Abstract
Objectives
Before the widespread use of antibiotics, most deep neck infections (DNIs) stemmed from complicated pharyngeal infections. Nowadays, they seem to be due mainly to dental infections. In 2010, our group reported that DNIs originated from a major salivary gland in 14% of cases. The main endpoint of the present investigation was to review our experience of the diagnosis and treatment of DNIs of salivary gland origin. We also compared the characteristics of DNIs originating from salivary glands with those originating elsewhere.
Methods
Between 2000 and 2011, 44 patients were treated for DNIs of salivary origin at our institution. These patients were compared with 191 cases of DNI diagnosed as having other sites of origin.
Results/conclusions
In the present series, DNIs originating from a major salivary gland accounted for 19% of all cases of DNI of known origin. Patients with DNI of salivary gland origin were more likely to be elderly than those whose DNI originated from elsewhere (p = 0.000). Our multivariate statistical model showed that comorbidities (p = 0.051, statistical trend) and the need for surgical treatment (p = 0.028) independently predicted long-term hospitalization for DNIs originating from a major salivary gland.
1
Introduction
Sialoadenitis is a general term describing acute, chronic, or recurrent infectious and/or inflammatory conditions affecting the salivary glands. Pathogens can spread to the salivary gland as a result of combinations of factors that favor the ascension of oral bacteria through the salivary ducts (including Stensen’s and Wharton’s ducts). Although such processes can occur in any of the major or minor salivary glands, they most often affect the parotid and submandibular glands .
Before the widespread use of antibiotics, several studies showed that most deep neck infections (DNIs) (70%–80%) stemmed from complicated pharyngeal infections , but nowadays there is ample evidence of a declining incidence of DNIs of pharyngotonsillar onset. On the other hand, despite worldwide improvements in dental care and oral hygiene, Parhiscar and Har-El described a significant prevalence of DNIs caused by dental infections (43%). More recently, Stalfors et al. , and our own group confirmed a high incidence of DNIs due to dental infection (49% and 41%, respectively). In 2010, analyzing a consecutive series of DNIs, our group concluded that 14% of these cases had a major salivary gland as their site of origin .
The main endpoint of the present investigation was to critically review our experience in the diagnosis and treatment of DNIs originating from a major salivary gland. Secondary aims were: (i) to analyze the variables relating to the prognosis for DNIs of salivary gland origin using univariate and multivariate statistical models; and (ii) to compare the demographic, clinical, radiological, and prognostic characteristics of DNIs originating from a major salivary gland as opposed to elsewhere.
2
Materials and methods
2.1
Patients
The present investigation was approved by the internal committee of our Otolaryngology Section. All available records concerning patients treated for DNI between April 2000 and December 2011 at the Otolaryngology Section, Department of Neurosciences, University of Padova (an academic tertiary referral center) were reviewed. The patients’ treatments were based on clinical findings (oral cavity exploration, upper aerodigestive tract endoscopy), radiological examination (contrast-enhanced computerized tomography [CT], magnetic resonance imaging [MRI], ultrasonography, mandible orthopantomography), and laboratory and microbiological evidence. Patients with peritonsillar abscesses, superficial infections, infections due to external (traumatic or surgical) neck injuries, infections in head and neck tumors, or active neoplastic diseases were excluded.
Among the cases reviewed, for the present study we only considered patients whose clinically and instrumentally established site of origin of their DNI was a major salivary gland. Over the period considered, 44 patients (23 males, 21 females; mean age 62.0 ± 18.8 years; median age 66 years) were admitted and treated at our institution for DNIs originating from a major salivary gland, which was submandibular in 38 cases ( Fig. 1 A, B, C ), and parotid in 6 ( Fig. 2 A, B, C ). Twenty-four patients were at least 65 years old (55.8% of the patients with available data).
The above patients were compared with a group comprising the other patients treated at our institution during the same period for DNIs of non-salivary origin. Cases of DNI of uncertain or unknown origin were ruled out. This second group consisted of 191 patients (114 males, 77 females; mean age 44.5 ± 18.5 years; median age 40 years). In 103 cases the DNI was of dental origin, while 53 originated from the oropharynx, 19 from an infected cyst in the ENT region, 11 from the hypopharynx, and 5 from other ascertained origins. Table 1 shows the main features of this group of patients treated for DNIs of non-salivary origin.
| Variables | DNIs of salivary gland origin No.(%) | DNIs originating elsewhere No.(%) | Odds ratio (95% confidence interval) | p-value |
|---|---|---|---|---|
| Main symptoms, no. (%) | ||||
| Neck pain | 23 (52.3) | 88 (46.1) | 1.28 (0.66–2.47) | 0.510 ⁎ |
| Odynophagia | 13 (29.6) | 103 (53.9) | 0.35 (0.18–0.72) | 0.004 ⁎ |
| Dysphagia | 14 (31.8) | 81 (42.4) | 0.63 (0.32–1.27) | 0.234 ⁎ |
| Main signs, no. (%) | ||||
| Fever | 15 (34.1) | 90 (47.1) | 0.58 (0.29–1.15) | 0.132 ⁎ |
| Neck swelling | 33 (75.0) | 137 (71.7) | 1.18 (0.56–2.51) | 0.713 ⁎ |
| Trismus | 10 (22.7) | 69 (36.1) | 0.52 (0.24–1.11) | 0.111 ⁎ |
| Other features, no. (%) | ||||
| Elderly patients | 24 (55.8) | 34 (17.8) | 5.83 (3.00–11.33) | 0.000 ⁎ |
| Male sex | 23 (52.3) | 114 (59.7) | 0.74 (0.38–1.43) | 0.395 ⁎ |
| Antibiotic treatment before admission | 30 (68.2) | 128 (67.0) | 1.05 (0.52–2.13) | 1.000 ⁎ |
| Steroid treatment before admission | 10 (22.7) | 52 (27.2) | 0.79 (0 36–1.71) | 0.705 ⁎ |
| Presence of comorbidities | 27 (61.4) | 58 (30.4) | 3.64 (1.89–7.03) | 0.000 ⁎ |
| Mean number of comorbidities per patient ± standard deviation | 1.05 ± 1.28 | 0.38 ± 0.71 | – | 0.000 ⁎⁎ |
| Leucocytosis | 22 (51.2) | 113 (62.4) | 0.63 (0.32–1.23) | 0.225 ⁎ |
| More than one neck site involved | 13 (29.6) | 57 (29.8) | 0.99 (0.48–2.02) | 1.000 ⁎ |
| Presence of complications | 4 (9.1) | 16 (8.4) | 1.09 (0.35–3.46) | 0.773 ⁎ |
| Surgical treatment | 21 (47.7) | 132 (69.1) | 0.41 (0.21–0.79) | 0.007 ⁎ |
| Mean hospital stay ± standard deviation(days) | 8.2 ± 4.3 | 7.9 ± 5.8 | – | 0.136 ⁎⁎ |
2.2
Statistical analyses
The statistical methods applied for our univariate analysis of DNIs of salivary origin were Fisher’s exact test and the Mann–Whitney U test, as appropriate.
The multivariate statistical analysis was performed by applying the logistic regression model to calculate the odds ratio (OR) for each variable considered, and identifying significant independent predictors of long-term hospitalization (> 7 days, which was the median hospital stay for our series of DNIs originating from major salivary glands). The adequacy of the models derived was checked for multicollinearity and goodness of fit. A p-exclusion value of P < 0.10 in Fisher’s exact test was adopted and a final multivariate model was generated.
For the comparison between the two groups (DNIs of salivary gland vs other origins), the statistical methods applied were Fisher’s exact test and the Mann–Whitney U test, as appropriate.
A p value < 0.05 was considered significant, while values in the range of 0.10 ≤ p ≤ 0.05 were assumed to indicate a statistical trend. The STATA 8.1 (Stata Corp, College Station, TX) statistical package was used for all analyses.
2
Materials and methods
2.1
Patients
The present investigation was approved by the internal committee of our Otolaryngology Section. All available records concerning patients treated for DNI between April 2000 and December 2011 at the Otolaryngology Section, Department of Neurosciences, University of Padova (an academic tertiary referral center) were reviewed. The patients’ treatments were based on clinical findings (oral cavity exploration, upper aerodigestive tract endoscopy), radiological examination (contrast-enhanced computerized tomography [CT], magnetic resonance imaging [MRI], ultrasonography, mandible orthopantomography), and laboratory and microbiological evidence. Patients with peritonsillar abscesses, superficial infections, infections due to external (traumatic or surgical) neck injuries, infections in head and neck tumors, or active neoplastic diseases were excluded.
Among the cases reviewed, for the present study we only considered patients whose clinically and instrumentally established site of origin of their DNI was a major salivary gland. Over the period considered, 44 patients (23 males, 21 females; mean age 62.0 ± 18.8 years; median age 66 years) were admitted and treated at our institution for DNIs originating from a major salivary gland, which was submandibular in 38 cases ( Fig. 1 A, B, C ), and parotid in 6 ( Fig. 2 A, B, C ). Twenty-four patients were at least 65 years old (55.8% of the patients with available data).
