Treatment and Prognosis of Deep Neck Infections

Abstract

Deep neck infections could have serious threats for life of patients, if not noticed adequately. Early diagnosis and correct treatment planning can save the patient’s lives and prevent complications of disease extension and also surgical procedures that in some instances may be performed in an emergent situation with higher complication rates. Herein, we have studied 815 cases of deep neck abscesses and infections with especial consideration to treatment and prognosis. In a retrospective case review, we studied 815 cases admitted in our medical center from 1998 until the year 2013. Only patients with abscesses or infections deeper than superficial layer of deep cervical fascia were included in this study, based on the review of their medical records. From 815 cases (485 males and 330 females) surgery was indicated and performed in 428 cases and the rest were treated medically. In cases with dental infections as the etiologic factor, dental procedures were performed as early as possible (extraction in almost all cases). Tracheostomy was performed in five cases. All of the patients in medical treatment group and most of the surgically managed patients were discharged while were stable with relative or complete resolution of their symptoms. One of our patients, a 15 year old boy died with symptoms suggestive for mediastinitis and air way compromise. Early diagnosis and medical management can be effective in treating deep neck infections. Dental infections and also procedures are the major cause in our patients, although tonsillitis and peritonsillar abscess also were important leading causes with almost equal numbers in our series. Extraction of the infected tooth as early as possible while medical treatment is continued can be very helpful. In some cases it may be necessary to perform surgical exploration of the neck more than once, and finally, malignant neoplasia, somewhere in the head and neck should be considered in some cases, as in one of our patients with left side submandibular abscess whose underlying disorder was tongue SCC with neck metastasis. Prognosis can be excellent in both medically and surgically managed groups if started and designed early and promptly.

Introduction

Deep neck infections could have serious threats for life if not noticed adequately. Most deep neck infections arise from foci in the mucosal surfaces of the upper aerodigestive tract or from a carious tooth [1]. Deep neck abscesses occur in the potential spaces between the layers of deep cervical fascia. Usually the results of cultures are polymicrobial but as a whole, Streptococcus are the organisms most commonly cultured from deep neck abscesses [2].

In an immunocompromised patient, however other uncommon organisms may be encountered [3]. Despite the availability of antibiotics, deep neck space infections with anaerobic germs (for example in Ludwig’s angina) still carry the potential for significant morbidity and mortality with delayed treatment [4].

Although introduction of antibiotics and improvements in oral hygiene have made deep neck infections occur less frequently today than in the past, but it is important to notice the patient because deep neck infections can cause severe morbidity and also mortality [4].

Early diagnosis and correct treatment planning can save the patient’s life and prevent complications of disease extension. Herein, we studied 815 cases of deep neck abscesses and infections with special considerations to treatment and prognosis. The aim of this study is to determine the effectiveness of early and correct diagnosis and treatment of this serious threat of life, and also to present modalities involved in both medical and surgical approaches.

Materials and Methods

This was a retrospective study of all patients with diagnosis of the different kinds of deep neck space infections who were admitted in Boo-Ali-Sina Hospital, a center of university, in duration of 15 years (from 1998 until 2013). Only patients with abscesses or infections deeper than the superficial layer of deep cervical fascia were included in this study. Information in the medical records, imagings or reports by the radiologist, operation reports and other data were used to define the cases of deep neck infections and include them in the study. CT scans of the neck had been performed in the majority of cases and the rest had conventional radiographs. All patients were supervised or operated on by the authors.

Results

Our survey found a total of 815 cases of deep neck infections. There were 485 (59.5 %) males and 330 (40.5 %) females with average age of 26 ± 18.3 years at presentation (ranging from 5 months to 90 years). All patients had fever at presentation. Perimandibular edema, pain in the involved region or in the neck, trismus, odynophagia, dysphagia, shivering, respiratory distress and otolgia were among other presenting symptoms in decreasing order. As is shown in Table 1, the most common involved space was submandibular space (Table 1).

Table 1.

The spaces involved in cases of DNIs

Space	Number (%)
Submandibular	367 (45)
Peritonsillar	330 (40.5)
Parapharyngeal	61 (7.5)
Parotid	35 (4.3)
Sublingual and submaxillary (Ludwig’s angina)	22 (2.7)

Dental infections were the most common etiologic factor (see Table 2). Also, dental procedures were of important and common factors. Tonsillitis and peritonsillar abscess were the second most common leading cause in our patients with only little difference. As is shown in Table 2, other underlying factors include trauma, foreign body penetration in the oral cavity mucosa, and salivary stone. In 196 of our cases, no definitive or suggestive precipitating factor was identified.

Table 2.

Precipitating factors for DNIs

Precipitating factor	Number (%)
Dental	286 (35.1)
Tonsillitis	247 (30.2)
Trauma
Nonsurgical	33 (4.1)
Surgical	17 (2.1)
Salivary stone and obstruction	25 (3.1)
Branchial cyst	5 (0.6)
SCC of tongue	1 (0.1)
Unidentified	196 (24.1)

As precipitating systemic diseases, diabetes were seen in 46 (5.6 %) and chronic renal failure (CRF) in 26 (3.1 %) of patients (Table 2).

In one of our patients, who had been presented with submandibular abscess and severe trismus, after the initial medical treatment with relative improvement of symptoms, we found an ulcerated tumor in the tongue and metastatic necrotic node in the submandibular space. The result of biopsy and pathology report was SCC of the tongue. Therefore, this rare presentation of a head and neck malignancy should be considered in high risk patients with deep neck infections.

Immediately after admission, medical management was started. Treatment strategy was individualized for each patient (Table 3).

Table 3.

Kind of treatment of patients with DNIs

Kind of treatment	Number (%)
Medical	387 (47.5)
Surgical	428 (52.5)	Neck exploration	290
		Tooth extraction	158
		Tracheostomy	5
Total	815

High dose intravenous penicillin G, solely, or in combination with metronidazole, or a combination of a cephalosporin (Ceftriaxone) and clindamycin used in the majority of patients before the reports of sensitivity results. However, in some patients with more serious problems, after infectious disease consultation, other antibiotics were used in a number of patients. Intravenous hydration and intensive care and control of vital signs were performed in all patients. Five patients underwent tracheostomy because of symptoms of airway compromise. Any patient without improvement within 24–48 h of medical treatment underwent surgery. Surgical exploration of the involved neck space was performed in 428 patients (we performed more than one procedure in some patients). The rest of our patients completed treatment medically. It should be mentioned that in the medically and also surgically treated patients with dental infections, extraction of the diseased tooth was performed as soon as the patient’s conditions permitted after starting treatment. Complications were few (Table 4).

Table 4.

Complications of DNIs

Complications	Number
Morbidities
Airway obstruction (tracheostomy)	63 (5)
Transient marginal mandibular paresis	28
Scar and granulation tissue	17
Bleeding after operation	4
Mortality	1

Unfortunately, one of our patients, a 15 years old boy died with symptoms suggestive for mediastinitis. He had been operated on his neck for parapharyngeal abscess a day before and during the immediate post-surgical period, he was stable and in relatively good condition. Nevertheless, his conditions got suddenly aggravated and finally he died before we could find any chance for operation.

Except this, respiratory problems in 63 patients and airway obstruction leading us to perform tracheostomy in five cases were other major complications. Other complications were not major and included bleeding after surgery (four cases), transient marginal mandibular nerve paresis (28 cases) and granulation tissue on the site of the incision. No other vascular, neurologic, central, or systemic complications had been occurred. One of the rare cases of SCC of the tongue refused all of the proposed managements and died about 2 months after the first presentation. The average period of hospitalization of patients was 5.2 days (4.7 days in medical and 5.8 days in surgical treatment groups).

All of the patients in medical treatment group and most of the surgically managed patients were discharged while were stable with resolution of their symptoms. Most of our patients were followed for an average period of 8 weeks.

Discussion

Direct extension of infection through facial planes may involve deep neck spaces (deeper than the superficial layer of deep cervical fasciitis). Less commonly, such infections are the result of perforation by foreign body or thrombophlebitis [1].

Many vital organs are at risk of being involved and the resultant respiratory, vascular, neurologic and systemic complications endanger the life of the patient and if not noticed in a well-timed manner, lead to death rapidly.

The major symptoms of infections in different deep neck spaces are similar. In Ludwig’s angina, they include fever, cervical pain, neck swelling, dysphagia and dyspnea, as in parapharyngeal or submandibular space involvement [5]. However, when complications occur, specific signs and symptoms could be found. Peritonsillitis and peritonsillar abscess are commonly encountered emergencies in day to day ENT practice [6], with just similar symptoms.

In one study, peritonsillar abscess is reported as the most common deep neck infection in adolescents [7]. However, usually odontogenic infections with involvement of the submandibular space are the source of deep neck infections in adults [4, 7].

Retropharyngeal infections, more commonly seen in infants and young children may have different and confusing symptoms with fever and restlessness at the initial phase.

Discovery of the underlying causative factors requires imaging. The addition of CT to the initial work up provides early detection of true underlying disease.

As is shown in Table 3, all of the medically treated patients (47.5 % of cases) had deep neck cellulitis (fasciitis). In those with abscess formation in imaging studies (52.5 % of cases) surgical interventions were performed.

Cross-sectional imaging is valuable in the evaluation of abscess and the pathway of spread [1, 8]. However, in many cases, a definite cause cannot be found. In our study, there were 196 cases (24.1 %) in whom no definite cause was found. Two main underlying factors were dental infections and tonsillitis (Table 2). An uncommon occurrence of acute retropharyngeal abscess in an adult as a result of a retained foreign body, (a large piece of wood impacted in neck in a road accident) has reported [9]. Deep neck infections may be lethal especially in immunocompromised hosts such as diabetic patients. Unique features of DNIs in diabetic patients were as older age, unclear source, involvement of multiple spaces and higher complication rate, in a study. During the second half of this century, intravenous drug abusers appeared as a new group of patients at risk for DNIs [4, 10].

In six of our patients, the underlying cause of submandibular infection was SCC of the tongue, with necrotic metastatic nodes in the submandibular space. In general, malignancies presenting as abscesses are uncommon [11]. There are reports of a neck abscess originating in metastatic nodes from esophageal SCC and retropharyngeal abscess in two cases of nasopharyngeal carcinoma [11, 12].

Deep neck infections require prompt treatment. After taking a complete history, physical examination, fluid and electrolyte resuscitation, laboratory and imaging studies, medical treatment is initiated.

Treatment consists of ensuring adequate ventilation by securing the airway, broad spectrum antibiotics, eradication of the source of infection, and if necessary, early surgical decompression or drainage.

Initial antibiotics are administered before the culture results have been obtained [5, 13]. High dose intravenous penicillin G, combined with metronidazole, or a combination of ceftriaxone and clindamycin were very effective in our study. Such combinations cover the oral mixed flora responsible for DNIs. Penicillin would be the drug of choice for aerobic Staphylococcus pyogenes, groups A, B, C, G, and H Streptococcus and most Clostridia species. Clindamycin will provide adequate therapy against anaerobes that are resistant to penicillin G. Gentamycin provides antibiosis against most aerobic gram negative bacilli including Pseudomonas aeroginosa [13].

When the clinical condition of the patient does not show improvement during the first 24–48 h after initiation of treatment (lowering of fever and decrease in severity of trismus), or when fluctuation is noted, immediate and extensive surgical treatment should be performed.

Different surgical techniques for neck exploration are discussed here. It should be noted that anesthesia and airway management may be difficult in these cases. A report of gush of pus into the oral cavity and laryngospasm causing acute upper airway obstruction is seen in the literature [14]. We also have had critical and riskful times at the induction of anesthesia in some of our emergency cases. Another clinical point is about timing of tonsillectomy in patients with peritonsillar abscess. Both “wait and observe” for a single isolated attack of peritonsillar abscess, or surgery (quinsy or delayed) are recommended [15]. We also performed tonsillectomy after a delay of about 4 weeks, (or longer in some patients) in all such cases. When an infection in the root of a diseased tooth is the cause of a deep neck infection, extraction of the tooth should be performed as early as possible.

Finally, although malignant lymph node metastases presenting as abscess are uncommon and have rarely been described, a biopsy of the abscess wall is recommended. Head and neck carcinoma should be considered in differential diagnosis of deep head and neck abscesses [13–15].

In this study, we considered 815 patients during a period of 15 years. Our study revealed common and also rare causes of deep neck infections. The prognosis among our patients was good. Only one patient was expired, with mortality rate of about 0.1 %.

Conclusion

Early diagnosis and medical management can be effective and lifesaving in deep neck infections. When there is a dental source of infection, and while medical treatment is continued, extraction of the infected tooth as early as possible can be very helpful. However, when medical management fails within the first 24–48 h, timely surgery prevents extension of disease and life threatening complications. When fluctuance or complications occur, aggressive surgical debridement should be performed.