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Indian Journal of Otolaryngology and Head & Neck Surgery logoLink to Indian Journal of Otolaryngology and Head & Neck Surgery
. 2020 May 12;74(Suppl 2):1870–1876. doi: 10.1007/s12070-020-01869-y

Clinical Presentation and Microbiological Profile of Deep Neck Space Infections in Different Age Groups

Gaurang Singhal 1, Shalini Jain 1,✉, Kanwer Sen 1
PMCID: PMC9702455  PMID: 36452853

Abstract

Deep neck space infection (DNI), is defined as infections in the deep fascia enclosing potential spaces of the neck. In the past the diagnosis and treatment of DNI have challenged. The health care personnel at all levels. The complex anatomy and the deep location of this region remains a big problem with significant risks of morbidity and mortality. The aim of this study is to analyse the difference in clinical presentation and microbiology of DNI in different age groups. Eighty two patients with DNI which were managed at the Department of Otorhinolaryngology, ABVIMS and Dr. Ram Manohar Lohia Hospital New Delhi, between November 2017 and March 2019 formed the basis of our prospective cross sectional observational study. We observed that DNI is a frequent and potentially life threatening condition in children and adults despite the use of antibiotics. For appropriate surgical management knowledge of complex spaces of the neck and their communication with the other spaces is necessary.

Keywords: Deep neck spaces, Parapharyngeal, Spaces abscess, Ludwigs angina, MRSA (methicillin resistant Staphylococcus aureus)

Introduction

Deep neck space infection (DNI) is defined as the infection in the deep fascial enclosing potential spaces of the neck [1]. These spaces contains adipose tissue, blood vessels, lymphatics and sensory nerves. They extends from the superior aspect of the head down by the shoulders, axilla and thorax and includes the superficial musculoaponeurotic system [2]. The hyoid bone is attached by strong fasical attachments anteriorly and provides barrier to downwards spread of the infection. Deep neck spaces are thus classified as:

  • Those located above the hyoid bone (peritonsillar, mandibular, parapharyngeal, masticator/temporal, buccal and parotid spaces).

  • Those located below the hyoid bone (anterior visceral space).

  • Those involving the entire neck length (carotid, retropharyngeal, danger, prevertebral spaces).

Ludwig angina is bilateral gangrenous cellulitis of all three primary mandibular spaces [3]. The usual cause is an odontogenic infection from a submandibular molar, less commonly peritonsillar or parapharyngeal abscess, epiglottitis and penetrating injuries [4]. Patient complaints of severe trismus, drooling, inability to swallow, tachypnea, dyspnoea, airway compromise. It can extend posteriorly where it can cause gross swelling, elevation and displacement of the tongue and tense, brawny induration of the submandibular region superior to the hyoid bone. If left untreated may progress to abscess [3]. Figures 1 and 2.

Fig. 1.

Fig. 1

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Submandibular space abscess

Fig. 2.

Fig. 2

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X ray showing Submandibular space abscess

Parapharyngeal space/pharyngomaxillary space takes an inverted pyramid extending from base of middle cranial fossa to hyoid bone. It communicates with peritonsillar, submandibular, retropharyngeal, visceral, carotid, masticator and parotid region [3]. Common causes includes pharyngitis, tonsillitis, otitis, mastoiditis, parotitis and cervical lymphadenitis. Dental infections also contribute to parapharyngeal space infection. Prestyloid compartment infection presents with chills, fever, neck pain, trismus, and anterolateral displacement of the ipsilateral palatine tonsil. In poststyloid compartment infection carotid sheath contents involves leading to septicaemia, Limerre’s syndrome, carotid artery aneurysm or rupture, ipsilateral Horner’s syndrome and IX to XII cranial nerve palsies [5]. Figure 3.

Fig. 3.

Fig. 3

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Parapharyngeal space abscess

The microbiology of DNI is similar as the bacteria causing the infection reflects oropharyngeal (peritonsillar and parapharyngeal) or nasopharyngeal flora. Most bacterial cultures are polymicrobial [6]. Studies have isolated approximately 600 species of bacteria utilizing cultivation independent molecular methods. Normal aerobes, anaerobes, fungal, viruses and protozoans foud in the oral cavity. Commonly cultured organisms include Streptococcus viridands, Staphylococcus epidermidis, Staphylococcus aureus, Group A Beta haemolytic streptococcus (Streptococcus pyogenes), Bacteroides, Fusobacterium and Peptostreptococcus species. Cultures occasionally reveal Nisseria, Pseudomonas, Escherichia and Haemophilus species [3]. Intravenous drug users have much higher rates of MRSA and Eikenella Corrodens in DNI [7].

The proportion of community acquired methicilin resistant Staphylococcus aureus (MRSA) associated DNI is increasing specially in paediatric population [8–10]. Atypical organisms are a relatively common cause of DNI. Actinomyces are endogenous saprophytic organisms of the oral cavity and tonsil. The most common site of cervicofascial actinomycosis is in the vicinity of the angle of mandible. A granulomatous reaction and necrosis and sulfur granules are the characteristic. Patients with tuberculosis and nontuberculosis presents with cervical lymphadenopathy and caseating necrotising granulomatous inflammation. Bartonella henselae causes Cat scratch disease manifests with swollen, tender cervical lymph nodes and late lesions may form an abscess [3].

Materials and Methods

Patients with diagnoses of DNIs of paediatric and adult age group who were managed at the Department of ENT, ABVIMS, Dr. RML Hospital, New Delhi between Novemeber 2017 to March 2019 were include in the study.

Patients excluded from the study were as follows:

  • Patients with superficial space neck infections.

  • Patients who have received antibiotics for more than 48 h.

  • Infections secondary to traumatic or iatrogenic neck wounds.

Only clinically or radiologically diagonesed cases of DNI were includes in the study. Written and informed consent was obtained. Detailed history and examinations of the patients were done. Patients below 18 years of age were included in the paediatric age group while those who were 18 years are above were includes in the adult age group. Three blood samples were taken and each send to hematology department (total leucocyte count with differential leucocyte count), biochemistry department (blood sugar and serum electrolyte) and microbiology [C reactive protein and viral markers namely HIV, Hepatitis B Virus Antigen (HBsAg) and anti Hepatitis C Virus (HCV)] respectively.

Viral markers screening is imperative in our institute before taking up needle aspirations or any surgical procedure. This is because the incidence of needle prick infections of HIV, or Hepatitis B or C is on the rise.

As per a quote in Mail today, in a study by the microbiology department at AIIMS in 2016, 476 staff members were surveyed on self-reported injuries; 73.7 percent of doctors were hurt by needles at some point followed by 19.1 percent nurses and 3.2 percent of disposal staff. Of the workers, 2.5 percent were not vaccinated against HBV. Recently, a senior resident anesthetist suffered a “needle prick” on the job and later tested positive for Hepatitis B.

Radiological imaging techniques X-ray soft tissue neck lateral view ultrasonography and Computed tomography were used for the final diagnoses.

Pus was collected aseptically by needle aspiration within 24 h. and was sent in three parts for (1) culture and sensitivity, (2) anaerobic culture and (3) Acid Fast Bacilli (AFB) and antibiotic sensitivity. Incision and drainage was done at the earliest stage. All patients were empirically started on broad spectrum intravenous, amoxicillin and clavulanic acid, metronidazole and amikacin.

The antibiotics were modified based on culture sensitivity reports or clinical unresponsiveness if required. Supportive therapy in the form of intravenous fluids, analgesiscs, antipyretics, antiemetics, mouth washes etc. were given. All patients were kept under observation for impending or manifest respiratory distress.

Statistical Analysis

Descriptive statistics were analyzed with SPSS version 17.0 software. Continuous variables were presented as mean ± SD. Categorical variables were expressed as frequencies and percentages. The Pearson’s Chi square test of association was used to determine the relationship between two categorical variables.

To identify potential factors associated with deep neck space infection univariate analyses was performed. Multivariate logistic regression model was used to identify independent factors for deep neck space infection. A stepwise approach was used to enter new terms into the model, with a limit of p < 0.05 to enter the terms.

Result

In our study, 82 (mean age 31.45 years) patients presented to our institution with DNI. Out of 82 patients, 22 patients (26.83%, mean age 7.53 years) belonged to the paediatric age group, while 60 patients (73.17%, mean age 40.22 years), belonged to adult age group. Among 22 patients belonging to paediatric age groups, 12 patients (55.55%) were males while 10 patients (45.45%) were females; whereas among 60 patients in the adult age group, 42 patients(70%) were males and 18 patients (30%) were females. 25 (41.66%) patients out of 60 patients of the adult age group were diagnosed to have diabetes mellitus.

Spaces Involved

In paediatric age group out of 22 patients, 16 (72.73%) patients had submandibular space involvement followed by 2 cases (9.09%) of parapharyngeal space involvement and 1 case (4.55%) each of ludwig angina, parotid space involvement, peritonsillar space involvement and retropharyngeal space involvement. While in the adult age group, 12 cases (20%) had involvement of the peritonsillar space followed by 10 cases (16.67%) involving the parotid space, 8 cases (13.33%) involving the submandibular space, 7 cases (11.67%) each of which had involvement of anterior visceral space and ludwig angina. 4 cases (6.67%) had involvement of parapharyngeal space, 2 cases (3.33%) of which had involvement of retropharyngeal space and massetric space each. 1 patient (1.67%) had involvement of zygomatic space and 1patient (1.67%) had facial cellulitis. Among 60 patients of age group 6 (10%) patients were found to have multiple space involvement. The distribution of cases according to deep neck space involved in paediatric and adult age group is statistically significant (p = 0.0006).

Clinical Presentation

In paediatric age group, the most common presenting symptom in submandibular space involvement was neck swelling and fever in 100% cases followed by odynophagia in 56.25%, pain and trismus in 25% each and dysphagia in 6.25%. While in case of ludwig angina among paediatric age group, the presenting symptoms were neck swelling and fever.

Among paediatric age group, all patients with parapharyngeal space involvement presented with neck swelling, fever, odynophagia, trismus and pain followed by dyspahgia in 50% cases.

The most common presenting symptom involving the submandibular space in adult age group was neck swelling and fever which was seen in 100% cases followed by odynophagia (50%), pain (50%) and trismus (12.50%). While in cases of ludwig angina in adult age group, neck swelling and odynophagia (100%) were the most common presenting symptom followed by fever (85.71%), pain (57.14%), dysphagia (28.57%), trismus (28.57%) and change in voice (14.29%). In cases of peritonsillar space involvement in adult age group odynophagia was the most common presenting symptom (100%) followed by fever (50%) and pain (25%). Facial swelling (100%) was the most common symptom in patients having parotid space infection in adult age group, followed by trismus (60%), pain (50%), odynophagia (40%) and fever (30%). In patients having involvement of the anterior visceral space in adult age group both neck swelling and pain (100%) were the most common presenting symptoms followed by fever (71.43%), dysphagia (57.14%) and change in voice (14.28%). Neck swelling, trismus and odynophagia were seen in 100% cases with parapharyngeal space infection in adult age group followed by fever (75%), dysphagia (50%) and pain (25%). Refer Table 1 for distributions of patients according to symptoms and spaces involved in Paediatric and Adult age group.

Table 1.

Distribution of patients according to clinical presentation in Adult and Paediatric groups

Space involved Clinical presentation
Facial swelling Neck swelling Fever Change in voice Difficulty in breathing
Paediatric group Adult group Paediatric group Adult group Paediatric group Adult group Paediatric group Adult group Paediatric group Adult group
Anterior neck space 0(0.00%) 0(0.00%) 0(0.00%) 7(100.00%) 0(0.00%) 5(71.43%) 0(0.00%) 1(14.29%) 0(0.00%) 0(0.00%)
Facial cellulitis 0(0.00%) 1(100.0%) 0(0.00%) 0(0.00%) 0(0.00%) 1(100.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%)
Ludwigs angina 0(0.00%) 0(0.00%) 1(100.00%) 7(100.00%) 0(0.00%) 6(85.71%) 0(0.00%) 1(14.29%) 0(0.00%) 0(0.00%)
Masseteric space 0(0.00%) 2(100.0%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%)
Multiple space 0(0.00%) 3(50.00%) 0(0.00%) 6(100.00%) 0(0.00%) 6(100.00%) 0(0.00%) 1(16.67%) 0(0.00%) 3(50.00%)
Parotid space 1(100.0%) 10(100.0%) 0(0.00%) 0(0.00%) 0(0.00%) 3(30.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%)
Para pharyngeal space 0(0.00%) 0(0.00%) 2(100.00%) 4(100.00%) 2(100.00%) 3(75.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%)
Peritonsillar space 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%) 1(100.00%) 6(50.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%)
Retro pharyngeal space 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%) 1(100.00%) 0(0.00%) 1(100.00%) 1(50.00%) 1(100.00%) 2(100.00%)
Submandibular space 0(0.00%) 0(0.00%) 16(100.00%) 8(100.00%) 15(100.00%) 8(100.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%)
Zygomatic space 0(0.00%) 1(100.00%) 0(0.00%) 0(0.00%) 0(0.00%) 1(100.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%)
p-value0 0.032 0.009 0.026 1 1
Space involved Clinical presentation
Dysphagia Odynophagia Pain Trismus
Paediatric group Adult group Paediatric group Adult group Paediatric group Adult group Paediatric group Adult group
Anterior neck space 0(0.00%) 4(57.14%) 0(0.00%) 0(0.00%) 0(0.00%) 7(100.00%) 0(0.00%) 0(0.00%)
Facial cellulitis 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%) 1(100.00%) 0(0.00%) 0(0.00%)
Ludwigs angina 0(0.00%) 2(28.57%) 1(100.00%) 7(100.00%) 0(0.00%) 4(57.14%) 0(0.00%) 2(28.57%)
Masseteric space 0(0.00%) 0(0.00%) 0(0.00%) 1(50.00%) 0(0.00%) 2(100.00%) 0(0.00%) 1(50.00%)
Multiple space 0(0.00%) 3(50.00%) 0(0.00%) 6(100.00%) 0(0.00%) 5(83.33%) 0(0.00%) 6(100.00%)
Parotid space 0(0.00%) 0(0.00%) 1(100.00%) 4(40.00%) 1(100.00%) 5(50.00%) 0(0.00%) 6(60.00%)
Para pharyngeal space 1(50.00%) 2(50.00%) 2(100.00%) 4(100.00%) 2(100.00%) 1(25.00%) 2(100.00%) 4(100.00%)
Peritonsillar space 0(0.00%) 0(0.00%) 1(100.00%) 12(100.00%) 1(100.00%) 3(25.00%) 0(0.00%) 0(0.00%)
Retro pharyngeal space 1(010.00%) 2(100.00%) 1(100.00%) 2(100.00%) 0(0.00%) 1(50.00%) 0(0.00%) 0(0.00%)
Submandibular space 0(0.00%) 1(6.25%) 9(56.25%) 4(50.00%) 4(25.00%) 4(50.00%) 4(25.00%) 1(12.50%)
Zygomatic space 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%) 0(0.00%) 1(100.00%) 0(0.00%) 0(0.00%)
p-value0 0.539 0.897 0.103 0.601
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Microbiology

Among 82 patients included in our study, bacteria were isolated in 54 (65.85%) cases. In paediatric age group, Staphylocccus aureus was the most common bacteria isolated in 8 cases (36.36%) among followed by methicillin resistant Staphylococcus aureus (MRSA) in 7 cases (31.82%), Escherichia coli and Klebsiella species in 2 cases (9.09%) each and Streptococcus viridans in 1 case (4.55%). Similarly in the adult age group, Staphylococcus aureus was the most common bacteria isolated among 11 cases (18.33%) followed by Klebsiella species in 9 cases (15%). Other bacteria isolated were Escherichia coli in 3 cases (5%) MRSA and Streptococcus viridans in 2 cases (3.33%) and Enterococcus faecum, Enterococcus species, Streptococcus species, Pseudomonas species and Klebsiella pneumoniae in 1 case (1.67%) each. Polymicrobial infections were seen in 2 cases (8%) who were diabetics. Klebsiella species was the most common organism isolated in 6 (24%) cases in diabetic patients. Other organisms isolated in diabetic patients were Staphylococcus aureus in 4 (16%) cases and Escherichia coli, MRSA and Pseudomonas species in 1 (4%) cases each. The distribution of patients according to microbiology in adult and paediatric age group is significant (p = 0.026).

Discussion

In the present study, total 82 cases of DNI were included and all patients underwent a thorough clinical examination. Out of 82 patients, 22 patients (26.83%) belonged to the paediatric age group, while 60 patients (73.17%), belonged to adult age group. 25 (41.66%) patients out of 60 patients of the adult age group were diagnosed to have diabetes mellitus.

The most common space involved in paediatric age group was submandibular space (72.73%), followed by parapharyngeal space (9.09%), ludwig angina, parotid space, peritonsillar space and retropharyngeal space in (4.55%) each. While in study done by, Huang et al. [11] reported that parapharyngeal space was the most common space involved followed by submandibular space, retropharyngeal space and peritonsillar space. Multiple space involvement was also seen in paediatric age group. Similar results were observed by Yang et al. [12], parapharyngeal space being the most common site involved followed by submandibular space.

The most common space involved in adult age group as peritonsillar space (20%), followed by parotid space (16.67%), submandibular space (13.33%), anterior visceral space and ludwig angina (11.67%) each, parapharyngeal space (6.67%), retropharyngeal space and massetric space (3.33%) each, zygomatic space and facial cellulitis (1.67%) each. 10% patients were found to have multiple space involvement.

Kauffman et al. [13] and Huang et al. [11] found parapharyngeal space as the most commonly involved space while submandibular space involvement was reported by Adoviča et al. [14], Das et al. [15] and Marioni et al. [16] as the most common space involved. Adults tend to have higher chances of multiple space involvement [12]. The distribution of space involved in the paediatric and adult agegroup found to be satistically significant.

Among diabetic patients most common space involved were anterior visceral space, peritonsillar space and submandibular space in 16% each, followed by parotid space, parapharyngeal space, retropharyngeal space and ludwig angina in 8% each and facial cellulitis and massetric space 4% each. 12% patients had multiple space involvement. Whereas Sharma et al. [17] in their study reported that parapharngeal space was the most common space involved in diabetic patients.

In paediatric age group, the most common presenting symptom in submandibular space involvement was neck swelling and fever in 100% cases followed by odynophagia, pain, trismus and dysphagia. While in case of ludwig angina among paediatric age group, the presenting symptoms were neck swelling and fever. Among paediatric age group, all patients with parapharyngeal space involvement presented with neck swelling, fever, odynophagia, trismus and pain followed by dyspahgia. In case of retropharyngeal space infection in paediatric age group the presenting symptoms were fever, respiratory difficulty, change in voice, odynophagia and dysphagia in all patients. In peritonsillar space involvement among paediatric age group, fever, pain and odynophagia were the presenting symptoms in all cases.

Similarly Huang et al. [11] in their study found that, all patients with submandibular space infection had neck swelling followed by fever. Neck swelling was also frequently found in patients with parapharyngeal space involvement followed by fever and dysphagia. Fever was common in patients with retropharyngeal infection while some had neck swelling and dysphagia. All patients with peritonsillar infection had fever followed by dysphagia.

All cases involving the submandibular space in adult age group presented with neck swelling and fever followed by odynophagia, pain and trismus. While in cases of ludwig angina in adult age group, neck swelling and odynophagia were the most common presenting symptom followed by fever, pain, dysphagia, trismus and change in voice.

Study conducted by Das et al. [15] found that in the adult age group, the most common presenting symptom was neck pain and neck swelling while the most common physical finding was swelling of neck, pain or stiffness during passive movement of neck and trismus. Similarly Eftekharian et al. [18] in their study reported neck swelling as the most common presenting symptom whereas Crespo et al. [19] reported neck swelling as the most common clinical finding.

The distribution of facial swelling, neck swelling and fever among DNI in paediatric and adult age group are found to be significant.

Staphylocccus aureus was the most common bacteria isolated (36.36%) among the paediatric age group followed by MRSA (31.82%), Escherichia coli, Klebsiella species and Streptococcus viridans. Our result was similar to the study conducted by, Huang et al. [11] which reported that Staphylococcus aureus was the most common organism isolated followed by Klebsiella pneumoniae, Streptococcus viridans, Mycobacterium tuberculosis and anaerobes. Similarly Shimizu et al. [20] also reported that Staphylococcus aureus was the most common pathogen involved in paediatric age group. While Celakovsky et al. [21] and Yang et al. [12] found Streptococcus pyogenes to be the most common pathogen in paediatric age group.

In the adult age group, Staphylococcus aureus was the most common bacteria isolated (18.33%) followed by Klebsiella species (9%), Escherichia coli, Streptococcus viridans, MRSA, Enterococcus faecum, Enterococcus species, Streptococcus species, Pseudomonas species and Klebsiella pneumoniae. Das et al. [15] reported in their study that Staphylococcus aureus was the most common organism as seen in our study followed by Enterococcus species, Streptococcus viridans, Klebsiella pneumoniae, Escherichia coli, Diptheriod and nonhemolytic streptococci. Similarly Boscolo-Rizzo et al. [22], Huang et al. [11] and Meher et al. [23] reported Staphylococcus aureus as the most common isolate. Whereas Huang et al. [24], Tsai et al. [25] and Hidaka et al. [26] reported Streptococcus to be the most common pathogen. Distribution of microbiology in paediatric and adult age group is found to be statistically significant.

Among diabetics, Klebsiella species was the most common organism isolated (24%) cases in. Other organisms isolated were Staphylococcus aureus, Escherichia coli, MRSA and Pseudomonas species. Polymicrobial infections were seen in 8% cases. In the study conducted by Sharma et al. [17] reported that Klebsiella was the most common pathogen isolated among the diabetics. Similarly Yang et al. [12], Huang et al. [24] and Hidaka et al. [26] in their study also found that Klebsiella pneumonia was the commonest organism isolated. However Hidaka et al. [26] reported that Streptococcus pyogenes was most common organism followed by Staphylococcus aureus. Klebsiella was seen only in 4% cases.

Conclusion

DNI remains a frequent and potentially life threatening condition in both children and adults despite the use of antibiotics. For appropriate surgical management knowledge of the complex spaces of the neck and their communication with other spaces is necessary. Location of the DNI may provide information about the origin of the infection and the likely organisms that causes the infection, this will benefit in the empirical therapy that is to be instituted. There is scope of more investigational studies including early interventional techniques for better and early evaluation of Deep Neck space infection.

Key Message

Early medical and surgical modality should be implemented in all types of Deep Neck space infection to minimize morbidity and mortality.

Funding

No source of support.

Compliance with Ethical Standards

Ethical clearance was obtained from the Institutional Ethical Committee.

Conflict of interest

None of the authors declare conflicts of interest.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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