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Eur Arch Otorhinolaryngol (2012) 269:12411249

DOI 10.1007/s00405-011-1761-1

HEAD AND NECK

Deep neck infections: a study of 365 cases highlighting


recommendations for management and treatment
Paolo Boscolo-Rizzo Marco Stellin Enrico Muzzi
Monica Mantovani Roberto Fuson Valentina Lupato
Franco Trabalzini Maria Cristina Da Mosto

Received: 2 May 2011 / Accepted: 26 August 2011 / Published online: 14 September 2011
Springer-Verlag 2011

Abstract The aims of this investigation were to review


the clinical behavior of deep neck infections (DNIs) treated
in our institution in order to identify the predisposing
factors of life-threatening complications and propose
valuable recommendations for management and treatment.
A total of 365 adult patients with DNIs were retrospectively identified. One-hundred and thirty-nine patients
(38.1%) underwent surgical drainage. Overall, 226 patients
(61.9%) responded effectively to intravenous antimicrobial
therapy only. There were 67 patients (18.4%) developing
life-threatening complications. Diabetes mellitus (odd ratio
5.43; P \ 0.001) and multiple deep neck spaces involvement (odd ratio 4.92; P \ 0.001) were the strongest independent predictors of complications. The mortality rate was
0.3%. Airway obstruction and descending mediastinitis are
P. Boscolo-Rizzo  M. Stellin  R. Fuson  V. Lupato 
M. C. Da Mosto
Department of Medical and Surgical Specialities,
University of Padua, School of Medicine, Padua, Italy
P. Boscolo-Rizzo  M. Stellin  M. Mantovani  R. Fuson 
V. Lupato  M. C. Da Mosto
Regional Center for Head and Neck Cancer,
University of Padua, School of Medicine,
Treviso Regional Hospital,
Treviso, Italy
P. Boscolo-Rizzo (&)
Viale Umbria 6, 30019 Chioggia, Italy
e-mail: paolo.boscolorizzo@unipd.it
E. Muzzi
Otorhinolaryngology Unit,
University Hospital S. Maria della Misericordia, Udine, Italy
F. Trabalzini
Department of Sense Organs, Otology and Skull Base
Surgery Unit, Siena University Hospital, Siena, Italy

the most troublesome complications of DNIs. In selected


patients, a trial of intravenous antibiotic therapy associated
with an intensive computed tomography-based wait-andwatch 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.
Keywords Abscess  Complications  Computed
tomography  Deep neck infections  Diagnosis  Treatment

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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upper aerodigestive tract flora and includes both aerobic


and anaerobic microorganisms. As a consequence, the
microbiology of DNIs is similar and no correlation usually
exists between the anatomical region and microbiology of
the infection [3].
The management of DNIs requires a multidisciplinary
approach including head and neck surgeon, thoracic surgeon, infectious disease specialist, and radiologist.
The aims of this investigation were to review the clinical
behavior of DNIs treated in our institution in order to
propose valuable recommendations for management and
identify the predisposing factors of life-threatening
complications.

Patients and methods


This is an observational descriptive retrospective study of
all cases of DNIs treated at the Department of Surgery,
Treviso Regional Hospital over a period of 15 years
(between May 1995 and November 2010).
Clinical charts, imaging and bacteriologic studies were
reviewed. Patients with head and neck cancer, peritonsillar
cellulitis or abscess, and post-traumatic infections were not
included in the study. The following variables were
reviewed: demographic and clinical data, associated systemic diseases, bacteriology, imaging studies, source, site,
and character of the infections, medical and surgical
treatment, complications, and outcome.
The infection was categorized according to the character
of infections (cellulitis vs. abscess) and to the involved
spaces (submandibular space, lateral pharyngeal space,
retropharyngeal space, prevertebral space, parotid space,
masticatory space, temporal space, visceral vascular space,
anterior visceral space) according to Levitt [4]. Patients
with involvement of two or more spaces were classified as
having multiple spaces infection.
The reference ranges for standard values at our laboratory were 4 9 10311 9 103/mm3 for white blood cell
count (WBC), 1.8 9 1038 9 103/mm3 for neutrophil
count, 1 9 1034.5 9 103/mm3 for lymphocytic count,
010 mm/h for erythrosedimentation rate (ESR), and less
than 0.5 mg/dL for C-reactive protein (CRP).
Descriptive data are reported as median, range, and
percentages, as appropriate. Data were recorded from all
patients unless otherwise specified. Following parameters
were analyzed in order to identify potential risk factors for
life-threatening complications: gender, age, body temperature, WBC, diabetes mellitus, character of infection,
multiple space involvement. A multivariate logistic
regression analysis was undertaken using a forward stepwise technique, in which including significant risk factors

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Eur Arch Otorhinolaryngol (2012) 269:12411249

in univariate analysis, in order to identify independent risk


factors for complications. Statistical analysis was performed using the SPSS/PC software package (SPSS Inc.,
Chicago, IL, USA).

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).

Eur Arch Otorhinolaryngol (2012) 269:12411249

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. of patients (%)


(N = 365)

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

Table 2 Isolated pathogens from 177 patients with deep neck


infections
No.
Aerobic/facultatives
Streptococcus viridans not typed

37

Coagulase-negative staphylococcus

33

Staphylococcus aureus

23

Klebsiella pneumoniae

18

Staphylococcus epidermidis

11

Haemophilus influenzae
Streptococcus pneumoniae

11
6

Streptococcus, b-hemolytic, group A

Streptococcus constellatus

Proteus mirabilis

Source, site, and character of DNIs

Streptococcus group F

Pseudomonas aeruginosa

The source of infection was identified in 297 patients


(81.4%): the most common cause was a pharyngitis
(n = 119; 32.6%), followed by dental infection (n = 102;
27.9%), submandibular sialadenitis (n = 39; 10.7%), parotitis (n = 23; 6.3%), cervical lymphadenitis (n = 7;
1.9%), otitis (n = 4; 1.1%), epiglottitis (n = 2; 0.5%). One
patient developed deep neck abscess with descending
mediastinitis secondary to cervical intravenous drug abuse.
The pathogenesis of DNI was not determined in 69 patients
(18.9%).
According to the source of infection, the most common
primary site of DNI was submandibular space followed by
parapharyngeal space (Table 1). In 191 cases (52.3%), a
multiple space involvement was observed. An abscess was
present in 213 patients (58.4%), a cellulitis in 152 patients
(41.6%).

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

obtained from the primary source of infection, the neck or


the mediastinum, using either a sterile swab or suction trap.
Microbiological diagnosis (Table 2) was successful in
177 patients (48.5%); 15.8% positive cultures were
polymicrobial.

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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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Overall, 226 patients (61.9%) responded effectively to


intravenous antimicrobial therapy only.
Sixty-five patients (17.8%) underwent tooth extraction.
On discharge, tonsillectomy was proposed to all patients
treated for DNI secondary to pharyngotonsillitis.
Complications
There were 67 patients (18.4%) developing life-threatening
complications (Table 3). Forty-three were men (64.2%)
and 24 were women (35.8%) with a median age of 59 years
(range 1889 years). Diabetes mellitus occurred in 27
patients (40.3%). An abscess was present in 54 patients
(80.6%) and a multiple-space involvement was diagnosed
in 52 cases (77.6%).
Sixteen patients (4.4%) developed descending necrotizing mediastinitis with a median of 6 days (range 312 days)
after onset of first symptoms of cervical infection. Most
common symptoms and signs included neck and/or upper
aero-digestive tract swelling (n = 16), dysphagia (n = 10),
throat pain (n = 11), neck stiffness (n = 5). Acute onset of
dyspnea and thoracic pain were seen in three and four
patients, respectively. Neck swelling was the only clinical
finding in five patients. In most cases (n = 10), the diagnosis of mediastinitis was made on the basis of CECT
findings in absence of clinical signs of mediastinum
involvement. Twelve patients underwent external drainage
of the cervical abscess in conjunction with posterolateral
thoracotomy, four patients with infection limited to the
upper mediastinal spaces above the tracheal carina underwent transcervical thoracic drainage. Among patients with
descending mediastinitis, a microbiological diagnosis was
obtained from 10 patients (62.5%). A polymicrobial infection was identified in six patients. The isolated aerobic
bacteria were Streptococcus spp (n = 5), Coagulase-negative staphylococcus (n = 3), Acinectobacter baumanii
(n = 1), Gemella morbillorum (n = 2), Stenotrophomonas
maltophilia (n = 1), and Klebsiella pneumoniae (n = 1).
Bacteroides spp (n = 3), Fusobacterium spp (n = 2),

Table 3 Life-threatening complications


Complications

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

Jugular vein thrombosis septic embolism

11 (3.0)

Pleural effusion

4 (1.1)

Disseminated intravascular coagulation

1 (0.3)

Eur Arch Otorhinolaryngol (2012) 269:12411249

1245

Peptostreptococcus spp (n = 2), and Veillonella spp


(n = 1) were detected in anaerobic cultures.
Among patients with critical airway narrowing, 15
patients (48.4%) had a bilateral diffuse gangrenous cellulitis of the submandibular and sublingual spaces (Ludwigs angina) with or without extension to the visceral
anterior space. In order to resolve airway obstruction, 8
patients underwent emergency tracheostomy, 17 patients
underwent fiberoptic guided awake endotracheal intubation, and 6 patients achieve relief after successful treatment
by intravenous corticosteroids.
Eleven patients developing visceral vascular space
infection with jugular vein thrombosis secondary to oropharyngeal infection, underwent long-term antibiotic therapy in association with anticoagulant therapy (enoxaparin
100 IU/kg twice daily for 3 months). All patients with
jugular vein thrombosis complained of neck stiffness.
Positive blood cultures for Fusobacterium spp. and Streptococcus constellatus were documented in four and one
patient, respectively. Septic embolization to multiple sites
(lung, liver, spleen, and joints) was observed in five cases
(Lemierres syndrome). Two patients with associated parapharyngeal abscessone of those with concomitant
descending mediastinitisunderwent surgical drainage of
the pus collection. No patients underwent ligation of the
internal jugular vein. Less severe complications account for
osteomyelitis (n = 2) and vocal cord palsy (n = 2).

involvement [odd ratio 4.92 (95% CI 2.3810.16);


P \ 0.001] were the strongest independent predictors of
complications.

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

Table 4 Univariate associations with life-threatening complications


Factor

Odds ratio
(95% CI)

P value

Sex: male vs. Female

1.50 (0.872.60)

0.145

Age: per 10-year increase

1.20 (1.041.39)

0.012

Body temperature: per increase of 1C

1.41 (1.101.80)

0.006

White blood cell count: per increase


of 1 9 103/mm3

1.11 (1.051.17)

\0.001

Diabetes mellitus

7.37 (3.9013.94) \0.001

Evidence of colliquation

3.63 (1.906.93)

\0.001

Multiple space involvement

3.96 (2.147.36)

\0.001

Table 5 Factors associated with life-threatening complications in the


stepwise multivariate model
Factor

Odds ratio
(95% CI)

P value

Body temperature: per increase of 1C

1.49 (1.092.04)

0.012

White blood cell count: per increase


of 1 9 103/mm3

1.09 (1.021.17)

0.005

Diabetes mellitus

5.43 (2.5511.53) \0.001

Evidence of colliquation

2.51 (1.225.15)

Multiple space involvement

4.92 (2.3810.16) \0.001

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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than two thirds of DNIs contain beta-lactamase-producing


microorganisms. The low tissue oxygen tension in the
loose areolar tissue of the cervical spaces favor the synergistic growth of aerobic and anaerobic bacteria. Streptococcus spp and Bacteroides spp were the most prevalent
microorganism in aerobic and anaerobic bacterial cultures,
respectively, reflecting the predominant pharyngeal source
of DNIs in the present series. No bacterial growth was
recorded in 188 patients and anaerobes were isolated in
minority of cases. Use of antibiotics before admission,
high-dosage intravenous empiric antibiotic therapy prior to
surgical drainage, improper collection of specimen, no
routine use of anaerobic cultures, and difficult in culturing
anaerobes may affect and may have affected the result of
microbiological tests in this series. Increase in the incidence of anaerobic bacteremias with multiple-drug-resistant organisms is emerging as a significant health problem
as there is an increasing population with multiple comorbidities and compromised immune system [10]. Anaerobes
express significant virulence factors including adherence
and spreading factors as hyaluronidase, collagenase, and
fibrolysin that may promote the dissemination of a localized infection [7]. Anaerobes also have the ability to produce the enzyme beta-lactamase protecting themselves and
other penicillin-susceptible organisms from the activity of
penicillins [11].
Therefore, all efforts should be directed to maximize
successful isolation of anaerobes. In order to increase the
chances of effective microbiological diagnosis, the specimen for anaerobic cultures should be an aspirate obtained
by needle and syringe, transferred into anaerobic culturette,
avoiding exposure to oxygen, and transported to the laboratory within 23 h [7]. Tissue samples and biopsies placed
in a sterile container are also adequate specimens for
anaerobic cultures. The high rate of coagulase-negative
Staphylococcus positive culture may reflect the collection
of contaminated specimens. In this sense, when the material for microbiological cultures is transmucosally collected, it is essential to decontaminate the mucous
membrane. Although no methicillin-resistant strains were
identified, as community-associated methicillin-resistant
Staphylococcus aureus (MRSA) isolation is increasingly
common among out- and inpatients with suppurative
infections, MRSA may play an increasing role in DNIs in
the next future [12, 13].
CECT was the modality of choice in the evaluation of
DNIs. Taken into account that trismus may significantly
limit an accurate inspection of the upper aerodigestive tract
and that clinical examination may underestimate the extent
of infection in about two-third of cases, CECT plays a
critical role in confirming the clinical suspect of DNIs, in
the differentiation of deep neck abscesses from cellulitis, in
the delineation of the involved spaces, in the diagnosis of

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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

Eur Arch Otorhinolaryngol (2012) 269:12411249

1247

Fig. 3 Necrotizing descending mediastinitis: histological section


showing agglomerates of neutrophil cells and bacteria (Streptococcus
oralis) in a contest of muscular necrosis

Fig. 1 CECT findings of a deep neck spaces abscess with left jugular
vein trombosis

Fig. 4 CECT findings of a deep neck space abscess descending in the


mediastinum

Fig. 2 Angio-MRI showing the absence of venous drainage from the


left internal jugular vein

diffuse gangrenous cellulitis of the submandibular and


sublingual spaces (Fig. 5). In these patients, who are not
rarely diabetic, conventional endotracheal intubation and
tracheotomy under general anesthesia may be made even
more difficult by morbid obesity. In our experience,
fiberoptic guided awake endotracheal intubation is an
appropriate procedure both allowing a safe and atraumatic

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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Fig. 5 A case of Ludwigs angina

Macrolides or ketolides plus metronidazole should be


considered in patients with a penicillin allergy. Clindamycin resistance among strains of Bacteroides fragilis has
increased over 10 years, and current resistance rates reach
2050% or more worldwide [24]. Take into account that in
the present and other series [22] Bacteroides spp were
among the most frequently isolated anaerobic pathogens
both in uncomplicated and complicated DNIs, clindamycin
may no longer be considered a first-line antibiotic in DNIs.
First intention antibiotic therapy should be reviewed 48 h
later and potentially adjusted according to the microbiological- and drug-resistance patterns. A prolonged antibiotic therapy should be advisable as anaerobic infections are
frequently chronic. After resolution of clinical signs of
DNIs, oral therapy can replace parenteral one.
Open surgical incision and drainage are considered the
mainstay of treatment for deep neck abscesses. Almost
two-third of the patients responded satisfactorily to medical
therapy only. We and several authors have demonstrated
previously that a trial of intravenous antibiotic treatment
associated with an aggressive CECT-based wait-and-watch
policy may result in a significant number of selected
patients (patients with cellulitis, abscesses \3 cm not
involving danger spaces or more than one space, stable
general condition) avoiding an unnecessary surgical
drainage [15, 17, 25].
This policy did not result in significantly higher number
of imaging procedures in patients selected for observations
mainly because imaging investigations were routinely
performed also after surgical drainage of deep neck abscess
in order to confirm the resolution of the infections.
In the present series, about one-fourth of patients
required an extensive external cervical approach. This
approach is mandatory for drainage of large abscesses,
multiple space abscesses, and impending complications. In
patients with Ludwigs angina, an external surgical

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Eur Arch Otorhinolaryngol (2012) 269:12411249

approach is justified, even if areas of colliquation are not


usually evident [6].
No correlation was found between duration of symptoms
and the necessity of surgical drainage. Considering that a
short duration of symptoms may correlate with a more
aggressive infection, one should have expected a higher
prevalence of surgical drainage in these patients. On the
other hand, an inappropriate antibiotic therapy and anaerobic
infections may be responsible for a slow course of disease
and longer duration of symptoms in patients who finally
develop complications requiring surgical procedures.
About 7.5% of patients were successfully drained by
needle aspiration. Minimally invasive techniques are
attractive options in patients with well-defined, unilocular
abscess without airway compromise. Draining an abscess by
needle aspiration reduces the morbidity of open surgery by
limiting surgical trauma, reducing healing time, minimizing
the risk of contaminating the surrounding healthy tissue. CT
or ultrasound guidance may improve the efficacy and safety
of percutaneous abscess drainage. In selected retro- and
parapharyngeal abscesses without involvement of visceral
vascular space, endo-oral aspiration and/or incision should
be considered in order to reduce patient morbidity, economic
burden and avoid aesthetic complications.
About 18% of patients developed life-threatening complications. Diabetes mellitus was confirmed to be the
strongest predictor of life-threatening complications [5].
Airway obstruction and spread of infection to the mediastinum are the most troublesome complications in patients
with deep neck space infections. In our study population,
most patients with mediastinitis had not shown any
symptoms and signs of mediastinum involvement with
symptoms of neck infection being common. Therefore,
prompt diagnosis of descending mediastinitis may be
missed in the absence of a high index of suspicion and
routine CECT through the mediastinum. On the basis of
our multivariate analysis, patients with diabetes mellitus,
multiple space involvement, evidence of colliquation, high
WBC, or high body temperature should be considered to
potentially have a descending mediastinitis until proven
otherwise. Descending necrotizing mediastinitis requires
an aggressive multidisciplinary management. Delay in
diagnosis as well as inadequate drainage of the mediastinum are considered to be the most significant factors
responsible for mortality [22]. Transcervical drainage of
the mediastinum should be reserved for patients with
infection limited to the upper mediastinal spaces above the
tracheal carina. On the other hand, cervicotomy along with
posterolateral thoracotomy incision is the standard of care
in patients with inferior mediastinum involvement.
Lemierres syndrome is an uncommon seen and often
forgotten complication of acute oropharyngitis affecting
healthy adolescents and young adults. Central to the

Eur Arch Otorhinolaryngol (2012) 269:12411249

pathogenesis of this disease is the internal jugular vein


thrombophlebitis. Septic metastases may occur and frequently affect the lungs. Clinically, the onset of septic
symptoms often coincides with the end of oropharyngeal
symptoms. Septic fever, tension of the sternocleidomastoid
muscle and a stiff neck are the most frequent symptoms
plus those connected with the site of the secondary localizations (chest pain, dyspnea, hemoptysis, and more
uncommonly joint pains, abdominal pain with possible
acute abdomen) [26]. Broad-spectrum therapy should be
given for more than 3 weeks. On the other hand, the role of
anticoagulation has remained controversial [27]. Ligation
and resection of the internal jugular vein, which was frequent in the pre-antibiotic era, is now recommended by
some authors only in the case of persistent sepsis with
embolism.

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

There are no potential conflicts of interest.

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