Deep Neck Space Infections Research Articles

The Use of Trendelenburg Position in the Management of Retropharyngeal Abscess: A Case Report and Clinical Considerations

Background: Retropharyngeal abscess (RPA) is a serious deep neck space infection that can lead to life-threatening complications such as airway obstruction, mediastinitis, and sepsis. The Trendelenburg position, where the patient's head is lower than their feet, has been traditionally used in the management of RPA to prevent aspiration of pus in case of abscess rupture. However, the optimal positioning for patients with RPA remains a topic of debate. Case presentation: A 51-year-old male patient presented to the emergency room with a 5-day history of progressive dysphagia and neck swelling. He was diagnosed with a ruptured retropharyngeal abscess extending to the mediastinum (descending necrotizing mediastinitis). The patient underwent surgical drainage and was subsequently admitted to the intensive care unit (ICU), where he was intubated and mechanically ventilated in the Trendelenburg position. Five days later, the patient developed pneumonia, suspected to be ventilator-associated pneumonia (VAP). Conclusion: The Trendelenburg position may be considered in the management of RPA to minimize the risk of aspiration. However, it is essential to weigh the potential benefits against the risks, including VAP, and to consider alternative positions such as the lateral Trendelenburg position, which may offer similar benefits with reduced risk. Further research is needed to determine the optimal positioning strategy for patients with RPA.

Lemierre’s syndrome associated-diabetic ketoacidosis in an elderly female: a case report

BackgroundThe co-occurrence of Lemierre’s syndrome, primarily triggered by Fusobacterium necrophorum following oropharyngeal infection, with diabetic ketoacidosis (DKA) in diabetes mellitus (DM) patients, underscores a rare but life-threatening clinical scenario. Lemierre’s syndrome induced DKA is extremely rare, with only one case report in adult and no case yet reported in elderly.Case PresentationWe reported a case of a 69-year-old female who presented with DKA triggered by deep neck space infection (DNSI), leading to rapid clinical deterioration within 6 h that necessitated high flow nasal cannula (HFNC) and antibiotic administration. Laboratory findings included leukocytosis, elevated serum C-reactive protein, hyperglycemia, ketonemia, and severe metabolic acidosis. Culture of the fluid from a neck mass puncture drainage and blood were positive for Klebsiella pneumoniae. The patient was further complicated by thrombosis of the left internal jugular vein with extension to the sigmoid and a neck abscess surrounding the carotid artery sheath, consistent with Lemierre’s syndrome. This condition was managed aggressively with fluid resuscitation, insulin therapy, surgical drainage, antibiotics, and anticoagulation led to a significant improvement in her condition. Following a 13-day hospitalization, there was significant clinical improvement, culminating in the patient’s discharge.ConclusionsThe case highlights the need for greater awareness and understanding of the interrelated and mutually promoting conditions of DKA and Lemierre’s syndrome among clinicians. Early recognition and treatment are crucial to prevent mortality in such complex cases.

Awareness of Atypical Presentations in Deep Neck Space Infections

Awareness of Atypical Presentations in Deep Neck Space Infections

Deep neck space infections of odontogenic origin are costly and preventable.

Deep neck space infections (DNSI), caused by the spread of an odontogenic infection to the floor of the mouth and neck, are potentially life-threatening but preventable. We explored the total cost of illness (COI) for patients with DNSI of odontogenic origin. Cross-sectional, register-based, multi-centre study of the health economics of DNSI treatment. Included were patients aged > 18 years who were treated in hospital for DNSI of odontogenic origin. Subjects were identified from the regional healthcare database VEGA based on the International Classification of Diseases (ICD) codes and surgical procedure codes. The cost per patient (CPP) values for the hospital care, prescription medications and sick leave were extracted. In total, 148 patients were included. The average length of the hospital stay was 6 days. Total COI was estimated as 15,400 EUR per patient and 2,280,000 EUR in total. Direct costs accounted for 93% of the COI, and indirect costs were 7%. The total COI for patients with DNSI of odontogenic origin was six-fold higher than the average COI for patients in otorhinolaryngology (ORL) care. Preventing DNSI will entail substantial cost savings for the specialised healthcare units and will have a significant impact on the patients.

Antibiotic Diversity Index: A novel metric to assess antibiotic variation among hospitalized children.

Despite nationally endorsed treatment guidelines and stewardship programs, variation and deviation from evidence-based antibiotic prescribing occur, contributing to inappropriate use and medication-related adverse events. Measures of antibiotic prescribing variability can aid in quantifying this problem but are not adequate. The objective of this study is to develop a standardized metric to quantify antibiotic prescribing variability (diversity) within and across children's hospitals, and to examine its association with outcomes. We performed a cross-sectional study of empiric antibiotic exposure among children hospitalized during 2017-2019 with one of 15 common pediatric infections using the Pediatric Health Information System database. Encounters for children with complex chronic conditions, transfers in, and birth hospitalizations were excluded. Using the Shannon-Weiner entropy index, we quantified antibiotic diversity for each infection type using the d-measure of diversity. Generalized linear mixed-effects models were used to examine the association between hospital-level antibiotic diversity and risk-adjusted length of stay and costs. A total of 79,515 hospitalizations for common pediatric infections were included. Antibiotic diversity varied within and across hospitals. Infections with low mean antibiotic diversity included appendicitis (mean diversity [mDiv] = 4.9, SD = 2.5) and deep neck space infections (mDiv = 5.9, SD = 1.9). Infections with high mean antibiotic diversity included pneumonia (mDiv = 23.4, SD = 5.6) and septicemia/bacteremia (mDiv = 28.5, SD = 12.1). There was no statistically significant association between hospital-level antibiotic diversity and risk-adjusted LOS or costs. We developed and applied a novel metric to quantify diversity in antibiotic prescribing that permits comparisons across hospitals and can be leveraged to identify high-priority areas for local and national stewardship interventions.

Retropharyngeal Abscess Complicated by Mediastinitis in Infants

Introduction: Most paediatric upper respiratory infections are virally mediated and result in self-limiting reactive lymphadenopathy. In children younger than 5 years, retropharyngeal lymph nodes may give rise to deep neck space infections in this potential space. Retropharyngeal infections are rare after 5 years because lymph nodes undergo atrophy. Methods: We present a series of 6 cases of paediatric retropharyngeal abscesses (RPA) complicated by mediastinitis, managed at a tertiary hospital over a 4-year period. Results: All our cases presented with fever, difficulty feeding, and neck swelling. The age range was 11 weeks–11 months, and all tested negative for human immunodeficiency virus. The diagnosis and complications were confirmed on computed tomography (CT) scan. The CT scans consistently revealed RPA with varying degrees of deep neck space and mediastinal extension. All children were promptly taken to theatre for source control. Two were extubated successfully immediately after surgery, and the other 4 were extubated in the paediatric intensive care unit, with the longest duration of intubation being 3 days. Methicillin-sensitive Staphylococcus aureus (MSSA) was cultured in all 6 cases. Conclusion: Management of these cases may be challenging, and young children with RPA require close care and airway monitoring. CT or magnetic resonance imaging is essential to delineate the extent of infection. Surgical drainage should be performed when there is a large abscess, a complication occurs, or an inadequate response in 24–48 h to medical management.

Deep neck space infections among patients attending a tertiary Ugandan hospital: clinical presentation, bacterial etiology and antimicrobial susceptibility

Deep neck space infections among patients attending a tertiary Ugandan hospital: clinical presentation, bacterial etiology and antimicrobial susceptibility

Diagnostic approaches and management of deep neck space infections

Diagnostic approaches and management of deep neck space infections

Anatomy, Diagnosis, and Clinical Management of Deep Neck Space Infections

Any surgeon providing care to patients with congenital, oncologic, infectious, or traumatic processes impacting the head and neck should have an intimate knowledge of the local anatomy. The complex fascial system in this region results in a series of loosely and tightly bound spaces that can both harbor and/or facilitate the rapid spread of infections through these fascial planes and potential spaces. Deep neck space infections may occur spontaneously from cutaneous, lymphatic, odontogenic, otologic, salivary gland, sinus, and hematogenous sources or develop as the result of surgical/iatrogenic manipulation. These infections are typically polymicrobial, involving a mixture of Gram-positive cocci, Gram-negative rods, and beta-lactam-resistant anaerobes commonly found in the oropharyngeal flora. Other populations, such as immunocompromised or hospitalized patients, are particularly vulnerable to infection by certain opportunistic and antibiotic-resistant pathogens. Understanding the deep neck anatomy is crucial for predicting the spread of infection and guiding treatment strategies. The superficial and deep cervical fascial planes form a series of compartments and spaces including the retropharyngeal, danger, prevertebral, carotid, parapharyngeal, submandibular, sublingual, parotid, masticator, temporal, and infrahyoid spaces. Despite their rarity in the post-antibiotic era, deep neck space infections pose a significant threat as they progress rapidly and can quickly lead to life-threatening complications. Delayed clinical presentation is common due to the compartmentalization by fascial planes, therefore early recognition requires a high index of suspicion, thorough clinical examination, and diagnostic imaging studies, typically contrast-enhanced computed tomography (CECT). Treatment requires a multidisciplinary approach, including advanced airway management, administration of empirical broad-spectrum antibiotics, and surgical drainage when indicated. This review provides a comprehensive overview of deep neck space anatomy and its defining fascial planes, as well as discussions on epidemiology, specific microbiology, clinical presentation, diagnosis, antibiotic selection, and surgical treatment options.

Abscess Lodged Within the Sternocleidomastoid Muscle Secondary to Septic Arthritis

In deep neck space infections, structures within the fascial compartments may become compromised, leading to neurovascular, bony, or airway issues. Most commonly, infections of the oral cavity, face, or superficial neck spread through the lymphatics into the deeper tissues, causing lymphadenopathy and suppurative fluid collection leading to abscess formation. While some neck abscesses occur idiopathically, a retrospective review found that dental infection was the most common etiology (43%), followed by intravenous (IV) drug use (12%) and tonsillitis (6%). In contrast, our patient denied IV drug usage and had no significant medical or dental history that could account for her symptoms. Instead, she developed her neck abscess secondary to septic arthritis of the knee. Although synchronous localized infection of multiple sites is possible, cultures taken from the knee and the neck were both sensitive to Methicillin Resistant Staphylococcus Aureus (MRSA), indicating that the abscess likely formed secondary to septic arthritis. Furthermore, the patient’s history of diabetes likely contributed to the progression of the infection. Rarely does a knee infection travel hematogenously and seed within the neck. Moreover, the abscess was lodged within the middle of the sternocleidomastoid muscle rather than within the fascial compartments. Physicians in the future should be aware of this distinct presentation of deep neck space abscesses.

Parapharyngeal Abscess: A Model of Continuity and Contiguity Deep-Neck Space Infections: A Diagnostic Dilemma!

The aims of the present case report were to review, computed tomography (CT) scans, clinical signs, treatment, and outcome of parapharyngeal space infections. These infections remain an important health problem with significant risks of morbidity and mortality. The term parapharyngeal abscess or infection is composed of two different disorders: infection located in the posterior part of the PPS with no invasion into the parapharyngeal fat and the second disorder is when the infection involving the parapharyngeal fat may be termed parapharyngeal abscess or deep neck abscess. Diffusion into the mediastinum and other severe complications are frequent. A 59 year old male, presented with three days history of intermittent high grade fever and left neck swelling which was rapidly increasing in size and associated with stridor, odynophagia and neck pain. The infection and accumulation of purulent discharge extend into the pharyngomaxillary space and inferiorly is located at the greater cornu of the hyoid bone. Temporary tracheostomy for respiratory assistance was performed. The frequent co-existence of parapharyngeal abscess and peritonsillar abscess favours careful consideration of addition of tracheotomy to lateral cervicotomy. Parapharyngeal abscess are deep neck abscesses that are common and thorough knowledge of their complex anatomy and aetiologies is essential in their treatment. Urgent surgical drainage is therefore mandatory.

Deep neck space infections in end-stage renal disease patients: Prevalence and mortality.

Deep neck space infections (DNSI) are severe infections within the layers of neck fascia that are known to be associated with underlying immunocompromised states. Although uremia associated with kidney disease is known to cause immune system dysfunction, DNSI in patients with kidney disease has been poorly studied. This study investigated the prevalence of DNSI and the associated risk of mortality within the United States end-stage renal disease (ESRD) population, using a retrospective cohort study design and the United States Renal Data System database of patients (ages 18-100) who initiated dialysis therapy between 2005 and 2019. International Classification of Disease-9 and -10 codes were used to identify the diagnosis of DNSI and comorbid conditions. Of the 705,891 included patients, 2.2% had a diagnosis of DNSI. Variables associated with increased risk of DNSI were female sex, black compared to white race, catheter, or graft compared to arteriovenous fistula (AVF) access, autoimmune disease, chronic tonsillitis, diagnoses in the Charlson Comorbidity Index (CCI), tobacco use, and alcohol dependence. DNSI diagnosis was an independent risk factor for mortality, which was also associated with other comorbidity factors such as older age, catheter or graft compared to AVF access, comorbidities in the CCI, tobacco use, and alcohol dependence. Because of the increased mortality risk of DSNI in the ESRD population, health professionals should encourage good oral hygiene practices and smoking cessation, and they should closely monitor these patients to reduce poor outcomes.

Deep Neck Space Infection among Diabetic and Non Diabetic Patients: A Prospective Cohort Study

Introduction: Deep Neck Space Infections (DNSI) were first described by Galen in the second century. They refer to infections of potential spaces and fascial planes of the neck and are a cause of significant morbidity and mortality. Additionally, the presence of Diabetes Mellitus (DM) increases the possibility of life-threatening complications. Aim: To compare the clinical characteristics, bacteriological spectrum, aetiological aspects, biochemical parameters, treatment protocol, complications, and mortality rate among diabetic and non diabetic patients with DNSIs. Materials and Methods: A prospective cohort study was conducted in the Department of Otorhinolaryngology, Mysore Medical College and Research Institute, Mysuru, Karnataka, India from January 2022 to December 2022. 52 patients with DNSIs were grouped into diabetics and non diabetics. The age group of the patients included in the study was 18-65 years. A detailed history, clinical examination, haematological investigations, and Contrast-enhanced Computed Tomography (CECT) were performed. Patients were either treated conservatively or underwent incision and drainage, depending on the presentation. The data obtained were analysed using the Statistical Package for the Social Sciences (SPSS) version 20.0. Results: The age range was 18 to 65 years, with a mean age of 51 years (51.35±13.46 years) in the diabetic group and 37 years (37.9±13.2 years) in the non diabetic group. Patients were divided into 26 (50%) diabetics and 26 (50%) non diabetics. Of the 52 patients, 34 (65.3%) were males and 18 (34.7%) were females. Multiple space involvement was present in eight patients among the diabetic group and three patients in the non diabetic group. Odontogenic infections constituted the leading foci in 17 (65.4%) of diabetics and 13 (50%) of non diabetics. In diabetics, 12 (46%) patients had high levels (>6.5%) of HbA1c, and Klebsiella was the causative organism in 9 (39%). A total of 23 (88.5%) diabetic patients underwent incision and drainage, while 13 (50%) non diabetic patients were treated conservatively. Among the diabetics, 21 (80.8%) patients had a hospital stay of >7 days, 7 (27%) patients had complications, and the mortality rate was observed in 5 (19.2%) patients. Conclusion: The study emphasises a definitive association of DM in the occurrence of DNSIs. Hence, the need for early detection and treatment of primary infections is highlighted, insisting on appropriate management of blood sugar levels.

Deep neck space infections in diabetic patients – a permanent challenge for the ENT surgeon

Deep neck space infections in diabetic patients – a permanent challenge for the ENT surgeon

Unveiling the etiology of peritonsillar abscess using next generation sequencing

BackgroundPeritonsillar abscess (PTA) is a severe deep neck space infection with an insufficiently characterized bacterial etiology. We aimed to reveal the bacteria associated with PTA applying next generation sequencing (NGS). Tonsil biopsies and pus samples of 91 PTA patients were analysed applying NGS method.ResultsOver 400 genera and 800 species belonging to 34 phyla were revealed. The most abundant species in both sample types were Streptococcus pyogenes, Fusobacterium necrophorum and Fusobacterium nucleatum. When present, S. pyogenes was normally a predominant species, although it was recovered as a minor population in some samples dominated by F. nucleatum and occasionally F. necrophorum. S. pyogenes and F. necrophorum were the predominant species (> 10% in a community) in 28 (31%) pus samples, while F. nucleatum in 21 (23%) and S. anginosus in 8 (9%) pus samples. We observed no substantial differences between the microbial findings in pus and tonsil biopsies.ConclusionsThe most probable causative agents of PTA according to our NGS-study include Streptococcus pyogenes, Fusobacterium necrophorum and Fusobacterium nucleatum. Some other streptococci (S. anginosus) and anaerobes (Prevotella, Porphyromonas) may contribute to the infection as well. Pus of the peritonsillar abscess is more representative specimen for microbiological examination than the tonsillar tissue. Our results are important in the context of optimizing the handling of the PTA patients.

Ludwig’s Angina – A Case Report

Ludwing angina is defined as progressive cellulitis of the submandibular space. It is a deep neck space infection. The two compartments affected are the sublingual and sub mylohyoid space. It progresses rapidly and needs to be addressed urgently. Early identification and initiating treatment will aid in reducing morbidity and mortality.

Predictive Performance Neutrophil-to-Lymphocyte Ratio of Acute Tonsillitis with Deep Neck Space Infection in Adult Patients.

The aim of this study was to examine the neutrophil-to-lymphocyte ratio (NLR) in patients diagnosed with a deep neck infection (DNI) to identify helpful indicators for the initial differential diagnosis. This study was conducted as a single-center, retrospective cohort study that utilized data from the electronic medical records of patients who visited the emergency department in a tertiary university hospital between February 2018 and April 2022. The study enrolled patients aged ≥18 years who were diagnosed with tonsillitis with or without DNI during the study period. The NLR of patients without DNI was 6.1 ± 5.03, and the NLR of patients with acute tonsillitis with DNI was 8.0 ± 5.67, showing significant differences. The rate of admission in the general wards (GWs) and ICUs was significantly higher in patients with DNI, and the length of hospital stay was also significantly longer in patients with DNI. Older age, male, lower body temperature, C-reactive protein, and NLR were significant independent risk factors for DNI in patients with tonsillitis. The cutoff value for predicting DNI in patients with body temperature <37.5 was 3.09. The NLR of patients with tonsillitis, especially those with normal body temperature, can be used to predict their prognosis.

Lemierre’s syndrome complicating deep neck abscess: a case report

BackgroundLemierre’s Syndrome is a severe medical condition that can result from oropharyngeal infection, typically caused by Fusobacterium necrophorum, leading to sepsis, internal jugular vein thrombosis, and metastatic septic emboli. However, there is limited literature on this syndrome caused by Streptococcus anginosus, and few previous cases have been reported to have deep neck space infection. We present the first case of Lemierre’s Syndrome caused by Streptococcus anginosus with deep neck abscess.Case presentationA 53-year-old male patient with no significant medical history presented with right neck pain after accidentally swallowing a fish bone one month ago. Laryngoscopy did not reveal any abnormalities. Five days prior to admission, the patient developed high fever. Imaging studies showed internal jugular vein thrombosis and a neck abscess surrounding the carotid artery sheath. Blood culture results were positive for Streptococcus anginosus infection, and the patient was diagnosed with Lemierre’s syndrome. The patient underwent surgical drainage and received antibiotics and anticoagulant therapy, and had satisfactory clinical progress. He was discharged after a 16-day hospitalization.ConclusionsAlthough Lemierre’s syndrome is rare, it needs attention because it can lead to serious complications and requires timely treatment. Deep neck space infections can be life-threatening and doctors must be aware of its potential severity.

Microbial isolates and antibiotic sensitivity in patients hospitalized with odontogenic infections at a tertiary center over 10 years.

This study investigated causative strains and their antibiotic sensitivity in patients who were hospitalized for maxillofacial odontogenic infections at a tertiary center in South Korea over the past 10 years with the aim of providing guidelines for the selection of appropriate empirical antibiotics. Patients with head and neck fascial space abscesses due to odontogenic infections who underwent incision and drainage surgery with pus culture tests between 2013 and 2022 at the Department of Oral and Maxillofacial Surgery, Dankook University Hospital were included. The bacterial isolates and antibiotic sensitivity of each strain were analyzed for 2013-2022, 2013-2017, and 2018-2022. The affected fascial spaces were classified into primary, secondary, and deep neck spaces. In the 192 patients included in this study, 302 strains were detected. Viridans streptococcus had the highest frequency (51.7%), followed by Prevotella spp. (16.9%), Staphylococcus spp. (5.6%), and Klebsiella pneumoniae (4.6%). The identification rate of viridans streptococcus significantly increased from 41.8% in 2013-2017 to 60.9% in 2018-2022. Viridans streptococcus showed an antibiotic sensitivity of 80.5% to ampicillin; the sensitivity to penicillin antibiotics decreased over the study period. Antibiotic susceptibility was approximately 94% for third-generation cephalosporins. K. pneumoniae, which was identified at a high percentage in patients with deep neck space infection, showed increasing antibiotic resistance to most antibiotics over the study period. Viridans streptococcus was identified in head and neck fascial space abscesses with the highest frequency. Empirical antibiotics should be effective against this strain; penicillin antibiotics are considered inappropriate. For effective treatment of deep neck space abscesses, bacterial culture and antibiotic sensitivity tests performed as soon as possible are essential.

Life-threatening complication of retropharyngeal abscess in an infant: a case report

BackgroundDeep neck space infections are uncommon in infants. Retropharyngeal abscess (RPA) is a deep space neck infection that can present with subtle signs and symptoms. Delay in diagnosis can lead to life-threatening complications. Here we describe life-threatening complication of retropharyngeal abscess.Case presentationWe report a life-threatening complication of retropharyngeal abscess in 10-month old Asian infant weighing 8.2 kg. The patient presented with fever, right-sided neck swelling, hoarseness of voice, and respiratory distress. The clinical and radiological findings were suggestive of airway obstruction complicated by retropharyngeal abscess. The patient was urgently taken to the operating room and underwent (grade 3) intubation. After stabilization, the patient underwent endoscopic trans-oral incision and drainage, during which 5 cc pus was aspirated. Antibiotics were prescribed for 2 weeks following the procedure based on the sensitivity result of the pus culture.ConclusionIn retropharyngeal abscess, a delay in diagnosis can result in life-threatening complications. This report highlights the importance of prompt recognition of a threatened airway and the management of retropharyngeal abscess by emergency physicians. If an emergency physician suspects RPA with airway obstructions, the airway should be immediately secured in a secure environment by otolaryngologist and an anesthesiologist.