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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 17-20

Deep neck space infection: Are we overlooking the elderly?


Department of ENT and HNS, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Date of Web Publication24-Apr-2019

Correspondence Address:
Dr. Shankar P Shah
Department of ENT and HNS, B.P. Koirala Institute of Health Sciences, Dharan
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_6_18

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  Abstract 


Context: Deep neck space infections (DNSIs) are unique among infectious diseases for potential life-threatening complications. Its early recognition is therefore challenging and a high index of suspicion is necessary to avoid any delay in treatment. Aims: This study aims to analyze the age, sex, source, nature, associated systemic conditions, neck spaces involved, and the bacteria isolated in patients with DNSIs. Settings and Design: A prospective, descriptive study was conducted in the Department of ENT and HNS, B.P. Koirala Institute of Health Sciences, Dharan, Nepal for a period of 2 years from August 2014 to July 2016. Subjects and Methods: All patients with DNSI who required hospitalization were included, whereas those with superficial skin soft-tissue infections, infections due to traumatic or surgical wounds or tumors were excluded. Statistical Analysis Used: The data were recorded on a pro forma and analyzed using Microsoft Excel 2007 (Microsoft, WA, USA). Results: Out of the 76 patients, 25 patients were >50 years of age (32.89%). Male: female ratio was 1:1.17. The most common source was dental infection occurring in 32 cases (42%). Diabetes mellitus was the most common associated systemic condition (4 cases). Submandibular and peritonsillar spaces were most commonly involved. A sterile culture was seen in the majority (18/32). Staphylococcus aureus and Escheria coli were the predominant bacteria isolated. Conclusions: DNSI is a common condition in the elderly populations. Odontogenic infection and diabetes mellitus are the predisposing factors. S. aureus and E. coli are the common causative agents.

Keywords: Abscess, deep neck infection, dental focal infection, Ludwig's angina


How to cite this article:
Shah SP, Chetri ST, Sah BP, Mishra S, Singh AK, Gautam S. Deep neck space infection: Are we overlooking the elderly?. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2018;2:17-20

How to cite this URL:
Shah SP, Chetri ST, Sah BP, Mishra S, Singh AK, Gautam S. Deep neck space infection: Are we overlooking the elderly?. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2018 [cited 2019 Jul 19];2:17-20. Available from: http://www.aiaohns.in/text.asp?2018/2/2/17/256994




  Introduction Top


Deep neck space infections (DNSIs) pose a clinical challenge for the head and neck surgeon in their versatility and potential for complications. Deep neck infections usually start as cellulitis in the soft tissues adjacent to the source of upper aerodigestive 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 fascia into to the mediastinum.[1]

In the preantibiotic era, 70% of DNSIs arose from tonsillitis or pharyngitis, while nowadays, although tonsillitis remains the most common cause in children, poor dental hygiene and intravenous drug abuse have become the most common nonsurgical causes of DNSI in adults, followed by foreign body ingestion and infections of unknown origin.[2],[3] In addition, a growing number of patients who have immune dysfunction, as in diabetes mellitus and human immunodeficiency virus infection, are at risk for atypical and more complicated cases of DNI.[4]

Odontogenic infections usually have anaerobic bacteria as pathogens, while aerobic bacteria are more often found in patients with trauma or DNSIs of unknown etiology.[5],[6] Therefore, to effectively manage such infections, one must have an extensive knowledge of the deep neck anatomy, etiology, microbiology, risks factors, and predisposing factors that aggravate the deep neck infections.

The aim of this study was to analyze the age, sex incidence, source, nature of infection, associated systemic conditions, neck spaces involved, and the organisms isolated in patients with DNSIs.


  Subjects and Methods Top


A prospective, descriptive study was conducted in the Department of ENT and HNS, B.P. Koirala Institute of Health Sciences, Dharan, Nepal for a period of 2 years from August 2014 to July 2016. All patients with DNSI presenting to the Emergency or the hospital OutPatient Department and requiring admission were included in the study, whereas those with superficial skin and soft-tissue infections of the neck, isolated salivary gland infection without deep neck space involvement, infections due to external neck wounds (traumatic or surgical), and head and neck tumors were excluded. The ethical approval was obtained from the Institutional Ethical Review Board and informed and written consent was obtained from all of the patients. All the cases were evaluated by history, clinical examination, routine blood investigations, and ultrasonography (USG) or computed tomography (CT)-scan of the neck as indicated. The patients who fulfilled the inclusion criteria were enrolled in the study. They were begun on intravenous penicillinase-stable antibiotics either cloxacillin (25–50 mg/kg body weight in divided doses q6 h) in combination with metronidazole (10 mg/kg body weight q8 h) or third-generation cephalosporin (50 mg/kg body weight q12 h). Clindamycin was also the drug of choice when the DNSIs originated or involved the salivary glands. Surgical serial aspiration or incision and drainage was performed as indicated. The data were recorded on a pro forma and analyzed according to frequency using Microsoft Excel 2007 (Microsoft, Redmond, WA, USA).


  Results Top


Among the 76 patients included in our study, the most common age group was patients >50 years of age which included 25 patients (32.89%). The age of the patients ranged from 7 months to 80 years. The second most common age group was those below 10 years [Figure 1]. Females (41) outnumbered the males (35) and the Male:female ratio was 1:1.17.
Figure 1: Age distribution.

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The most common source was dental infection occurring in 32 cases (42%). This was confirmed by a dental surgeon. In the present series, the second most common site of origin was secondary to infection of pharyngotonsillar structures (6 cases, 7%). Other causes were furunculosis of skin seen in four cases. Submandibular duct calculi and duck bone impaction were the sources in one each. No obvious etiology was detected in 32 cases [Figure 2]. Diabetes mellitus was the most common associated systemic condition (4 cases). Tuberculosis, anemia, immunosuppressive drugs intake for rheumatoid arthritis, cerebrovascular antecedents with hemiplegia, and pregnancy were other associated factors [Figure 3].
Figure 2: Source of infection.

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Figure 3: Associated comorbidities.

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Submandibular and peritonsillar spaces were most commonly involved in 32% (25/76) and 17% (13/76), respectively. The other spaces that were involved were parotid space (n = 10), submental space (n = 3), and retropharyngeal and masticator space in one each. There was also suppuration of thyroid in six cases [Figure 4]. Multiple space was involved in 18 cases.
Figure 4: Involved space (single).

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Abscess (69%) was more common than cellulitis (31%). While cases of abscess required surgical intervention, cellulitis resolved with medication only. Surgical incision and drainage of abscess were performed in 37 patients. Abscesses in the submandibular space were accessed through an external approach about 2.5 cm below the body of the mandible. One case of parapharyngeal abscess required drainage by an external transcervical approach. The parapharyngeal space was opened through an incision along the anterior border of the sternocleidomastoid muscle, and in one patient, the incision was made through the posterior pharyngeal wall to drain the retropharyngeal abscess after removal of the impacted duck bone. Serial aspiration of the abscess alone was sufficient in 7 cases, whereas 5 cases required incision and drainage when the abscess did not resolve with needle aspiration. The abscess ruptured and drained spontaneously in two cases obviating the need for any surgery. All patients in our series recovered completely without any sequelae.

A sterile culture was seen in the majority (18/32). Staphylococcus aureus (9/32) and Escheria coli were the most common bacteria isolated. Streptococcus, Providencia, and Klebsiella were also cultured in one each patient.


  Discussion Top


Geriatric medicine evolved because of the need for specialized care for the aging population. As such, an understanding of these unique problems allows for the delivery of qualitative health-care services to this class of people.[7] Not many studies have been conducted on the pattern of ENT condition common among elderly in our country. Pattern of otorhinolaryngology head and neck diseases in Outpatient Clinic vary depending on the countries. A retrospective study done on the patients seen in the ENT outpatient department clinic in Malaysia revealed allergic rhinitis to be the most common condition,[8] whereas another study conducted in Turkey[9] showed ear and hearing disorder to the most common disorder that brought the elderly to the hospital.

The objective of our study to determine the epidemiology of DNSI and we found that in our series about a third of the patient were elderly population >50 years which included 25 patients (32.89%). The eldest patient in our series was an 80-year-old female who had developed submandibular abscess following dental caries. Under cover of intravenous antibiotics, she had undergone incision and drainage of abscess from which 15 ml of frank pus was drained. The pus was sterile on culture. There are few series which report DNSIs to be common around the age of 45 years.[10],[11] The coincidental finding in our study may serve as a platform for research in the future and analysis on a larger sample. In a country plagued by civil war for the last decade, compelling the young productive population to leave the country in search of better opportunity abroad often the elderly are left behind in the mountainous countryside, and this may be the cause of their lack of attention and therefore the high prevalence in this age group.

As a large proportion of DNSIs (43% in this study) were found to be of odontogenic origin, it is very important that treatment be performed in close cooperation with the dental surgeon. A dental surgeon often at times may drain infections orally at an early stage thereby preventing the cellulitis from spreading to the spaces of the neck. Our series also included 6 cases of not very common thyroid abscess, 5 of which were managed with serial aspiration followed by incision and drainage whereas one with serial aspiration. A subtle correlation was found between the source of infection and the space involved. Dental infections primarily involved the submandibular space or while upper respiratory tract infections tended to involve the parapharyngeal space and peritonsillar space, as found in other studies.[10],[12]

Ultrasound is a potential tool for the diagnosis of DNSIs. They help to delineate the spaces involved and to differentiate cellulitis from an abscess or a lymphadenopathy. CT scans of the head and neck area are very useful in monitoring DNSIs. Although magnetic resonance imaging scans may be better for diagnostic purposes, they are more difficult to perform in practice as they require good patient compliance.[10] Although routine CT is indicated for DNSIs, the cost is also an important factor in an economically deprived nation like ours and was performed after USG of neck seemed inadequate.

The choice of antibiotics when a DNSI is suspected depends on the bacteria cultured. In our study, only 14/32 cultures displayed growth. This is comparable to a study by Stalfors et al.[10] where no growth was seen in 15 of 39 specimens of deep neck abscess sent for culture. This may be due to the administration of antibiotics before taking the sample for culture. Another probable explanation for the high negative culture could be due to the presence of anaerobic organisms, and in our center, the facility for culturing of anaerobic organism does not exist. Further, studies of DNSIs should be conducted using proper techniques for culturing of anaerobic bacteria and the specimens taken before administering any antibiotics, perhaps using fine-needle aspiration.[6]

There is great uncertainty concerning the optimal treatment and choice of antibiotics when a DNSI is suspected.[12] An optimal medical treatment in our case included penicillinase-stable antibiotics, for example, a cephalosporin or cloxacillin in combination with an anti-anaerobic drug, such as metronidazole. Clindamycin may also be the drug of choice when the DNIs originated or involved the salivary glands. The anticipated bacteria also depends on the portal of entry/origin of the infection, which must be considered when the choosing therapy


  Conclusions Top


DNSI is a common condition in the elderly populations. Odontogenic infection and diabetes mellitus are the predisposing factors. Early diagnosis, aggressive antibiotic therapy, and surgical intervention are the cornerstones to successfully treat DNIs. Prompt recognition of dental caries and its restoration is of paramount significance. S. aureus and E. coli are the common causative agents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Daramola OO, Flanagan CE, Maisel RH, Odland RM. Diagnosis and treatment of deep neck space abscesses. Otolaryngol Head Neck Surg 2009;141:123-30.  Back to cited text no. 1
    
2.
Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, González-Valdepeña H, Bluestone CD, et al. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995;112:375-82.  Back to cited text no. 2
    
3.
Parhiscar A, Har-El G. Deep neck abscess: A retrospective review of 210 cases. Ann Otol Rhinol Laryngol 2001;110:1051-4.  Back to cited text no. 3
    
4.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am 2008;41:459-83, vii.  Back to cited text no. 4
    
5.
Bartlett JG, Gorbach SL. Anaerobic infections of the head and neck. Otolaryngol Clin North Am 1976;9:655-78.  Back to cited text no. 5
    
6.
Brook I. Microbiology of abscesses of the head and neck in children. Ann Otol Rhinol Laryngol 1987;96:429-33.  Back to cited text no. 6
    
7.
Okhakhu AL, Okolugbo NE, Onyeagwara NC. Pattern of otolaryngological disorders amongst geriatric population in Benin City, Nigeria. Int J Mod Altern Med Res 2013;1:14-19.  Back to cited text no. 7
    
8.
Sing T. Pattern of otorhinolaryngology head and neck diseases in outpatient clinic of a Malaysian hospital. Int J Head Neck Surg 2006;2.  Back to cited text no. 8
    
9.
Özler GS, Yengil E. Why do geriatric patients visit otorhinolaryngology? Ear Nose Throat J 2016;95:224-9.  Back to cited text no. 9
    
10.
Stalfors J, Adielsson A, Ebenfelt A, Nethander G, Westin T. Deep neck space infections remain a surgical challenge. A study of 72 patients. Acta Otolaryngol 2004;124:1191-6.  Back to cited text no. 10
    
11.
Kinzer S, Pfeiffer J, Becker S, Ridder GJ. Severe deep neck space infections and mediastinitis of odontogenic origin: Clinical relevance and implications for diagnosis and treatment. Acta Otolaryngol 2009;129:62-70.  Back to cited text no. 11
    
12.
Kim HJ, Park ED, Kim JH, Hwang EG, Chung SH. Odontogenic versus nonodontogenic deep neck space infections: CT manifestations. J Comput Assist Tomogr 1997;21:202-8.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Subjects and Methods
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