Head and neck space infections

Head and neck space infections

Otolaryngology–Head and Neck Surgery (2006) 135, 889-893 ORIGINAL RESEARCH Head and neck space infections Varqa Larawin, MMed, James Naipao, MMed, a...

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Otolaryngology–Head and Neck Surgery (2006) 135, 889-893


Head and neck space infections Varqa Larawin, MMed, James Naipao, MMed, and Siba P. Dubey, MS, Papua, New Guinea OBJECTIVE: The purpose of this study was to evaluate the incidence, causes, management, and complications of the different head and neck space infections in a Melanesian population. STUDY DESIGN AND SETTING: We conducted a retrospective study in a tertiary referral and teaching hospital. RESULTS: Of the total 103 patients with deep neck space infections (DNSI), odontogenic causes and suppurative lymphadenitis were responsible in 62 (60%) patients. A wide range of DNSI was encountered in our series. Ludwig’s angina was the most commonly encountered infection seen in 38 (37%) patients, whereas prevertebral abscess was only seen in 1 (1%) patient. A combination of surgical drainage and medical treatment was the main mode of treatment. Nine (8.7%) patients with DNSI with upper airway obstruction underwent tracheostomy; 9 (8.7%) patients with DNSI succumbed to their infection. CONCLUSION: DNSI needs early detection and aggressive management in order to evade dreaded complications. © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.


ead and neck space infections are simply defined as infections that spread along the fascial planes and spaces of the head and neck. They can be divided into superficial and deep neck space infections.1 Superficial neck space infections are usually easy to treat. In contrast, deep neck space infections (DNSI) are difficult to diagnose early. Even in the modern antibiotic era, life-threatening complications, namely, airway compromise, jugular vein thrombosis, mediastinal involvement, pericarditis, pneumonia, emphysema, arterial erosion, and extracranial and intracranial extensions may develop due to delays in diagnosis and treatment of DNSI.2-5

From the Department of Ear, Nose, and Throat (Drs Larawin, Naipao, and Dubey); Port Moresby General Hospital, Papua New Guinea; and School of Medicine and Health Sciences (Dr Dubey); University of Papua New Guinea.

This article is a retrospective review of DNSI in the Melanesian patients of Papua New Guinea.

METHODS This study is composed of 103 cases of head and neck space infections that were admitted to Port Moresby General Hospital and managed by the Otolaryngology–Head and Neck Division, from January 1, 1993 to August 31, 2005. In our institution we have no Institutional Review Board. However, all patients admitted to our hospital are informed about their participation in any research project as it is a teaching hospital. They then sign a special consent attached to the admission chart that allows them and their medical records to be used for research purposes. In the case of minors, their parents are informed and consent is sought on behalf of the patient. All the relevant clinical, hematologic, radiologic, and treatment details of these patients are gathered from their clinic and admission chart records. Subsequently, these data are analyzed.

RESULTS Of the 103 cases of DNSI, Ludwig’s angina was seen in 38 (37%) cases, submandibular space infection in 28 (27%), masticator space infection in 14 (13%), parapharyngeal abscess in 11 (11%), parotid space abscess in 6 (6%), retropharyngeal abscess in 5 (5%), and prevertebral abscess in 1 (1%). The symptoms of DNSI were fever in 84 (82%) cases, neck swelling in 70 (68%), trismus in 53 (51%), facial swelling in 46 (45%), cutaneous erythema in another 46 Reprint requests: Dr S. P. Dubey, Post Box 3265, Boroko, National Capital District, Papua New Guinea. E-mail address: [email protected]

0194-5998/$32.00 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2006.07.007


Otolaryngology–Head and Neck Surgery, Vol 135, No 6, December 2006

Table 1 Causes of deep neck space infection (n ⴝ 103) Deep neck space infection Cause









Odontogenic Suppurative lymphadenitis Upper respiratory infection Sialolithiasis Parotitis Otogenic Trauma Foreign body ingestion HIV/AIDS NIDDM TB Unknown Total

25 3 1 7 — — 2 — — 1 — — 39

10 11 6 1 — — — — — — — — 28

13 — — — — — 1 — — — — — 14

— — 2 — — 5 — 2 2 — 1 1 13

— — — — 6 — — — — — — — 6

— — 3 — — — — — — 1 1 — 5

— — — — — — — — 1 — — — 1

48 14 12 8 6 5 3 2 3 2 2 1 106

LD, Ludwig’s angina; SS, submandibular space; MS, masticator space; PP, parapharyngeal; PO, parotid; RP, retropharyngeal abscess; PV, prevertebral.

(45%), dysphagia in 27 (26%), toothache in 23 (22%), and stridor in 9 (9%). Odontogenic causes were seen in 48 (47%) cases with DNSI (Table 1). In 14 (14%) cases, the causes were attributed to suppurative lymphadenitis, in 12 (12%) to upper respiratory infections, in 8 (8%) to sialolithiasis, in 6 (6%) to parotitis, in 5 (5%) to otogenic causes, in 3 (3%) to trauma, and in 2 (2%) to ingested foreign bodies (Table 1). In 6 (6%) cases, no cause was found. A total of 7 (7%) cases had associated systemic diseases. Two patients had acquired immunodeficiency syndrome (AIDS). Another had AIDS with tuberculous (TB) lymphadenitis. Two patients had non–insulin dependent diabetes mellitus (NIDDM). One patient each had TB lymphadenitis and protein-energy malnutrition, respectively. The incidences of DNSI by age are described in Table 2. In the 0 to 18 age group, submandibular space infections were seen in 18 (43%) patients, Ludwig’s angina in 12 (29%), retropharyngeal abscess in 4 (10%), parotid and masticator spaces each in 3 (7%), and parapharyngeal in 2 (5%).

Conventional radiology, orthopantomogram (OPG), ultrasonography (USG), and in selected cases computed tomography (CT) were used to detect the extent of inflammation and the location of the pus. Once a diagnosis was made, airway protection and intravenous antibiotics were given, and incisions and drainage were made (Table 3). The common parenteral antibiotics used in different combinations were chloramphenicol, metronidazole, flucloxacillin, gentamycin, and ceftazidime. A dentist’s opinion was sought regularly in all cases of DNSI. In 27 (25%) patients, the dentist did tooth extraction and evacuation of dental abscess during the emergency drainage of the abscess by the otolaryngologist. In 17 (17%) cases, dental procedures were performed separately from the otolaryngologic procedures. The complications of DNSI are shown in Table 4. Nine (8.3%) patients had upper airway obstruction for which they underwent tracheotomies. Five (5%) patients developed recurrence of their abscess and hence needed re-exploration. Four (4%) patients developed discharging sinuses over their abscess sites. Another four (4%) patients with parapharyn-

Table 2 Age distribution of DNSI (n ⴝ 103) Space

0 to 12 yr

13 to 16 yr

17 to 18 yr

0 to 18 yr Total (%)*

19 yr and over

Submandibular Ludwig’s Retropharyngeal Parotid Parapharyngeal Masticator Prevertebral Total (%)†

18 5 4 3 2 1 — 33 (32)

— 4 — — — 1 — 5 (5)

— 3 — — — 1 — 4 (4)

18 (43) 12 (29) 4 (9) 3 (7) 2 (5) 3 (7) — 42 (40)

10 26 1 3 9 11 1 61 (60)

*Percentage of 42 patients. †Percentage of 103 patients.

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Table 3 Management of deep neck space infections (n ⴝ 103) Space

Number of patients

Tracheostomy (%)*

Ludwig’s angina Submandibular Masticator Parapharyngeal Parotid Retropharyngeal Prevertebral Total

38 28 14 11 6 5 1 103

4 (4) 0 0 0 0 4 (4) 1 (1) 9 (9)

Drainage and medicine (%)* 25 25 13 8 5 5 1 82

Medicine only (%)*

(24) (24) (13) (8) (5) (5) (1) (80)

13 3 1 3 1

(13) (3) (1) (3) (1) 0 0 21 (20)

*Percentage of 103 patients.

geal abscess developed intracranial complications, namely, meningitis in one (1%), lateral sinus thrombosis in one (1%), and cerebellar abscess in two (1 with AIDS). All four succumbed to their complications. Two (2%) with retropharyngeal abscess developed septic shock and failed to recover. Two (2%) patients with Ludwig’s angina developed asphyxiation and descending mediastinitis and also died. One (1%) patient with prevertebral abscess, who also had AIDS, developed atelectasis and went into respiratory failure and died. Another important contributing factor to all these patients’ demise was that the contrast-enhanced CTscans were done some time after the patients were admitted. This delay was due to the slow gathering of funds by the patients’ relatives to pay for this costly investigation.

due to the advent of antibiotics and improved dental care in our current society as opposed to the preantibiotic era.6 However, head and neck space infections still pose a greater threat due to the multiple cervical fascia, many portals of entry of infections, and vital structures that are adjacent to these fascia and fascial spaces.7 A comparison of incidences of the different types of DNSI in different series is made in Table 5. Our series had the second highest incidence of Ludwig’s angina. This was the result of poor orodental hygiene as well as low socioeconomic status of our patients. A similar finding was obtained by Har-El et al10 in their study in patients with poor socioeconomic backgrounds. Tom and Rice9 and Parhiscar and Har-El6 had a similar incidence of submandibular space infections like our series. Parhiscar and Har-El6 had a higher incidence of retropharyngeal and parapharyngeal infection in comparison with our series. It may be associated with colder climatic conditions and food habits leading to persistent pharyngotonsillar and upper respiratory tract infec-

DISCUSSION Head and neck space infections have significantly been reduced at present when compared with the past.6 This is Table 4 Complication of deep neck space infection (n ⴝ 103)

Deep neck space Complication









Upper airway obstruction Reinfection Discharging sinus Asphyxiation Descending mediastinitis Intracranial complications Jugular vein thrombosis Osteomyelitis of mandible Orbital cellulitis Spread to other spaces DIC Atelectasis Septic shock Death Total

4 3 1 1 1 — — — — 1 — — — 2 13

— 1 3 — — — — 1 — — — — — — 5

— 1 — — — — — — 1 — — — — — 2

— — — — — 4 4 — — 1 1 — — 4 14

— — — — — — — — — — — — — — —

4 — — — — — — — — — — — 2 2 8

1 — — — — — — — — — — 1 — 1 3

9 5 4 1 1 4 4 1 1 2 1 1 2 9 45

LD, Ludwig’s angina; SS, submandibular space; MS, masticator space; PP, parapharyngeal; PO, parotid; RP, retropharyngeal abscess; PV, prevertebral.


Otolaryngology–Head and Neck Surgery, Vol 135, No 6, December 2006

Table 5 Comparison of incidence of DNSI in different series Series 8

Beck (n, unknown) Spaces

Pre* %

Post* %

Tom-Rice9 n ⫽ 51 %


23 0 0 53 0 3 0

58 0 0 29 0 1 0

0 26 10 18 2 10 0

Chen et al5 n ⫽ 214 %

Parhiscar-Har-El6 n ⫽ 210 %

Current n ⫽ 103 %

14.5 0 0 15.9 0 2.8 0

17 28 0 43 0 12 0

37 27 13 11 6 5 1

LD, Ludwig’s angina; SS, submandibular space; MS, masticator space; PP, parapharyngeal; PO, parotid; RP, retropharyngeal abscess; PV, prevertebral. *Denotes the word antibiotic.

tions, which in turn lead to frequent retropharyngeal and parapharyngeal infections in their series. Prevertebral abscess is rarely encountered in developed countries.5,6,8,9 We tend to encounter such cases because patients present late to our hospital with advanced disease. The lack of available transportation contributed to the delay in patients’ arrival to the nearest health facility. Air travel is the usual mode of interprovincial transport in this country due to the presence of abundance of forests, rugged hilly terrains, and the Pacific Ocean in between the mainland and the innumerable surrounding islands. Pediatric head and neck space infections require a special mention because of the high number of patients with DNSI. Submandibular space infections and Ludwig’s angina were the most common pediatric deep neck space infections in our series, unlike other series where retropharyngeal and parapharyngeal abscesses were more frequent.11-13 Our pediatric series had the widest spectrum of DNSI compared with others’ series,11-13 the reasons for which are related to the late presentation of patients as mentioned previously. In a study by Mayor et al,14 the most common clinical presentation of DNSI was odynophagia in 83.9% of patients. It was followed by dysphagia in 71%, fever in 67.7%, neck pain in 54.8%, neck swelling in 45.2%, trismus in 38.7% and respiratory distress in 9.7%.14 Most of the study14 was done on retropharyngeal and parapharyngeal abscesses. The symptoms in the Tom and Rice9 series were pain (76%), fever (64%), swelling (62%), dysphagia (42%), IV drug abuse (32%), trismus (14%), respiratory difficulties (14%), toothaches (6%), and recent tooth extraction (2%). Except for intravenous drug abuse, the presentation of the patients in our series of DNSI was similar to other series.9,14 The lateral soft tissue neck x-ray of the patients remains one of the most important diagnostic procedure to evaluate the retropharyngeal space.15 This investigation together with USG was mandatory in all our patients with DNSI.

Very little choice was available for anything else as these were the only two radiological investigations available in our setting, unlike others.6,9,10,11,13 The measurements of the retropharyngeal spaces given by Barratt et al15 and Wholey et al16 were extremely useful in arriving at our diagnosis. Patients with Ludwig’s angina and submandibular space infections also routinely underwent OPG. This investigation was important in ruling out submandibular calculi.17 All patients with DNSI were informed of the necessity for contrast-enhanced CT scan as this investigation was only available in a private set-up and was also costly to the patients. Due to the latter reason, only a few undertook this investigation, but it was still beneficial to those that were able to afford it immediately after their admission to the hospital. Treatment of head and neck space infections consists of medical treatment, surgical drainage, and airway management, if necessary. Medical and surgical management obviously depends on the type of head and neck space infection and on the organisms that are causing it.19 Our choice of antibiotics, unlike others,6,7,9,10,11,13 was dependent on the availability of the drug and its affordability. Our indiscriminant use of chloramphenicol as a first line drug can be scrutinized because of its hematologic complications.20 However, it is less expensive and also of therapeutic value in the treatment of DNSI. Moreover, we rarely encountered any hematologic complications in our patients. We routinely used steroids with antibiotics in patients with impending airway compromise. Tracheostomy is necessary when there are signs of imminent upper airway obstruction. In our setting, tracheostomy was needed in nine (8.3%) of our patients as a life-saving measure. In comparison to the studies of Chen et al5 and Mayor et al,14 our tracheostomy incidence was relatively higher. This was because as patients tended to present late, they arrived in a state of

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well-established upper airway obstruction that required urgent tracheostomy. The complications of DNSI depend on the type and the location of head and neck space infection, the virulence of the organisms involved, and the host’s immune status. The fatal complications encountered in our series were DIC, atelectasis, descending mediastinitis, internal jugular vein thrombosis, intracranial extension of infection, and septic shock. We encountered higher mortality than others.5,6,10 Apart from late arrival and delayed diagnosis, low immunologic status of the patients was also a major contributing factor to a relatively higher mortality in our series. Evidently, four of the fatalities in our series had underlying systemic conditions, which also contributed to their low immune status. Two cases had underlying AIDS, one had NIDDM, and the other one had underlying protein-energy malnutrition.

CONCLUSION Head and neck space infections remain potentially lethal infections if they are not diagnosed early and treated promptly. Infections in these spaces exert fatal effect by causing local airway obstruction or extension to vital areas, such as the mediastinum or carotid sheath. Low socioeconomic conditions that lead to poor orodental hygiene were responsible for the high incidence of odontogenic causes of the DNSI in our patients. Moreover, our patients presented with more advanced stages of the disease that resulted in relatively higher incidence of tracheostomy and mortality.18

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