Abstract
Purpose
The purpose of this study is to review our recent experience with deep neck infections and emphasize the importance of radiologic evaluation and appropriate treatment selection in those patients.
Materials and Methods
The records of 173 patients treated for deep neck infection at the Department of Otolaryngology and Head and Neck Surgery of Dicle University Hospital during the period from 2003 to 2010 were retrospectively reviewed. Their demography, symptoms, etiology, seasonal distribution, bacteriology, radiology, site of deep neck infection, durations of the hospital admission and hospital stay, treatment, complications, and outcomes were evaluated. The findings were compared to those in the available literature.
Results
Dental infection was the most common cause of deep neck infection (48.6%). Peritonsillar infections (19.7%) and tuberculosis (6.9%) were the other most common cause. Pain, odynophagia, dysphagia, and fever were the most common presenting symptoms. Radiologic evaluation was performed on almost all of the patients (98.3%) to identify the location, extent, and character (cellulitis or abscesses) of the infections. Computed tomography was performed in 85.3% of patients. The most common involved site was the submandibular space (26.1%). In 29.5% of cases, the infection involved more than one space. All the patients were taken to intravenous antibiotic therapy. Surgical intervention was required in 95 patients (59.5%), whereas 78 patients (40.5%) were treated with intravenous antibiotic therapy alone. Life-threatening complications were developed in 13.8% of cases; 170 patients (98.3%) were discharged in stable condition.
Conclusion
Despite the wide use of antibiotics, deep neck space infections are commonly seen. Today, complications of deep neck infections are often life threatening. Although surgical drainage remains the main method of treating deep neck abscesses, conservative medical treatment are effective in selective cases.
1
Introduction
Deep neck space infection (DNI) means infection in the potential spaces and fascial planes of the neck, either with abscess formation or cellulitis . Despite the prevalence and the complications incidence of DNI has been diminished with improved diagnostic techniques and widespread availability of antimicrobial therapy, these infections are still serious and potentially life threatening today as in the past. The DNIs may arise from several focuses in the head and neck, including teeth, adenotonsillar tissue, and salivary glands . The origin of DNI is different in many publications. In the preantibiotic era, most of DNIs arose from tonsillitis or pharyngitis . Today, dental infections are the most common causes of DNI . The DNIs are generally polymicrobial. Streptococci, Peptostreptococcus spp, Staphylococcus aureus and anaerobes are the organisms most commonly cultured from deep neck abscesses . The main complications include respiratory obstruction, mediastinitis, pleural empyema, pericarditis, jugular vein thrombosis, and septic shock . Complications can even result in death . The advent of modern imaging techniques has made it possible to diagnose these complications earlier and to localize them exactly . Management of deep neck infections has usually been based on prompt surgical drainage of purulent abscesses through an external approach or nonsurgical treatment with on the basis of appropriate antibiotics . The purpose of this study is to review our recent experience with DNI and emphasize the importance of radiologic evaluation and appropriate treatment selection in those patients.
2
Materials and methods
In this study, the records of 173 patients treated for DNI at the Department of Otolaryngology and Head and Neck Surgery of Dicle University Hospital between January 2003 and August 2010 were retrospectively reviewed. Their demography; symptoms; etiology; seasonal distribution; bacteriology; radiology; site of deep neck infection; durations of the hospital admission; and hospital stay, treatment, complications, and outcomes were evaluated. The findings were compared to those in the available literature.
2
Materials and methods
In this study, the records of 173 patients treated for DNI at the Department of Otolaryngology and Head and Neck Surgery of Dicle University Hospital between January 2003 and August 2010 were retrospectively reviewed. Their demography; symptoms; etiology; seasonal distribution; bacteriology; radiology; site of deep neck infection; durations of the hospital admission; and hospital stay, treatment, complications, and outcomes were evaluated. The findings were compared to those in the available literature.
3
Results
There were 80 (46.2%) male and 93 (53.8%) female patients, with a female-to-male ratio of 1.16/1. The mean age was 25.1 years (±15.5) (range, 3–69 years) ( Fig. 1 ). The duration of admission ranged from 2 to 33 days with an average of 6.6 ± 4.7 days.
The seasonal distribution of patients presenting with deep neck infections: autumn (43.4%), summer (24.3%), spring (16.8%), and winter (15.6%) ( Fig. 2 , Table 1 ).
| Origin | Seasons | Total | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Spring | Summer | Autumn | Winter | ||||||
| No. of cases | % | No. of cases | % | No. of cases | % | No. of cases | % | ||
| Dental | 15 | 17.9 | 24 | 28.6 | 31 | 36.9 | 14 | 16.7 | 84 |
| Tonsil | 5 | 14.7 | 6 | 17.6 | 15 | 44.1 | 8 | 23.5 | 34 |
| Tuberculosis | 0 | .0 | 2 | 16.7 | 10 | 83.3 | 0 | .0 | 12 |
| Unknown | 7 | 24.1 | 4 | 13.8 | 14 | 48.3 | 4 | 13.8 | 29 |
| Salivary gland | 1 | 10.0 | 5 | 50.0 | 4 | 40.0 | 0 | .0 | 10 |
| Thyroid | 1 | 100.0 | 0 | .0 | 0 | .0 | 0 | .0 | 1 |
| Neck cyst | 0 | .0 | 1 | 33.3 | 1 | 33.3 | 1 | 33.3 | 3 |
| Total | 29 | 16.8 | 42 | 24.3 | 75 | 43.4 | 27 | 15.6 | 173 |
Pain was present in almost all cases. After pain, the other common complaint was neck swelling (66%), odynophagia (48%), dysphagia (44%), fever (35%), dysphonia (28%), trismus (27%), otalgia (13%), dyspnea (12%), and draining fistulas in the neck (2%).
Physical examination revealed that 77 patients (45%) had fever (>37.5°C). The white blood cell (WBC) count was higher than 10 000 cells/mm 3 (cells per cubic millimeter) in 98 cases (56%). In addition, 57 patients (33%) had a WBC count of more than 15 000 cells/mm 3 , and 23 patients (15%) had a WBC count of more than 20 000 cells/mm 3 .
Considering clinical and radiological evidence, the causes of deep neck infections were identified in 144 patients (83.2%). The most common cause of deep neck infection was odontogenic (84 cases, 48.6%). Odontogenic causes were diagnosed through dental consultations. Orthopantograms of the mandible were obtained in 26 cases. The second most common cause of deep neck infection was peritonsillar abscess (34 cases, 19.7%). In 12 patients, the abscess was caused by tuberculosis (6.9%), and in 10 patients, an infected salivary glands were found (5.8%). In 3 patients, abscess was caused by branchial cleft cyst (1.7%), and in 1 patient, caused by thyroiditis (0.6%). In the remaining 29 patients (16.8%), the origin of the DNI remained unclear. The etiology of deep neck infections is recorded in Fig. 3 .
There were 4 patients (2.3%) with diabetes mellitus (DM) in our study. There was no case of known liver, lung, kidney disease or malignancies, trauma, intravenous drug abuse, or immunodeficiency.
The results of bacterial cultures were available for 34 of the 96 cases who underwent surgical treatment or needle aspiration (35.4%). Anaerobic and aerobic cultures were obtained. Anaerobes account for 5 (14.7%) of the positive cultures. The cultures of 20 patients (58.8%) were polymicrobial. The most common bacteries were anaerobic Peptostreptococcus (21.3%), and Staphylococcus epidermidis (19.7%).
Radiologic evaluation was performed almost all of the patients to identify the location, extention, and character (cellulitis or abscesses) of the infections (170 patients, 98.3%). In 28 patients (16.5%), ultrasonography was the only imaging procedure. For 145 DNI patients, computed tomography (CT) was performed (85.3%), and in 14 of those, an additional magnetic resonance imaging also was performed. Neck ultrasonography and magnetic resonance imaging of the neck were performed less relatively to the CT. In 26 patients, orthopantograms of the mandible were indicated.
According to clinical, surgical and imaging findings, 122 (70.5%) had one involved space. The most common one involved site was the submandibular space (26.1%), followed by the peritonsillar space (14.5%), the parapharyngeal space (11.6%), the submental space (10.4%), the retropharyngeal space (3.5%), the parotid space (2.9%), the carotid space (0.5%), the masseter space (0.5%), and the anterior visceral space (0.5%). In 51 patients (29.5%), the infection involved more than one space. If 2 or more spaces were concurrently involved in a significant way, they were classified as extended spaces. The diagnostic criteria of Ludwig’s angina are defined as the simultaneous involvement of the sublingual, submylohyoid, and submental spaces, either as cellulitis or abscesses. Twenty-seven patients (15.6%) were evaluated as Ludwig’s angina, and 24 patients (13.9%) were evaluated as extended spaces. According to clinical and imaging findings, the distribution of involved spaces and sites is recorded in Fig. 4 .
