positives out of all positives on imaging. To estimate pooled PPV, we used both the median with an interquartile range and a model-based estimate. For narrative purposes, we reviewed the utility of common morphological CT criteria for abscesses, such as central hypodensity, the size of the collection, bulging, rim enhancement, and presence of air, as well as sensitivity and specificity values reported by the original reports.

RESULTS

23 studies were found reporting 1453 patients, 14 studies in children (771 patients), two in adults (137 patients), and seven including all ages (545 patients). PPV ranged from 0.67 to 0.97 in individual studies, had a median of 0.84 (0.79-0.87), and a model-based pooled estimate of 0.83 (95% confidence interval 0.80-0.85). Most morphological CT criteria had considerable overlap between abscesses and cellulitis.

CONCLUSIONS

The pooled estimate of PPV is 0.83 for diagnosing neck abscesses with CT. False positives may be due to limited soft tissue contrast resolution. Overall, none of the morphological criteria seem to be highly accurate for differentiation between abscess and cellulitis.

Cavernous Sinus Involvement and Near Miss Mediastinitis following Mandibular Tooth Infection Treated during the COVID-19 Pandemic: Clinical Diagnosis and Treatment

Odontogenic infections represent a frequent condition that in some cases, if not treated promptly, can spread quickly to the rest of the body and turn into life-threatening infections. In this work, the case is reported of a 59-year-old woman, diabetic and overweight, who presented to the Odontostomatology and Otolaryngology Section of the Policlinic of Bari with mandibular tooth infection that had developed into a deep neck space infection leading to the involvement of cavernous sinuses and near mediastinum. The diagnosis, the surgical drainage of the phlegmon and removal of infection foci, appropriate control of the airways, and a correct antibiotic therapy made it possible to avoid a potentially fatal condition. Prompt management and early diagnosis of deep space neck infections, such as phlegmon and/or necrotizing fasciitis, with the auxilium of CT scans and tools such as LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis), NLR (Neutrophil-to-Lymphocyte Ratio), and LRINECxNLR scores (Laboratory Risk Indicator for Necrotizing Fasciitis and Neutrophil to Lymphocyte Ratio), are advised to evade delays and complications that could potentially worsen the patient’s outcome.

Surgical treatment of deep neck infections in 19 dogs

OBJECTIVE

Describe clinical features, treatment, and outcomes in dogs with deep neck infections.

ANIMALS

19 dogs undergoing surgical treatment of deep neck infections from January 1, 2015, through December 31, 2020.

PROCEDURES

Retrospective record review was conducted, with data collected including clinical signs; neutrophil-to-lymphocyte ratio (NLR); diagnostic imaging, surgical, and histopathologic findings; and follow-up. Spearman correlation and Wilcoxon rank sum were used to compare variables to NLR.

RESULTS

All dogs had cervical swelling, and 9 were febrile. On CT, a distinct mass or abscess (7/13) or abscessed lymph node (4/13) was common, with contrast enhancement (10/13), fluid tracking (8/13), and displacement of the trachea, pharynx, or larynx (6/13) also frequently seen. Foreign material was suspected on CT for 4 dogs and was identified at surgery or histopathology for 4 dogs, only 1 of which was suspected on CT. Histopathology most commonly revealed pyogranulomatous inflammation (14/15). Increasing NLR was moderately correlated to a decreased duration of clinical signs before presentation (ρ = –0.548; P = .035) and an increased length of hospitalization (ρ = 0.645; P = .009). Bacterial culture was submitted for all dogs, and polymicrobial infections were common (8/19). Broad-spectrum empirical antimicrobials were commonly prescribed. Change in antimicrobial treatment based on culture was uncommon (3/19). All dogs survived to hospital discharge; 18 dogs with long-term follow-up had complete resolution of clinical signs.

CLINICAL RELEVANCE

CT was useful to plan for surgery, and surgical treatment resulted in resolution of clinical signs in all dogs with long-term follow-up available. Empirical antimicrobial treatment, such as amoxicillin–clavulanic acid or ampicillin-sulbactam, should be considered.

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.

Management of Ludwig's Angina at a Tertiary Care Hospital in Western Region of India

Introduction

Ludwig’s angina is cellulitis of submandibular space, submental space, and sublingual space. The main causative factors include dental infections (dental caries with atypical periodontitis, pericoronitis, and dental procedures). Other predisposing conditions include poor dental hygiene, dental caries, malnutrition, diabetes mellitus, AIDS, and various other immunocompromised states. It presents as an acute onset and spreads very rapidly causing bilateral diffuse neck swelling, edema of floor of mouth, pain, fever, trismus, foul-smelling pus discharge, difficulty in swallowing, airway edema, and tongue displacement creating a compromised airway with stridor. So it requires early diagnosis and aggressive management.

Material and methods

Clinical data of all patients with clinical diagnosis of Ludwig’s angina managed at the Department of Otorhinolaryngology-Head and Neck Surgery, Sir Takhatsinhji (T) General Hospital and Government Medical College, Bhavnagar, India, from 2015 to 2019 were analyzed retrospectively in this study.

Result

Over the review period, 30 cases were diagnosed as Ludwig’s angina, out of which 12 (40%) were males and 18 (60%) were females; male to female ratio was 1:1.5. The age of the patients ranged from six months to 64 years, with a mean age of 38.86 years. Fever, neck swelling, and neck pain were present in all patients.

In 16 patients, incision and drainage were done under general anesthesia while the rest five patients required only local anesthesia. In six patients (20%), for maintenance of airway, tracheostomy was required. The most common complication was necrotizing fasciitis and death followed by septicemia. Mortality was observed in three patients (10%) in this study.

Conclusion

Despite improved outcomes compare to pre-antibiotic era, Ludwig's angina still remains a potentially life-threatening disease in ENT at present. Dental caries, uncontrolled diabetes mellitus, and malnutrition are commonly associated conditions. With early diagnosis, close airway observation, aggressive intravenous antibiotic treatment, and timely surgical intervention, morbidity, and mortality can be reduced.

Ludwig's angina in Nigeria: The disease of the poor and health inequality!

AIM

highlight the health inequality and identify opportunities to improve the care delivered to the patients who suffer from Ludwig's angina which could have national and international clinical impact.

MATERIALS AND METHODS

Data was collected from three major oral and maxillofacial centers, in Nigeria including Benin, Lagos and Kano. A protocol was developed for data collection which included demographic details, socio-economic status, management of the air way, the associated morbidities and mortalities.

RESULTS

Forty-nine were managed in Benin, 57 in Lagos and 66 in Kano. Diabetes was the most prevalent underlying systematic condition, affecting 21% of the Ludwig's angina patients in Lagos. Poverty was a common denominator, 90% of the patients from Kano were unemployed compared to 23% and 8% from Lagos and Benin respectively. For most of the patients, the airway was monitored. Incision and drainage were carried out in most of the cases at Benin and Lagos, but it was only considered in 50% of the cases in Kano. Mortality ranged from 4% in Benin to 12% in Lagos and it was as high as 19% in Kano.

CONCLUSION

poor access to oral healthcare, unemployment and low socio-economic status are important predisposing factors of Ludwig's angina.

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.

Microorganisms involved in deep neck infection (DNIs) in Greece: detection, identification and susceptibility to antimicrobials

Background

To determine, from October 2010 to October 2018, the epidemiology of Deep Neck Infections (DNIs), regarding the detection, the identification and the susceptibility to antimicrobials of causative microorganisms, in Thessaly-Central Greece.

Methods

An analysis of data from a prospective database was conducted on 610 consecutive patients with DNIs treated in the Otolaryngology / Head & Neck Surgery Department of University Hospital of Larissa. Demographics, clinical features and microbiological data were analyzed.

Results

Among the 610 patients (1,9/1 male to female ratio, mean age: 39,24 ± 17,25) with DNIs, 579 had a single space (94,9%), while the remaining 31 had a multi-space (5,1%) DNI. The most common areas affected were the peritonsillar space (84,6%) followed by the submandibular space (6,5%). Clinical samples were obtained from 462 patients, and were tested by culture and by the application of 16S rRNA PCR. Two hundred fifty-five samples (55,2%) gave positive cultures, in which Streptococcus pyogenes and Staphylococcus aureus were predominant. The application of the 16S rRNA PCR revealed that 183 samples (39,6%) were positive for bacterial DNA; 22 of them, culture negative, were found to be positive for anaerobic (Fusobacterium necrophorum, Actinomyces israellii etc) and for fastidious microorganisms (Brucella mellitensis, Mycobacterium avium).

Conclusion

DNIs represent a medical and surgical emergency and evidence-guided empirical treatment with intravenous infusion of antibiotics at the time of diagnosis is mandatory, highlighting the importance of epidemiological studies regarding the causative microorganisms. Although, in our study, the predominant pathogens were S. pyogenes and S. aureus, the combination of culture and molecular assay revealed that anaerobic bacteria play also a significant role in the pathogenesis of DNIs. Based on the local epidemiology, we propose as empirical therapy the intravenous use of a beta-lactam /beta-lactamase inhibitor; metronidazole or clindamycin can be added only in specific cases such as in immunocompromised patients.

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.

A Prospective Comparison of Computed Tomography and Magnetic Resonance Imaging as a Diagnostic tool for Maxillofacial Space Infections

Aims and Objectives:

The aim of this work was to assess the advantages and disadvantages of magnetic resonance imaging (MRI) versus computed tomography (CT) in the initial evaluation of maxillofacial space infections by comparing various parameters of the imaging studies and comparing them on a three-point scale.

Materials and Methods:

We prospectively evaluated 15 patients with head and neck space infections. All patients underwent CT and MRI using similar slice thickness. We reviewed all imaging studies with special attention to location, extension, source of infection, extent of bone involvement, odontogenic or nonodontogenic, and presence of gas/calcium in the lesions. All the parameters were graded based on a three-point scale and were compared statistically by paired t-test.

Results:

According to the results we arrived at, MRI was superior to CT in regard to lesion conspicuity, extension, number of anatomic spaces involved, and source on infection. Although not significant, MRI detected a greater number of abscess collections. However, in the aspects of detection of intralesional gas and calcium and motion artifacts, CT was superior to MRI. However, these advantages of CT over MRI are not significantly better than those of MRI.

Conclusion:

MRI was considered superior to CT in the initial evaluation of head and neck space infections. Our study thus concludes that MRI may be used as the primary modality to evaluate patients with head and neck infections when clinically feasible.

Infrahyoid involvement may be a high-risk factor in the management of non-odontogenic deep neck infection: Retrospective study

OBJECTIVES

This study sought to investigate the impact of involvement of the infrahyoid neck space on the management of non-odontogenic DNI.

METHOD

Eighty-one patients treated for non-odontogenic DNI over 5 years were retrospectively recruited into this study. Demographics, etiology, radiology results, treatments, duration/cost of hospital stay, and complications were recorded. Differences between DNIs with and without infrahyoid involvement, as defined based on an anatomical chart, were analyzed.

RESULTS

Sixty-two male and 19 female patients with a median age of 46.22 years were included. Fifteen patients had cellulitis, and 66 patients had abscesses. Streptococcus was the most commonly observed bacterium. Compared with DNIs only in suprahyoid spaces (n = 60, 74.07%), DNIs with infrahyoid space involvement (n = 21, 25.93%) were associated with higher incidences of the involvement of ≥3 spaces (85.71%, P = 0.000), mediastinitis (38.10%, P = 0.000), tracheostomy (28.57%, P = 0.008), surgery using a transcervical approach (66.67%, P = 0.000), and intensive care unit therapy (19.05%, P = 0.004), as well as longer hospital stays (16 days, P = 0.000) and higher costs ($2872, P = 0.000).

CONCLUSION

Infrahyoid involvement should be regarded as a high-risk factor in the management of deep neck infection (DNI). A relatively aggressive plan that includes transcervical surgery and tracheostomy should be considered at earlier stages for DNI with infrahyoid involvement.

A clinical prediction score to determine surgical drainage of deep neck infection: A retrospective case-control study

BACKGROUND

The objective of this retrospective study was to identify predictors of an abscess guaranteed to be surgically drained successfully in patients with deep neck infection (DNI).

MATERIALS AND METHODS

We divided 97 consecutive patients with DNI into a drained group and a non-drained group. We then developed a clinical prediction score and validated it in 32 further patients.

RESULTS

Significant predictors of successful surgical drainage (i.e., positive for pus) were rim enhancement on computed tomography, C-reactive protein, erythrocyte sedimentation rate, and the neutrophil to lymphocyte ratio. The estimated cut-off values (excluding rim enhancement, which is a yes/no parameter) were 41.25, 56.5, and 8.02, respectively, and the clinical prediction score for each of the four other factors was determined to be 2, 2, 3, and 3 points, respectively. The cut-off score for the sum of these points was 6.5 and the scoring system had an accuracy of 87.5% in the validation group.

CONCLUSION

Our clinical prediction scoring system can predict whether drainage is successful in patients with DNI.

Neck abscess: 79 cases

OBJECTIVE

Neck abscess is a disease that might cause mortality and severe morbidity, if it is not treated urgently. In our study, patients with diagnosis of neck abscess in our clinic were analyzed retrospectively and presented in the light of the literature.

METHODS

In our clinic, age distribution, source of infection, systemic disease, imaging methods that were used in diagnosis, preferred anaesthesia during drainage, abscess sites, culture results of abscess material, complications during treatment procedure, any antibiotherapy before admission and duration of hospitalization of 79 cases with neck abscess who were treated in the hospital between January 2008 and January 2015 were assessed.

RESULTS

Cases in our study were aged between 1-79 (mean 28.3) years and 43 of them were female and 36 were male patients. Systemic diseases were determined in 19 of the cases. The most common systemic disease was diabetes mellitus. Abscesses were localized mostly at peritonsillar region and 13 of the cases were operated when abscess were in multipl localizations. In 74 of the cases, drainage was performed under local anaesthesia and in 5 cases under general anaesthesia. Four of these 5 cases, abscesses were localized within retropharyngeal region and 1 of them had multiple abscesses at various regions. Staphylococcus aereus was the most detected microorganism based on culture results. Three adult cases were followed up in the intensive care unit because of development of mediastinitis. One of these 3 cases exited because of sepsis. Hospitalization periods of 79 cases ranged between 2-21 days (mean 7.64 days). Hospitalization period of 19 cases with systemic diseases were 9.47 days (p<0.05) and statistically which were statistically significantly longer when compared with those without any systemic disease.

CONCLUSION

Neck abscess must be diagnosed early and treated with surgical drainage and parenteral therapy because it might cause severe complications.

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.

Images of deep neck space infection and the clinical significance

BACKGROUND

Deep neck infection is not difficult to diagnose clinically, but correct localization of the involved space for timely incision and drainage is not easy without assistance of imaging.

PURPOSE

To investigate the images of deep neck space infection of phlegmon and abscess and the role of imaging examination in correct localization and treatment.

MATERIAL AND METHODS

Between June 2004 and June 2010, 28 patients were diagnosed with deep neck infection (14 men, 14 women; age range, 17-72 years; mean age, 46 years). Clinical presentations included neck swelling, pain, dysphagia, fever, and elevated white blood cell count. Of the 28 cases, 20 had computed tomography (CT) scans, 18 had magnetic resonance imaging (MRI) examinations, and 10 had both CT and MRI.

RESULTS

All 28 patients were confirmed by CT and/or MRI to have deep neck infection, with 11 cases in the retropharyngeal space, five in the parapharyngeal space, four in the masseteric space, and eight in multiple spaces. Thirteen cases had abscesses that were successfully treated with incision and drainage under CT guidance in combination with large doses of antibiotics, and 15 had phlegmon managed with large doses of antibiotics. Followed up for 5-20 months, all patients recovered completely. Two patients were confirmed by imaging examination to have retropharyngeal infection spreading to the superior mediastinum with abscess formation and another two patients had multiple space infection because inappropriate puncture or incision for drainage without imaging guidance in these patients caused the spread of infection. Clinical diagnosis was not accurate with only 12 patients (42.9%) being correctly diagnosed of the exact deep neck space involved before imaging confirmation. CT and/or MRI made the correct diagnosis in all 28 patients. CT and/or MRI also directly changed the treatment plan in seven patients and contributed to the recovery of these patients.

CONCLUSION

CT and MRI play a crucial role in both the diagnosis and correct puncture and incision for drainage of the deep neck space infection.

Orbital fracture leading to severe multifascial space infection including the parapharyngeal space: a report of a case and review of the literature

Orbital trauma can result in periorbital and orbital infections. Orbital infections have been classified by Chandler et al in 1970 to their anatomic location and boundaries. This case report describes a patient who developed a severe orbital infection following orbital fractures. The infection progressed to the parapharyngeal space. The patient required multiple incision and drainage surgeries and tissue debridements to have clinical resolution. To our knowledge, there has not been a case described in the literature of an orbital infection progressing to the parapharyngeal space. A literature review of orbital trauma leading to infection discusses the pathogenesis of the infections. This case demonstrates that close clinical follow-up and appropriate medical management of comorbidities that put a patient at higher risk of developing an infection is of the utmost importance in the treatment of maxillofacial trauma patients.

Characteristics of deep neck infection in children according to weight percentile

Objectives

To evaluate the effect of weight percentile on deep neck infections in children.

Methods

A retrospective evaluation of 79 patients who were treated for deep neck infections. The patients were divided into six groups according to weight percentile. Patients who had systemic and/or congenital disease were excluded. Their demographics, etiology, localization, laboratory, and treatment results were reviewed.

Results

In total, 79 pediatric patients were recorded: 48.1% were females and 51.9% were males, with a mean age of 7.3 years. In total, 60 patients were under the 50th percentile according to their weight versus all children. The anteroposterior triangle (29.1%) and submandibular (26.5%) spaces were most commonly involved with deep neck infection. However, the anteroposterior triangle space was the highest in the group below the 3rd percentile (44.4%). In the blood analysis, white blood cell levels in patients with at percentile values of 75-50 were higher than other groups (P<0.05). Significant differences were found between C-reactive protein and hemoglobin levels and diameter of abscesses. The need for surgical drainage in patients in lower percentiles was higher. The patients who needed surgical drainage consisted of 56 patients (93.3%) below the 50th percentile and 9 patients (100%) below the 3rd percentile.

Conclusion

Deep neck infection is more insidious and dangerous in low-weight-percentile children, especially those having low white blood cell counts, low hemoglobin levels, and high C-reactive protein in laboratory results.

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.

Management of intratonsillar abscess in children

BACKGROUND

The aim of this study was to assess outcomes of medical and surgical treatment of intratonsillar abscess in children.

METHODS

The medical charts of children with intratonsillar abscess were reviewed to obtain information on history and physical examination, imaging, management, and follow-up assessment.

RESULTS

Eleven children (six male, five female; age range, 4-18 years) were identified. The common complaints included sore throat, fever, and odynophagia. Asymmetric tonsil hypertrophy was present in nine patients and erythema of tonsils in all patients. Peritonsillar fullness was present in three patients. One patient needed emergency intubation due to respiratory compromise. Computed tomography indicated unilateral intratonsillar abscess in nine patients, bilateral intratonsillar abscess in one, and unilateral phlegmon in one. Inflammatory changes were observed in the parapharyngeal space in all patients, retropharyngeal space in one, and pyriform sinus and aryepiglottic folds in two. Antibiotic treatment included clindamycin in seven patients, ampicillin/sulbactam in one, and clindamycin plus ceftriaxone in three. The patients with respiratory compromise underwent surgery prior to antibiotic treatment. Patients with isolated intratonsillar abscess or phlegmon had resolution of their symptoms with i.v. antibiotic treatment. Patients with combination of intratonsillar and peritonsillar abscess required incision and drainage of peritonsillar abscess.

CONCLUSIONS

Clinically stable children with intratonsillar abscess or phlegmon respond to i.v. antibiotic therapy. Surgical drainage can accomplish clinical resolution in the presence of a combination of intra- and peri-tonsillar abscess, airway compromise, or unresponsiveness to medical treatment.

CT differentiation of abscess and non-infected fluid in the postoperative neck

BACKGROUND

Differentiation of postoperative neck abscess from non-infected fluid is important because the treatment is different.

PURPOSE

To determine specific CT findings that might help to differentiate abscesses from non-infected fluid collections in the postoperative neck.

MATERIAL AND METHODS

We retrospectively reviewed CT scans of 50 patients (43 men and 7 women; mean age, 62.5 ± 8.9 years) who had postoperative fluid collections in the neck (26 abscesses and 24 non-infected fluid collections). Diagnosis of an abscess was determined by a positive bacteria culture from the fluid collection. Diagnoses were correlated with the following CT findings: anatomic spaces involved, the maximum transverse diameter, margin, attenuation, rim enhancement, gas bubbles, and manifestations of soft tissue adjacent to a fluid collection.

RESULTS

Rim enhancement pattern and soft tissue manifestations showed significant differences between abscess and non-infected fluid. The reliable CT findings for abscess were: (i) rim enhancement > 50% of the circumference, 54% sensitive, 71% specific, and 62% accurate; and (ii) severe soft tissue manifestations, 39% sensitive, 92% specific, and 64% accurate. There were no significant differences in the anatomic spaces involved, the maximum transverse diameter, margin, attenuation, and gas bubbles between abscess and non-infected fluid.

CONCLUSION

CT findings that may help differentiate postoperative neck abscess from non-infected fluid were rim enhancement > 50% of the circumference and severe soft tissue manifestations.

Antibiotic therapy for pediatric deep neck abscesses: a systematic review

OBJECTIVE

To evaluate the current evidence regarding the safety and efficacy of medical management for deep neck abscesses in children.

DATA SOURCES

Pubmed and Embase databases accessed 3/27/2012.

REVIEW METHODS

An a priori protocol defining inclusion and exclusion criteria was developed to identify all articles addressing medical therapy of pediatric deep neck abscesses where details regarding diagnostic criteria, specifics of medical therapy and definitions of failure were presented. The search included electronic databases to identify candidate articles as well as a manual crosscheck of references. The level of evidence was assessed and data extracted by three authors independently. Data were pooled using a random effects model due to significant study heterogeneity.

RESULTS

Eight articles met inclusion criteria. The overall level of evidence was grade C. There was significant heterogeneity among the studies (I(2)=98.8%; p<.001). However, each article uniformly presented cases suggesting that medical therapy may be a viable alternative to surgical drainage in some patients. The pooled success rate of medical therapy in avoiding surgical drainage in children with deep neck infections was 0.517 (95%CI: 0.335, 0.700). When patients taken immediately to surgery were excluded and patients were placed on author defined medical protocols, the success rate increased to 0.951 (95%CI: 0.851, 1.051). Subgroup analysis by duration of intravenous antibiotic trial greater than 48h demonstrated a pooled success rate of 0.740 (95%CI: 0.527, 0.953).

CONCLUSION

The current literature suggests medical management may be a safe alternative to surgical drainage of deep neck abscesses in children. However, the level of evidence lacks strength and further investigation is warranted.

Accuracy of ultrasonography versus computed tomography scan in detecting parapharyngeal abscess in children

OBJECTIVE

Significant morbidity and rarely mortality have been described in parapharyngeal space infections in children; hence, the decision on the timing of surgical intervention might be crucial. The aim of this study was to compare the accuracy of plain x-rays, ultrasonography (US), and contrast-enhanced computed tomography (CT) in demonstrating a parapharyngeal abscess.

METHODS

A retrospective study on all patients with parapharyngeal abscess admitted and operated on from January 1996 to December 2000 was carried out. Charts were reviewed for patients' demographics, symptoms and signs, details of workup, intraoperative findings, and culture results. The CT scans were reviewed for the presence of a rim enhancement, a presence of a definable wall, and fluid-fluid level and were correlated with the plain x-rays and US results and intraoperative findings.

RESULTS

Eighteen patients with proven parapharyngeal infection were included: 10 with proven abscess and 8 with cellulitis. The sensitivity and specificity of lateral neck radiograph and US were low compared with a specificity of 87.5 while evaluating fluid-fluid level seen on the CT scan, sensitivity of 58.3% for the presence of a definable abscess wall, and a sensitivity of 100% for the presence of a prominent wall.

CONCLUSIONS

Our study demonstrates good rates of accuracy of CT scan for diagnosing a parapharyngeal abscess. Our study suggest that it is appropriate to obtain a CT scan upon presentation in all children with suspected parapharyngeal abscess and that a CT scan is proven to be a useful diagnostic tool in establishing a treatment plan.

Ludwig's Angina-A Controversial Surgical Emergency: How We Do It

Objectives. To review the current protocols used for management of Ludwig's angina and to assess the efficacy of conservative measures in these cases. Methods. A retrospective review of patients who were admitted to our institution for management of Ludwig's angina between 2003 and 2010. Results. Two patients were identified. Both were managed successfully with conservative measures and close airway observation. None needed an emergency intubation or surgical tracheostomy. There were no mortalities, and both had a short hospital stay. Conclusion. Recently, management of Ludwig's angina has evolved from aggressive airway management into a more conservative one. This is based on close airway observation on a specialised airway unit and a serial clinical airway assessment. Improved imaging modalities, antibiotic therapy, surgical skills, and clinical experience are the key factors behind this change in practice.

A pain in the neck--imaging in neck sepsis

Deep neck infection has a high morbidity and mortality and the extent of infection is often difficult to estimate clinically. The complex anatomy and the communication between neck spaces means that infection can spread along fascial planes leading to life-threatening complications such as airway compromise, vascular erosion/thrombosis, neural dysfunction, and ultimately descending necrotizing mediastinitis. Imaging has an important role to play in identifying the extent of infection and the presence of complications.

Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses

Peritonsillar, retropharyngeal, and parapharyngeal abscesses are the most common deep cervical fascial space infections. Most develop secondary to an oropharyngeal or dental infection. Additional factors such as smoking and periodontal disease may also contribute to the formation of a peritonsillar abscess. The CT scan is used to confirm the presence of deep neck abscesses, but its accuracy has some limitations. Adequate drainage with accompanying antimicrobial therapy and hydration are the cornerstones of management. Catheter or needle drainage of these abscesses may provide an alternative to open procedures and is the drainage method of choice for peritonsillar abscesses. However, in selected cases, medical therapy alone, especially in children, can resolve parapharyngeal and hypopharyngeal abscesses. Ancillary use of steroids reduces morbidity in patients with a peritonsillar abscess and there is a limited but useful place for immediate tonsillectomy in the treatment of this disease.

Deep space neck infection: principles of surgical management

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

Peritonsillar abscess with parapharyngeal and retropharyngeal involvement: incidence and intraoral approach

CONCLUSION

This study illustrates common sites of infection seen in peritonsillar abscesses with involvement of the pharyngeal space and retropharyngeal space. Abscesses behind and/or inferior to the tonsil were encountered more frequently than expected. In these cases, the drainage had to be placed in the inferior pole of the tonsil and these types were frequently seen in older patients.

OBJECTIVES

The aim of this study was to assess to what extent abscesses spread in patients with peritonsillar abscess and to determine to what extent pus can be drained intraorally.

PATIENTS AND METHODS

The clinical charts of 45 patients with peritonsillar abscess involvement of the parapharyngeal space and/or retropharyngeal space were retrospectively reviewed.

RESULTS

In 45 cases, 21 patients were diagnosed with the superior type, and we could drain the pus intraorally in 90% of the patients. On the other hand, 24 cases were diagnosed with the inferior type and they were drained intraorally in 58% of the cases.

Management of pediatric lateral neck infections: Does the adage "... never let the sun go down on undrained pus ..." hold true?

OBJECTIVES

Pediatric neck infections are frequently treated by Otolaryngologists, Head and Neck surgeons. The relative role of medical versus surgical treatment of pediatric neck infections is debated. The aims of this study are to analyze the management of pediatric neck infections with respect to clinical assessment, radiological assessment and treatment.

METHODS

Medical records from January 1999 to June 2005 were reviewed and analyzed.

RESULTS

Two hundred and five children with lateral neck infections were included in the study. The clinical diagnosis correlated with the radiology finding in 73.6% with a sensitivity of 28% and a specificity of 92% for lateral neck abscess recognition. The ultrasound finding correlated with the surgical finding in 65.2% with a sensitivity of 70% and a specificity of 33%. When an ultrasound scan was used it changed the intended treatment plan in 10.5% of children.

CONCLUSIONS

Accurate clinical assessment of lateral neck infections is poor, generally under estimating suppuration. However, when an abscess is diagnosed clinically this correlates highly with the surgical finding. Radiological assessment has inaccuracy in identifying suppuration and this should be borne in mind when being used as a diagnostic tool for neck infections.

Parapharyngeal Abscess: Comprehensive Management Protocol

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

Cervical infection with descending mediastinitis: a review of six cases

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

Severe odontogenic infections, part 1: prospective report

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Severe odontogenic infections, part 2: prospective outcomes study

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Clindamycin in dentistry: More than just effective prophylaxis for endocarditis?

Clindamycin is a broad-spectrum antibiotic with activity against aerobic, anaerobic, and beta-lactamase-producing pathogens. This antibiotic has been used for many years as prophylactic treatment during dental procedures to prevent endocarditis. However, the spectrum and susceptibility of the bacteria species involved in dental infections indicate that clindamycin would also be an effective treatment option for these conditions. In addition to its antiinfective properties, clindamycin has high oral absorption, significant tissue penetration, including penetration into bone, and stimulatory effects on the host immune system. This review discusses the microbiologic and clinical evidence supporting the efficacy and safety of clindamycin for the successful management of dental infections.

Use of interventional radiology in the management of mediastinitis of odontogenic origin

Descending necrotising mediastinitis is a rare complication of odontogenic infection. The key to diagnosis is to maintain a high index of suspicion when antibiotics and adequate surgical drainage do not lead to resolution of symptoms. Open thoracic operation to drain mediastinal collections is potentially lethal and interventional radiological techniques are thought to reduce mortality. We report the use of interventional radiology in the diagnosis, monitoring and treatment of this condition and illustrate our experience with three case reports.

Deep neck infection: Analysis of 185 cases

PURPOSE

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

METHODS

A retrospective review was conducted of patients who were diagnosed as having deep neck infections in the Department of Otolaryngology at National Taiwan University Hospital from 1997 to 2002. Their demographics etiology, associated systemic diseases, bacteriology, radiology, treatment, duration of hospitalization, complications, and outcomes were reviewed. The attributing factors to deep neck infections, such as the age and systemic diseases of patients, were also analyzed.

RESULTS

One hundred eighty-five charts were recorded; 109 (58.9%) were men, and 76 (41.1%) were women, with a mean age of 49.5 +/- 20.5 years. Ninety-seven (52.4%) of the patients were older than 50 years old. There were 63 patients (34.1%) who had associated systemic diseases, with 88.9% (56/63) of those having diabetes mellitus (DM). The parapharyngeal space (38.4%) was the most commonly involved space. Odontogenic infections and upper airway infections were the two most common causes of deep neck infections (53.2% and 30.5% of the known causes). Streptococcus viridans and Klebsiella pneumoniae were the most common organisms (33.9%, 33.9%) identified through pus cultures. K. pneumoniae was also the most common infective organism (56.1%) in patients with DM. Of the abscess group (142 patients), 103 patients (72.5%) underwent surgical drainages. Thirty patients (16.2%) had major complications during admission, and among them, 18 patients received tracheostomies. Those patients with underlying systemic diseases or complications or who received tracheostomy tended to have a longer hospital stay and were older. There were three deaths (mortality rate, 1.6%). All had an underlying systemic disease and were older than 72 years of age.

CONCLUSIONS

When dealing with deep neck infections in a high-risk group (older patients with DM or other underlying systemic diseases) in the clinic, more attention should be paid to the prevention of complications and even the possibility of death. Early surgical drainage remains the main method of treating deep neck abscesses. Therapeutic needle aspiration and conservative medical treatment are effective in selective cases such as those with minimal abscess formation.