Deep Neck Space Infections: Current Trends and Intricacies of Management?

Abstract

This study aims to describe the current epidemiological and etiological trends for deep neck space infections (DNIs) with an objective to understand the intricacies of their management. In this retrospective analytical study records of 52 patients with DNIs were reviewed. Patients having superficial abscess, peritonsillar abscess and abscess due to trauma/surgical procedure were excluded. Various epidemiological and etiological parameters (Demography, site, presentation, etiology, association with co-morbidities, bacteriology) and management guidelines (need for surgical interventions for DNIs and airway management, hospital stay duration, treatment outcome and complications) were reviewed and analyzed. Study recorded preponderance of DNIs in males (male:female = 1.6:1) and in younger generation (50% of patients presenting in first 2 decades). Commonest etiology being odontogenic infections (38.46%) followed by URTIs and tonsillopharyngitis (19.23%). Submandibular space involvement was noted in 42.3% cases followed by parapharyngeal space involvement in 21.15%. Nearly 55% cases of submandibular space involvement were because of odontogenic causes. 69.23% culture specimens reported no growth. 61.53% patients were diagnosed with anaemia. Up to 80% required open surgical drainage. All received broad spectrum antibiotics as a starting regime. No severe complications were recorded. Understanding the current epidemiological and etiological trends can help in early and definitive diagnosis of DNIs. Empirical starting treatment regime including broad spectrum antibiotics (till sensitivity pattern is availed) and maintaining low threshold for required surgical intervention are required to manage DNIs satisfactorily. Selected cases should be given conservative trials with close monitoring.

Introduction

Superficial and multilayered deep fascia of neck creates multiple potential spaces between the fascial planes in neck. Infectious involvement of these fascial planes leading to cellulitis or abscess formation is known as Deep Neck Space Infection (DNI) [1]. Fascial layers prevent this infection from involving important neck structures to some extent however infection can spread from one neck space to another easily travelling through these planes. DNIs are potentially life threatening but modern era experiences reduced mortality from deep neck infections [2, 3]. The reduction in mortality rate can safely be attributed to improved diagnostic techniques, availability of potent antibiotics and better surgical clearance due to better anesthesia techniques. Etiology is very varied ranging from but not limited to tonsillitis, dental caries, trauma, IV drug abuse, sialadenitis, and changing its trends with time [4]. Polymicrobial flora including Streptococci, Peptostreptococci, Staphylococci and anaerobes, in variable combinations, are the commonly grown organisms in the culture specimen of DNIs [5, 6]. Timely intervention (surgical drainage, debridement and airway management) is a mandate for favorable outcome. However no or inadequate treatment, associated co-morbidities and immunosuppressive conditions can divert the outcome towards various complications like mediastinitis, upper airway obstruction, septic emboli, erosion and rupture of carotid artery, venous thrombosis, septic shock and death [7].

This article presents review analysis of 52 cases of DNIs, managed at a tertiary health care center in year 2019, aims to describe the current epidemiological and etiological trends for deep neck space infections (DNIs) with an objective to understand the intricacies of their management.

Materials and Methods

Study Population

We conducted this retrospective analytical study at our tertiary health care center in the Department of Otorhinolaryngology and Head and Neck surgery by reviewing the patient records for the year 2019.

Patient Selection

We reviewed records of all the patients who were admitted with a diagnosis of deep neck space infection (DNI). Diagnosis was made mostly based on clinical assessment along with needle aspiration and/or radiological findings.

Exclusion Criteria

Patient records having superficial skin infections, peritonsillitis, non-suppurative lymphadenopathy, post traumatic or iatrogenic infections and infected tumours were not included.

Detailed Methodology

As per the institutional protocol all records showed that the patients received standard intravenous antibiotic therapy covering for both aerobic and anaerobic organisms responsible for DNIs. Therapy was later changed based on sensitivity reports. Required interventions (repeated needle aspiration or incision and drainage) were done considering the disease process. Airway management was done by means of surgical interventions, whenever needed.

Multiple parameters concerning epidemiology, etiology and management were analyzed (like demographic data, presentation with symptomatology, sites involved (single or multiple), microbiological reports, existing co-morbidities, hemoglobin levels, need for surgical intervention, duration of hospital stay and treatment outcomes) to attempt defining current trends and management intricacies related to DNIs.

Results

The following results were obtained from this study;

Epidemiological Analysis

We reviewed records of 52 patients, who were admitted to our center with a diagnosis of DNI in year 2019. Out of which 32 (62%) were males and 20 (38%) were females with a male to female ratio of 1.6:1. The age group ranged from 3 months to 70 years of age. Most of the patients records were from early age groups (Table 1). Age group 0–10 years had 14 (27%) patients and 11–20 years had 12 (23%) patients. Right side was involved in 46%, left in 39% and remaining 15% had midline/bilateral involvement.

Table 1.

Showing age distribution of study records

Age groups	Number of DNIs cases	Percentage (%)
0–10	14	26.92
11–20	12	23.07
21–30	6	11.55
31–40	5	9.61
41–50	7	13.61
51–60	6	11.53
61–70	2	3.84

Presentation to our center after onset of symptoms ranged from day 1 to day 45. Twenty nine (55.76%) patients presented to us within 7 days of onset of symptoms. One record showed presentation with a delay of 45 days and this patient was diagnosed to have tubercular etiology.

Patients with a primary complain of swelling were 40 (76.92%). Other complains were pain in swelling 37 (71.15%), tooth ache 21 (40.38%), trismus 20 (38.46), dysphagia 15 (28.84%), fever 14 (26.29%), odynophagia 9 (17.30%), feeding difficulty 5 (9.61%), dyspnoea 1 (1.92%) and pus discharge from swelling 1 (1.92%).

The involvement of various deep neck spaces were as per the Table 2 and Fig. 1. Submandibular space was the most commonly involved space with total of 22 (42.3%) cases. The second largest group of 11 (21.15%) patients had parapharyngeal space involved. Others had involvement of parotid (11.53%), masticator space (9.61%), submental space (5.76%), retropharyngeal space (3.84%), Ludwig’s angina (3.84%) and visceral space (1.92%). 73% patients had involvement of an isolated deep neck space and remaining had more than one spaces involved.

Table 2.

Distribution of involvement of deep neck spaces

DNS involved	Number of records	Percentage (%)
Submandibular	22	42.30
Parapharyngeal	11	21.15
Parotid	6	11.53
Masticator	5	6.61
Submental	3	5.76
Retropharyngeal	2	3.84
Ludwigs angina	2	3.84
Visceral space	1	1.92
Grand total	52	100

Fig. 1.

Various spaces involved in DNIs

Considering WHO guidelines for diagnosing anaemia based on haemoglobin levels, patient records were evaluated [8]. Based on this 32 (61.53%) were labeled anaemic, 9 (17.30%) had mild anaemia and 23 (44.23%) had moderate anaemia (Table 4). Our records showed only two patients with uncontrolled diabetes as co-morbidity, six patients had hypertension, controlled with medication. One female was in her second trimester of pregnancy.

Table 4.

Distribution of anaemia cases in reviewed records

Anaemia	Number of cases	Percentage (%)
Absent	20	38.46
Mild, present	9	17.30
Moderate, present	23	44.23
Grand total	52	100

Etiological Analysis

Etiological evaluations revealed that majority of cases were due to poor oro-dental hygiene resulting in dental caries or periodontal disease (Fig. 2). Orthopantomograms were obtained and these patients were managed in consultation with dental surgery department. 24 (46.15%) patients had odontogenic diseases and 20 (38.46%) patients had DNI because of odontogenic issues. 54.54% (12 out of 22) cases of submandibular space infection were caused by dental caries or periodontal disease. Episodes of Upper respiratory tract infection (URTIs)/tonsillopharyngitis accounted for 10 (19.23% cases). Other etiological attributes were sialadenitis for 4 (7.69%), parotitis for 3 (5.76%) and tubercular for 1 (1.92%) patient. However etiology for 14 (26.92%) cases remained unknown. Diabetes was present only in 2 patients as comorbidity.

Fig. 2.

Distribution of etiological factors for DNIs

Pus culture specimens showed no growth in 36 (69.23%) of specimens despite repeated cultures. Remaining specimen yielded mixed flora in six, MRSA in five, Streptococcus spp. in three, Staphylococcus spp. in one and Enterococcus spp. in one specimen samples. (Table 3 and Fig. 3).

Table 3.

Results of pus culture specimens of DNIs

PUS culture	Number of specimens	Percentage
No growth	36	69.23
Mixed flora	6	11.53
MRSA	5	9.61
Steptooccous spp.	3	5.76
Staphylococcus spp.	1	1.92
Enterococcus spp.	1	1.92
Grand total	52	100

Fig. 3.

Results of pus culture specimens of deep neck space abscess

Analysis Related to Management

10 patients were managed either conservatively or by repeated needle aspiration. 42 (80.76%) required open surgical drainage. Active airway management by tracheostomy was done for 2 patients. Tracheostomy was closed before discharging the patients in stable condition. All the patients had satisfactory outcome and were discharged in stable condition. Superficial venous thrombophlebitis and non-cosmetic surgical site scar were present in few cases. Records revealed that 28 patients were discharge in 1st week, 21 were in second, and 3 were discharge by the end of third week. The average duration of hospital stay for these patients remained 8.19 day, with a range of 3–21 day.

Discussion

Our study of records for deep neck space infections (DNIs) in revealed many important aspects of this disease process. The inferences drawn from this study can help clinicians dealing better with these potentially life threating conditions.

Epidemiological Trends

We documented male preponderance for DNIs, (Male:female is 1.6:1) by this analysis. The fact, that the odontogenic causes account for majority of cases of DNIs, can have implications in this as higher tobacco chewing habits and poor orodental hygiene in males can be held accountable for it. We also documented presence of periodontal disease/dental caries in 53.12% of males in comparison to only 45% in females, supporting the aforementioned correlation.

50% patient records of DNIs in this study belonged to early age groups. 27% were in their first decade and 23% in second. This differed from other studies documenting higher incidence in elderly age groups [3, 6]. This is attributable to factors such as longevity with comorbidities and intravenous drug abuse, which were either less or absent in our study records.

When charts were evaluated based on WHO guidelines for diagnosing anaemia based on haemoglobin levels, nearly up to 2/3rd of our patients were found to have mild to moderate anaemia (Table 4). This can be attributed to increased susceptibility of children for infections, as 50% of our patients in 1st decade of their life had anaemia. However we do not have any control data available with us in this respect, thus it needs further evaluation.

No significant difference was noted in side preference for DNIs. Right was involved in almost 46%, left in 39% and midline or bilateral involvement was noted in 15% of cases. Since we studied records of our tertiary care center where only 55.76% patients came within one week of onset of symptoms, almost 1/4th of the cases presented to us with more than one space involvement. Symptomatology of patients was also not very different from the usual DNIs presentation. Presenting complains of patients were with symptomatology in varying proportions including swelling, pain, dysphagia, odynophagia, trismus, difficulty in feeding dyspnea etc.

Our records showed only two patients with uncontrolled diabetes as co-morbidity, six patients had hypertension, controlled with medication. One female was in her second trimester of pregnancy. No other significant co-morbidity/altered physiological state was recorded.

Etiological Trends

We found comparability with the recent literature where the most common etiology considered was odontogenic [2–4, 6, 9, 10]. Older reports documented pharyngotonsillitis as the most common cause accounting for almost 70% of cases [11]. In our study we reported odontogenic causes to account for up to 54.54% of cases. Episodes of URTIs/tonsillopharyngitis were the second most common etiological attribute, accounting for almost up to 20% of cases. This change in etiology can easily be explained by the fact that in modern era URTIs are getting treated aptly and effectively with antibiotics. Increase in periodontal disease as an etiology in this particular study population can be considered because of tobacco chewing habits leading to poor orodental hygiene and periodontal diseases. Cases where the etiology cannot be identified were nearly 1/4th (26.92%) of the total records. This could have been due to resolution of the primary focus of infection (with the use of antibiotics prescribed by referring doctor) by the time patients presented to our tertiary care center.

Odontogenic infections can spread to the nearby areas including sublingual, submandibular, and masticator space. Thus submandibular space involvement was recorded in most of (42.3%) of our cases. Not only episodes of URTIs/tonsillopharyngitis can lead to parapharyngeal space infection, it can also be involved by direct continuous extension from submandibular, masticatory and parotid space and thus was the second most common site involved (21.15%). Involvement of masticator space can also be explained by odontogenic origin. Studies have reported Ludwig’s angina as a sequel to the odontogenic infections of 2nd or 3rd molar in varying proportions (up to 90% of cases) [12]. Retropharyngeal space involvement can also have varied etiology depending upon age of the patients. Pediatric age group is usually involved by suppurative lymphadenitis, while in adults it is mostly involved by trauma leading to direct inoculation, or by extension of infection from adjacent structures [13]. Since the prevalence of tuberculosis is high in this study population, tuberculous involvement of deep neck spaces is not very uncommon. Records also revealed one patient with tubercular etiology for DNI.

Management Intricacies

DNIs were diagnosed at our center based on clinical evaluation supplemented by required radiological assessment including X-rays, USG or Computed tomography. CT was done (mostly to note the extent of involvement of DNI) only when X-rays and USG had limitations in detailing required information. There are studies considering computed tomography as gold standard and suggest using it to evaluate the pediatric patients for retropharyngeal abscess [14, 15]. However we could diagnose an adult patient with retropharyngeal abscess using X-rays with characteristic findings of increased prevertebral soft tissue shadow (Figs. 4 and 5). However CT scan was done for follow up.

Fig. 4.

X-ray soft tissue neck showing increased prevertebral soft tissue shadow in a patient with retropharyngeal abscess

Fig. 5.

X-ray soft tissue neck showing improvement and decreased prevertebral soft tissue shadow of the same patient with retropharyngeal abscess with treatment

All of our patients were started with broad spectrum intravenous antibiotics (Amoxicillin with Potassium clavulanate and Metronidazole). Antibiotics were changed later either based on sensitivity reports or in case of no improvement with ongoing regime. Second line regime of antibiotics included clindamycin and amikacin for patient who had no growth on sequential cultures and were not responding to ongoing regime. Pus was sent for culture and sensitivity testing collected either by needle aspiration or during surgical drainage. Most of our record (69.23%) reported no growth. We hold prior use of antibiotics responsible for that to some extent, as many of the patients were taking antibiotics prescribed by their primary physician before presenting to this tertiary care center. In cases where growths were reported, it resembled other existing studies [16]. A low threshold was maintained for surgical interventions in DNIs, and thus tracheostomy was needed only for two patients. However younger patients/patients without existing co-morbidities or cases with limited collection confirmed by radiology were dealt with repeated needle aspiration or conservatively and 10 patients responded to this line of management. This corroborates with some older studies in view of conservative management [17].

Owing to appropriate surgical care along with younger patient profile and patients without significant co-morbidities we did not have complications of DNIs like jugular vein thrombosis, mediastinal involvement, pericarditis, pneumonia, arterial rupture or erosion and extra or intracranial extension of infections, reported in other older as well as newer studies [18–20]. Records revealed recovery of all patients with a variable duration of hospital stay ranging from 3 to 21 days, who were discharged in stable conditions.

Conclusion

Once feared as fatal, currently DNIs can be managed very effectively without much mortality. Early age groups (1st and 2nd decade of life), patients having low hemoglobin levels, periodontal disease and history of tobacco chewing are high risk groups for having DNIs. In attempts to look for etiology, an active search is to be made to find a cause by assessing oro-dental health of the patient, more so when DNIs involves submandibular space. While dealing with these infections, the management team should have high index of suspicion for diagnosis. Although low threshold for required surgical interventions is advocated, but selected cases can be given a conservative trial with close monitoring. Broad spectrum antibiotics should be used in cases of DNIs as 1st line regime and should be changed either based on the sensitivity reports (whenever available) or if patients are not responding with ongoing regime despite adequate surgical drainage (as most of the culture reports shows no growth). Active monitoring of airway along with emergency airway management skills are mandatory while managing such cases. Management of comorbidities like diabetes is equally important for these patients in order to avoid complications. We can have satisfactory outcome in patients with DNIs, if all the above mentioned intricacies are considered during management.

Funding

None.

Compliance with Ethical Standards

Conflict of interest

The authors declares that they have no conflict of interest.

Ethical Approval

Not required.