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DOI 10.1007/s00405-011-1761-1
Received: 2 May 2011 / Accepted: 26 August 2011 / Published online: 14 September 2011
Springer-Verlag 2011
Introduction
The deep neck spaces are regions of loose connective tissue
filling the areas between the three layers of deep cervical
fascia. Deep neck infections (DNIs) are suppurative
infections that develop within deep neck spaces.
Deep neck infections usually starts as cellulitis in the
soft tissues adjacent to the source of upper aero-digestive
tract infection: if left untreated and depending on the virulence of the causative pathogen, the infection will eventually lead to an abscess and spread along cervical into to
the mediastinum [1].
The insidious evolution of this pathology still represents
an open problem. An unsuspecting physician may underestimate an initially localized infection, which could
shortly present as airway collapse or descending
mediastinitis.
In most of cases, the source of the infection is a periapical infection, involving the mandibular second or third
molar teeth, or an acute follicular tonsillitis [2, 3]. The
microbiology of DNIs reflects the normal endogenous
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Results
Demographic and clinical data
A total of 365 adult patients with DNI were identified for
this evaluation. The 365 patients consisted of 205 males
(56.2%) and 160 females (43.8%) ranging in age from 18
to 96 years (median 52).
Patients were symptomatic for a median of 5.5 days
prior to admission to our institution ranged from 1 to
22 days.
On admission neck swelling (n = 340; 93.2%), throat
pain (n = 205; 56.2%), and dysphagia (n = 201; 55.1%)
were the most common symptoms. Other symptoms and
signs included fever (n = 257; 70.4%), swelling of the
upper aero-digestive tract (n = 218; 59.7%), dyspnea
(n = 54; 14.8%), neck stiffness (n = 54; 14.8%), trismus
(n = 51; 14.0%), dysphonia (n = 50; 13.7%), and otalgia
(n = 19; 5.2%).
The total WBC count (median 11.8 9 103/mm3; range
2.533.6 9 103/mm3) was increased above the upper limit
of normal in 171 cases (46.8%), normal in 192 cases
(52.6%), and under the lower limit of normal in two cases.
Neutrophil count (median 8.7 9 103/mm3, range
1.126.9 9 103/mm3, rate of unknown data 16.4%) was
increased above the upper limit of normal in 172 cases
(56.4%), normal in 129 cases (42.3%), and under the lower
limit of normal in 4 cases. Lymphocytic count (median
1.4 9 103/mm3, range 0.16.2 9 103/mm3, rate of
unknown data 16.4%) was decreased under the lower limit
of normal in 76 cases (24.9%), normal in 224 cases
(73.4%), and above the upper limit of normal in 5 cases.
ESR (median 50 mm/h, range 2140 mm/h, rate of
unknown data 26.8%) and CRP concentration (median
17.5 mg/dL, range 245 mg/dL, rate of unknown data
56.2%) were elevated above the upper limit of normal in
260 cases (97.4%) and in all cases, respectively.
Comorbidity
Eighty-two patients (22.5%) had relevant associated systemic disorders including cardiovascular diseases (n = 53),
diabetes mellitus (n = 52), pulmonary diseases (n =
14), liver diseases (n = 13), hematological diseases
(n = 13), renal diseases (n = 5), connective tissue diseases
(n = 3).
Diagnostic investigations
All patients underwent otolaryngological examination with
fiber-optic, b-mode ultrasonography of the neck and/or
contrast-enhanced computed tomography (CECT)/magnetic resonance imaging (MRI) of the neck. CECT and
MRI were performed in 321 (87.9%) and 23 (6.3%)
patients, respectively. 3-mm slides from skull base to the
superior mediastinum were obtained before and after contrast injection using either the spiral or multi-slice technique. The CECT scan was interpreted as demonstrating an
abscess in presence of the enhancing rim around nonenhancing central density consistent with fluid. The initial
CECT scan was extended to include the chest in cases of
suspected descending infection. Acquisition of high-resolution axial scans of the jaw together with curved and orthoradial multiplanar reconstructions was performed in
patients with submandibular space infections and/or suspected odontogenic infection. Follow-up CECT was the
diagnostic procedure of choice to evaluate response to
medical and/or surgical treatment and was performed in
286 cases (78.3%). Overall, the median number of imaging
examinations was two per patient (range 19). No significant differences were found in number of imaging procedures between patients who were immediately operated
and in patients selected for observation (P = 0.670). On
the other hand, a higher number of imaging procedures,
particularly CECT, was performed in patients developing
complications (median 4, range 39).
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Table 1 Site and character of deep neck infections
Involved spaces
No.
cellulitis
No.
abscess
Submandibular
220 (60.3)
108
111
Parapharyngeal
211 (57.8)
88
123
Parotid
48 (13.1)
40
Retropharyngeal
36 (9.9)
10
26
Visceral anterior
29 (7.9)
22
Visceral vascular
12 (3.3)
Masticatory
Prevertebral
11 (3.0)
9 (2.4)
3
1
8
8
3 (0.8)
Temporal
37
Coagulase-negative staphylococcus
33
Staphylococcus aureus
23
Klebsiella pneumoniae
18
Staphylococcus epidermidis
11
Haemophilus influenzae
Streptococcus pneumoniae
11
6
Streptococcus constellatus
Proteus mirabilis
Streptococcus group F
Pseudomonas aeruginosa
Acinectobacter baumanii
Gemella morbillorum
Stenotrophomonas maltophilia
Streptococcus oralis
Microbiology
Microbiological analysis included aerobic anaerobic
cultures and were performed from blood samples, material
Anaerobic
Bacteroides spp
19
Peptostreptococcus spp
15
Fusobacterium spp
Prevotella melaninogenica
Propionibacterium acnes
4
2
Veillonella spp
Others
Candida spp
Aspergillus spp
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Treatment
All patients received empirical broad-spectrum intravenous
antimicrobial therapy on admission in order to eradicate
both aerobic and anaerobic microorganisms. The first-line
therapy was later modified according to microbiological
findings if the isolated microorganisms revealed resistance towards the empiric therapy. The most frequently
provided treatment regimens, alone or in combination,
were amoxicillin/clavulanate potassium (58.9%), secondand third-generation cephalosporins (37.3%), ampicilline/
sulbactam (12.9%), clindamicyn (11.4%), metronidazole
(3.6%), and vancomycin (2.4%).
Patients who were clinically unstable (airway obstruction,
signs and symptoms of sepsis); patients with descending
infection; patients with anterior visceral space involvement,
with abscess involving more than two deep neck spaces; and
patients with abscess larger than 3.0 cm, underwent immediate surgical drainage. Gas-forming infections were not in
itself an absolute indication for immediate surgery unless
large amount of tissue were involved. In all the other cases,
patients were observed for 48 h. If the patients symptoms
and signs worsened or if no clinical improvement was noted
after 48 h, surgical drainage was performed. On the other
hand, if clinical response was seen, a radiographic study was
repeated to confirm clinical judgment. If the repeat imaging
did not confirm a regression of collection of pus, surgical
intervention was anyway considered. In selected cases,
therapeutic needle aspiration of abscess was considered an
alternative to conventional open surgery.
One-hundred and thirty-nine patients (38.1%) underwent surgical drainage. Of the abscess group (n = 213),
111 patients (52.1%) underwent surgical drainage. Of the
cellulitis group (n = 152), 28 patients (18.4%) underwent
surgical drainage.
In 112 cases (30.7%), an open surgical drainage was
performed under general anesthesia. An exclusively
transoral approach was used in 21 cases. An external or
combined approach was necessary in 91 patients. In all
cases, a wide exposure of the abscess cavity was performed
including blunt avulsion of any loculations, the devitalized
tissue was debrided, and the wound was irrigated with halfstrength hydrogen peroxide. In patients with extensive
tissue necrosis, the cervical incision was packed with plain
gauze and left open to allow oxygenation of the tissue and
daily irrigations with antiseptic solutions. In other cases,
wounds were closed after placement of large-bore drains
for irrigation. Twenty-seven patients (7.4%) underwent
needle aspiration of abscess, with CT-scan guidance in five
cases. Intraoperative findings confirmed the CECT diagnosis of abscess in 87.1%. Duration of symptoms (\5 days
vs. C5 days) was not found to be predictive of necessity of
surgical drainage (P = 0.566).
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No. of
patients (%)
(N = 365)
No.
deaths
Airway obstruction
31 (8.5)
Sepsis
22 (6.0)
Descending mediastinitis
Pneumonia
16 (4.4)
12 (3.3)
0
0
11 (3.0)
Pleural effusion
4 (1.1)
1 (0.3)
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Predictors of complications
Discussion
In univariate logistic-regression analysis, we assessed factors associated with life-threatening complications. The
strongest predictor of life-threatening complications was
diabetes mellitus [odd ratio 7.37 (95% CI 3.9013.94);
P \ 0.001]. Other variables significantly associated with
complications are shown in Table 4. Factors that were
independently associated with life-threatening complications on the basis of a multinomial regression model, are
shown in Table 5: diabetes mellitus [odd ratio 5.43 (95%
CI 2.5611.53); P \ 0.001] and multiple deep neck spaces
This is the largest series of DNIs reported in Western literature. Although DNIs can affect all age-group, most of
cases in the present series were concentrated between the
fifth and seventh decade of life. About one-fourth of
patients have relevant associated comorbidities with diabetes mellitus being the most frequent. Diabetes mellitus is
commonly reported in patients with DNIs [5]. Several
authors have identified diabetes mellitus as a significant
risk factor for infection-related morbidity and mortality
[5, 6]. The results of our study confirmed diabetes mellitus
as the strongest independent predictors of complications.
Peripheral vascular disease in diabetics may predispose
patients to anaerobic infection [7]. Furthermore, patients
with a hyperglycemic state have functional leukocyte,
macrophage, and fibroblast impairments that increase their
susceptibility to serious infections [8, 9]. Therefore, optimal control of diabetes mellitus play a critical role in DNIs
management: insulin use is the best option due to flexibility
of timing and dose.
Most DNIs are mixed polymicrobial infections including aerobes and anaerobes. Bacteroides fragilis, Prevotella,
Porphyromonas, and Fusobacterium spp resist penicillin
through the production of beta-lactamase. Overall, more
Odds ratio
(95% CI)
P value
1.50 (0.872.60)
0.145
1.20 (1.041.39)
0.012
1.41 (1.101.80)
0.006
1.11 (1.051.17)
\0.001
Diabetes mellitus
Evidence of colliquation
3.63 (1.906.93)
\0.001
3.96 (2.147.36)
\0.001
Odds ratio
(95% CI)
P value
1.49 (1.092.04)
0.012
1.09 (1.021.17)
0.005
Diabetes mellitus
Evidence of colliquation
2.51 (1.225.15)
0.012
Outcome
One patient with diabetes mellitus and liver dysfunction
who have developed sepsis and disseminated intravascular
coagulation died from severe hepatic insufficiency 16 days
after successful drainage of bilateral submandibular
abscess with extension to the anterior visceral space. All
other patients were discharged in stable condition after a
median length of inpatient stay of 11 days (range
673 days).
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complications, such as descending necrotizing mediastinitis and internal jugular vein trombosis, and in monitoring
the evolution of the infection [14]. Although CECT scan
has a good sensitivity in detecting infection and delineating
the cervical spaces involved, its accuracy is lower in differentiating abscess from cellulitis [15, 16]. A single or
multiloculated low density area with a complete circumferential rim of enhancement, surrounded by soft tissue
swelling, is considered the hallmark of abscess. Also, the
presence of an air-fluid level and subcutaneous air are
findings suggesting an abscess formation [17]. Deep neck
cellulitis presents as a mass with low-density core and
surrounding edema without enhancing rim or air-fluid level
[16]. On the other hand, lymphadenitis presents as a soft
tissue swelling obliterating adjacent fat planes. It is lapalissian that, as the diagnosis of deep neck abscess is based
on subjective findings, the accuracy of CECT is dependent
upon the experience of the radiologist and may be considerably lower in the transition stages from cellulitis to
abscess. In the present series, intraoperative findings did
not confirm the CT diagnosis of abscess in 13%. It has been
reported that pus may not be intraoperatively found in up to
one-fourth of cases with CECT scans suggestive of deep
neck abscess [18]. A scalloped contour of the ringenhancement, was more recently found to have a positive
predictive value of 94% in predicting the presence of pus
[19]. In order to identify periapical infections in patients
with suspected odontogenic DNIs, acquisition of highresolution axial scans of the jaw together with curved and
orthoradial multiplanar reconstructions are desirable [20].
On CECT, internal jugular vein thrombosis appears as an
enlarged vein with a low-density lumen surrounded by a
sharply defined wall [21] (Figs. 1, 2). In patients with
descending mediastinitis (Figs. 3, 4), CECT may show
fluid collection with gas formations, soft tissue thickening
and enhancement with loss of the normal fat planes, pleural
or pericardial effusion [22]. As descending mediastinitis
may be clinically silent [22], we suggest to routinely
extend the CT scans to the superior mediastinum in all
cases of DNI.
The mainstay of treatment of DNIs consists of airway
control, effective antibiotic therapy, and, when appropriate,
surgical incision and drainage of the pus collection.
The maintenance of a secure airway, a challenging task
both for surgeon and anesthesiologist, is the first step in
the treatment of patients with DNIs and airway compromise. Upper airway obstruction may result from laryngeal
edema secondary to anterior visceral space involvement
or tongue pushing against the roof of the mouth and the
posterior pharyngeal wall secondary to extensive submandibular space infection. In the present series about
half of patients with critical airway were affected by
Ludwigs angina, a potentially life-threatening bilateral
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Fig. 1 CECT findings of a deep neck spaces abscess with left jugular
vein trombosis
intubation in cooperative patients and enabling the surgeon to explore an anatomically distorted upper aerodigestive tract [23].
On the basis of the above considerations, empirical
antibiotic therapy with a combination of a penicillin plus a
beta-lactamase inhibitor (amoxicillin/clavulanate, ticarcillin/clavulanate, piperacillin/tazobactam), cefoxitin, carbapenem, or clindamycin should provide sufficient coverage
for both anaerobic and aerobic bacteria. Metronidazole has
excellent activity only against strict anaerobic bacteria and
therefore is poorly effective as a single-agent in DNIs [7].
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Conclusion
The availability of effective antibiotics and improved oral
hygiene have dramatically modified the epidemiology of
DNIs making them less common today than in the past.
However, even in this era of antibiotic therapy and modern
imaging techniques, DNIs remain a constant challenge.
Airway obstruction and descending mediastinitis are the
most troublesome complications of DNIs. In selected
patients, a trial of intravenous targeted or broad-spectrum
empiric antibiotic therapy associated with an intensive
CECT-based wait-and-watch policy may avoid an unnecessary surgical procedure. However, about one-fourth of
patients present significant comorbidities, which may
negatively affect the course of the infection. In these cases
and in patients with large or multiple spaces infections, a
more aggressive surgical strategy is mandatory.
Conflict of interest
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