Characterizations of Life-Threatening Deep
Cervical Space Infections: A Review of One
Hundred Ninety-Six Cases
Ling-Feng Wang, MD,* Wen-Rei Kuo, MD,* Shih-Meng Tsai, MD, PhD,†
and Kuan-Jung Huang, MD*
Purpose: The incidence of deep cervical space infections has decreased after the introduction of antibiotics and improvement of oral hygiene, but they still may be lethal especially
when life-threatening complications occur. In this article, we try to find out whether there are
predisposing factors related to complicated deep cervical space infections and prolonged
hospitalization.
Materials and Methods: We conducted a retrospective analysis of medical records of 196
patients with deep neck infections during the period from March 1996 to February 2002.
Among the 196 patients, 15 patients developed lethal complications. As for data analysis,
multiple regression and logistic regression with dummy variable were used.
Results: In multiple regressions, patients with older age or with neck swelling, trismus,
underlying diseases, complications, and C-reactive protein more than 100 ␮g/mL stayed
longer in the hospital, and the P value reached statistical significance (P ⬍ .05). In logistic
regression, male patients and patients with neck pain had negative correlation, and the P
value reached statistical significance (P ⬍ .05). Patients with neck swelling and patients with
respiratory difficulty had positive correlation, and the P value reached statistical significance
(P ⬍ .05). That means female patients, patients with neck swelling, and patients with
respiratory difficulty were more likely to have complicated deep neck infections.
Conclusion: Complicated deep neck infections remain potentially fatal, but the morbidity
and mortality can be reduced. Doctors should pay more attention to those high-risk patients;
they are female patients, patients with neck swelling, and patients with respiratory difficulty.
(This is a US government work. There are no restrictions on its use.)
A deep cervical space infection, in brief, is
an infection occurring in a potential space
bounded by deep cervical fascia. It has been
recognized and described since the time of
Galen in the second century. Although the
incidence of these space infections has been
greatly reduced by modern antibiotic therapy
and the improvement of oral hygiene, these
infections continue to be a cause of significant
morbidity and mortality.1-4 Life-threatening
complications include upper airway obstruction, descending mediastinitis, pleural empyema, pericarditis, jugular vein thrombosis,
septic shock, and carotid pseudoaneurysm or
rupture.5,6 The mortality rate may reach 40%
to 50%7 while these complications occur.
Therefore, if we could identify the predisposing factors of these lethal deep cervical infections as early as possible, we could administer
appropriate treatment and reduce the mortality and morbidity rate.
In this article, we analyzed the medical
records of 196 cases with deep neck infections
who were treated in our department with a
multiple and logistic regression. In this way,
we hoped to find whether or not there are
predisposing factors for identifying complicated or lethal deep neck infection.
From the Departments of *Otolaryngology and †Public Health, Kaohsiung Medical University, Kaohsiung,
Taiwan.
Address correspondence to: Ling-Feng Wang, MD,
Department of Otolaryngology, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung City
807, Taiwan.
Copyright 2003 Elsevier, Inc. All rights reserved.
0196-0709/03/2402-0001$30.00/0
10.1053/ajot.2003.31
MATERIALS AND METHODS
We reviewed the medical records of 225
Taiwanese patients with a diagnosis of deep
neck infection during the period from March
1996 to February 2002. All of them had been
admitted to Kaohsiung Medical University
American Journal of Otolaryngology, Vol 24, No 2 (March-April), 2003: pp 111-117
111
112
WANG ET AL
TABLE 1.
Types of Isolated Microorganisms
Numbers of
Culture
Fig 1.
Distribution of age and sex (n ⴝ 196).
Hospital for treatment. A total of 196 patients
with complete medical records were enrolled
in this study, including 131 men and 65
women. Their ages ranged from 1 to 86 years,
and the mean age was 41.8 years. The details
are shown in Figure 1. The duration of admission ranges from 2 to 30 days with an average
of 8.5 days. The most common symptom is a
sore throat (72.4%) followed by odynophagia
(62.8%). But if peritonsillar abscess is excluded, the most common presentation is
neck swelling (69.6%) followed by neck pain
(62.9%). The details were shown in Figure 2.
There were 144 (73.5%) cases being operated
on, including repeated needle aspiration in 91
cases and surgical drainage in 53 cases. The
results of bacterial cultures were positive in
82 patients and are shown in Table 1. There
were 15 patients acquiring life-threatening
complications. The details are shown in Table
2. These complications included upper airway obstruction with tracheostomy (8 cases),
descending mediastinitis (5 cases), sepsis (6
cases), and jugular vein thrombosis (2 cases).
Two patients died, and the mortality rate was
1%. We used multiple regressions as the statistical method to find out which variables
will contribute to longer hospitalization. The
equation adopted was as follows:
Duration of admission ⫽ ␣ ⫹ ␤1 (sex) ⫹ ␤2
(age) ⫹ ␤3 (fever ⬎38°C)⫹ ␤4 (neck swelling)
⫹ ␤5 (neck pain) ⫹ ␤6 (trismus) ⫹ ␤7 (underlying disease) ⫹ ␤8 (respiratory difficulty) ⫹
␤9 (complication) ⫹ ␤10 (C-reactive protein
G(⫹) aerobic
Streptococcus viridans
␤-hemolytic streptococci
Staphylococcus aureus
Streptococcus pneumoniae
␣-hemolytic streptococci
Staphylococcus epidermidis
G(⫺) aerobic
Klebsiella pneumoniae
Escherichia coli
Pseudomonas aeruginosa
Acinebacter levotti
Citrobacter spp
Anaerobic
Provotella spp
Peptostreptococcus spp
Bacteroides spp
Clostridium spp
Total pathogens
24
5
3
3
1
1
33
3
2
2
1
7
5
4
4
98
%
45.1
29.3
6.1
3.7
3.7
1.2
1.2
50
40.2
3.7
2.4
2.4
1.2
24.4
8.5
6.1
4.9
4.9
[CRP] ⬎100 ␮g/mL) ⫹ ␤11 (white blood cells
[WBCs] ⬎15,000 cells/mm3).
We assumed male patients or patients with
fever (⬎38°C), neck pain, neck swelling, underlying diseases (diabetes mellitus, uremia,
liver cirrhosis, and cancer), trismus, respiratory difficulty, complications, CRP ⬎100 ␮g/
mL, and WBCs ⬎15000 cells/mm3 to be the
dummy variable “1” and the age to be the
actual value.
Besides, logistic regression with dummy
variable was also used to see whether or not
there were predisposing factors related to
complicated deep cervical space infection.
The dependent variable was with or without
complication, and independent variables included age, sex, fever ⬎38°C, neck swelling,
neck pain, respiratory difficulty, trismus, underlying diseases (diabetes mellitus, uremia,
and liver cirrhosis), WBCs ⬎15,000 cells/
mm3, and CRP ⬎100 ␮g/mL.
RESULTS
Fig 2.
Distribution of symptoms and signs.
The JMP4.0 software (SAS Institute, Cary,
NC) was used for calculations. The results
were shown in Table 3 (multiple regression)
and Table 4 (logistic regression).
In multiple regression, patients with older
age (P ⫽ .04), neck swelling (P ⫽ .002), trismus (P ⫽ .01), underlying disease (P ⫽ .03),
CERVICAL SPACE INFECTIONS
113
TABLE 2. The Characterization of Patients With Lethal Complications
Case
Age
Sex
Space
1
55
M
P-p, S-m, R-p,
parotid, masticator
2
69
M
P-p, S-m
3
71
M
P-p
4
1
M
P-p, S-m
5
6
34
44
M
M
P-p, S-m
P-p
7
50
M
P-p, S-m, buccal
8
79
M
P-p
9
30
M
10
64
F
P-p, S-m, R-p,
parotid, masticator
P-p, S-m, R-p
11
6
F
P-p
12
53
M
13
14
68
71
F
M
P-p, R-p, parotid,
masticator
P-p, R-p, S-m
P-p, R-p, S-m
15
65
M
Complications
Sepsis, airway
obstruction,
mediastinitis,
tracheostomy
Mediastinitis, jugular
vein
thromosis
Airway obstruction,
tracheostomy
Airway obstruction,
tracheostomy
Sepsis
Airway obstruction,
tracheostomy
Airway obstruction,
tracheostomy
P-p, R-p, S-m,
prevertebral
Underlying
Operation
DM, liver cirrhosis
I&D
Klebsiella
pneumonia
Good
—
I&D
Klebsiella
pneumonia
Good
DM
Repeated
aspiration
I&D
Sterptococcus
viridans
No growth
Good
Good
—
Pathogen
Outcome
DM, odontogenic
—
—
I&D
—
No growth
Good
Good
I&D
No growth
Good
Sepsis
DM, old stroke
with
bed-ridden
—
I&D
Good
Sepsis
Liver cirrhosis
—
Klebsiella
pneumonia
—
Airway obstruction,
tracheostomy,
mediastinitis
DM, liver cirrhosis
Jugular vein
thrombosis
Airway obstruction,
tracheostomy
Mediastintis
Sepsis
Branchiogenic
cyst
Old stroke
Mediastinitis
DM
DM
I&D, thoracotomy
I&D
I&D
Thoracotomy
I&D
—
—
Expired
Klebsiella
Expired
pneumonia,
Staphylococcus
epidermidis
Eschenchia coli
Good
Citrobacter
freundii
No growth
Klebsiella
pneumonia
—
Good
Good
Good
Good
Abbreviations: P-p, parapharyngeal space; R-p, retropharyngeal space; Sm, submandibular space; I&D, incision and
drainage.
complication (P ⫽ .02), and CRP more than
100 ␮g/mL (P ⫽ .002) stayed longer in the
hospital. Factors such as sex, fever, neck pain,
respiratory difficulty, and WBCs more than
15000 cells/mm3 did not have statistical significance.
The results of logistic regression analysis
showed that male patients (P ⫽ .04) or pa-
tients with neck pain (P ⫽ .045) had negative
correlation, and the P value reached statistical
significances, which meant male patients or
patients with neck pain was less likely to have
complicated deep neck infections. Patients
with neck swelling (P ⫽ .03) or patients with
respiratory difficulty (P ⬍ .0001) had positive
correlation and reached statistical significance, which meant patients with neck swell-
TABLE 3. Results of Multiple Regression
TABLE 4.
Parameters
Age
Sex
Fever
Neck swelling
Neck pain
Trismus
Underlying disease
Respiratory difficulty
Complication
WBC ⬎15000/mm3
CRP ⬎100␮g/ml
Sum of
Square
F ratio
90.81
46.49
2.07
203.45
6.68
132.93
101.58
8.78
123.69
2.39
211.39
*P ⬍ .05, reach statistical significance.
4.29
2.2
0.1
9.61
0.32
6.28
4.8
0.41
5.84
0.11
9.99
Results of Logistic Regression
Parameter
Odds
Ratio
95% Confidence
Interval
Age
Sex (male ⫽ 1, female ⫽ 2)
Fever
Neck swelling
Neck pain
Trismus
Underlying disease
Respiratory difficulty
WBC ⬎ 15,000/mm3
CRP ⬎ 100 ␮g/mL
34.71
0.12*
1.77
11.7*
0.09*
1.09
0.6
211.06*
2.55
0.41
(0.03 ⬇ 2,378.09)
(0.01 ⬇ 0.75)
(0.35 ⬇ 9.53)
(1.34 ⬇ 133.5)
(0.01 ⬇ 0.82)
(0.1 ⬇ 7.56)
(0.06 ⬇ 4.72)
(26.11 ⬇ 3,314.37)
(0.47 ⬇ 14.03)
(0.06 ⬇ 2.41)
P Value
0.04*
0.14
0.75
0.002*
0.58
0.01*
0.04*
0.52
0.02*
0.73
0.002*
*P ⬍ .05, reach statistical significance.
114
ing or patients with respiratory difficulty were
more likely to have complicated deep neck
infections. The remaining variables were not
statistically significant.
DISCUSSION
In our department, the treatment protocol
had been formulated as follows: when a patient with the suspicion of deep neck infection was admitted, we performed thorough
physical examination and laboratory studies,
including a complete blood count with differentiating count, serum electrolytes, blood
sugar, C-reactive protein, and liver and renal
function tests. Imaging studies such as neck
soft-tissue radiograph and neck computed tomography were used selectively. Empirical
intravenous antibiotics were administered before the culture results were available. All
patients were closely monitored for impending airway obstruction, and tracheostomy was
performed if necessary. When the presence of
an abscess was established, repeated aspiration and/or incision and drainage were performed.
Deep neck infections can arise from various
head and neck regions, including teeth, salivary gland, nasal cavity, paranasal sinuses,
pharynx, and adenotonsillar tissues. The most
common cases are those of dental and tonsillar origins, which have been addressed in
many articles.1,8,9 In our study, upper respiratory track infections (33 cases) accounted for
the most often source, followed by odontogenic origin (15 cases). In over half of the
cases, the cause of infection remained unknown. The reason may be that inciting infection can precede the deep neck infection by
weeks, and it is often difficult to discern the
primary source of infection. Other studies
have similar results and conclusions.2,10
There were 2 cases worth mentioning. One
was laryngeal carcinoma and the other nasopharyngeal carcinoma presented initially as a
prelaryngeal neck abscess and retropharyngeal abscess, respectively. Although clinically
and on the computed tomography studies the
2 cases were suspected of having underlying
malignancy, the initial biopsies were negative
for cancer. Despite strong antibiotics and surgical drainage, the pus formation and lymphadenopathy still existed. It was because of
WANG ET AL
persisted suspicion repeated biopsies finally
confirmed the diagnosis. These 2 cases emphasize the importance of repeated biopsies,
and higher suspicion must be given for those
with refractory lymphadenopathy even with
adequate treatment. There may be malignancy
presented initially by deep neck infection.
The most common symptom is a sore throat
(72.4%) followed by odynophagia (62.8%).
But if peritonsillar abscess is excluded, the
most common presentation is neck swelling
(69.6%) followed by neck pain (62.9%) (Fig
2). Our results showed that there was a statistically significant positive correlation (P ⬍
.05) between complicated deep neck infections and neck swelling or respiratory difficulty and a negative correlation between complicated deep neck infection and neck pain.
The reason may be that most peritonsillar
abscesses patients did not have neck swelling.
For patients with peritonsillar abscesses, empiric antibiotic therapy and repeated needle
aspiration were the treatment of choice and
the prognosis as well.11
Of the 196 cases, 61 cases had a peritonsillar abscesses. In the remaining 135 cases, 118
cases had a computed tomography. Based on
the radiological finding, the space involved
most commonly is parapharyngeal space
(79 cases, 66.9%), followed by submandibular
space (49.2%) and retropharyngeal space
(20.3%). Male preponderance is identified in
our reports and others,1,2,4 but the reason remains unknown. In Taiwan, poor oral hygiene
because of betel nut chewing may play a major
part of the causes. Although male patients
predominated the cases of deep neck infection, logistic regression showed that female
patients were more likely to have complicated
deep neck infections.
Early studies of the bacteriology of deep
neck infections have pointed out 3 microorganisms: Staphylococcus aureus, Streptococcus pyogenes, and anaerobic bacteria.2,12 But
now, mixed infection with both aerobic and
anaerobic bacteria becomes the rule.1-3 Har-El
et al1 reported that about two thirds of the
positive cultures had polymicrobial growth,
and 40% of them were anaerobes. But in our
study (Table 1), only 13 (15.9%) positive cultures have more than one organism, and the
anaerobes only account for 20 (24.4%) of the
positive cultures. There may be 2 reasons for
CERVICAL SPACE INFECTIONS
this different result. One is that many of our
patients had received antibiotic therapy before admission and thus the flora had
changed, and the other is because of delayed
culture, especially during the nighttime when
facilities for anaerobic cultures were not available.
According to the present study (Table 1),
the bacteriologic pattern of deep neck infection is changing. Klebsiella pneumonia accounts for the most common pathogen of the
positive cultures (40.2%), followed by Streptococcus viridans (29.3%). This was different
from other reports1,4,12 in which Streptococcus viridans was the most common pathogen.
The hemolytic streptococci (7.3%), which
were among the most common pathogen in
the preantibiotic era and children, do not play
a significant role in deep neck infection any
more. S aureus was only found in 3 positive
cultures (3.7%). The results were lower than
that of Har-El et al1 (18.6% and 27.3,% respectively) and Nagy et al15 (39% and 17%, respectively). We believe that these findings reflect the declining incidence of pharyngitis
and tonsillitis from the list of causes and the
increasing incidence of dental infections and
immunocompromise as causes of deep neck
infection. However, upper respiratory tract infections are still an important cause of deep
neck infection in children.16
The most common associated systemic disease was diabetes mellitus. Of those 33 patients who had Klebsiella pneumonia as a
pathogen, 21 patients (63.6%) had diabetic
mellitus. We believe that it was because the
virulence of Klebsiella pneumonia was decided by the hosts’ macrophage function,13
and the macrophage function was impaired in
hyperglycemic state.14 For those with diabetes
mellitus, control of blood sugar plays an important role in the treatment strategies. According to our study, patients who had diabetes mellitus stayed longer in the hospital (12.7
days) than patients who did not (7.3 days),
and the difference was statistically significant.
However, patients with underlying conditions, such as diabetes mellitus, uremia, and
liver cirrhosis, were more unlikely to have
complicated deep neck infection. The reason
may be that once these patients had deep neck
infection, we would pay more attention to
them, and the antibiotics we administered
115
were different to those we used in usual.
Therefore, these patients had intensive care,
and complicated deep neck infection was less
likely to occur.
Contrast-enhanced computed tomography
scanning (CECT) is the radiologic examination of choice in the evaluation of deep neck
infection. Lateral soft-tissue radiographs of
the neck may be helpful in the diagnosis of
retropharyngeal abscesses, but they are not
beneficial in the workup of patients strongly
suspected of having a deep neck infection.
However, CECT has a high sensitivity but low
specificity, which may lead to unnecessary
operation for some patients if CECT is used
isolatedly.17,18 Therefore, clinical examination and CECT together yield the most accurate result in defining the location, severity,
and size of the deep neck abscess. An advantage of CECT is that it can differentiate abscess
from solid mass or cellulitis, and this will
change our methods of therapy. Under CECT,
an abscess could be identified with the presence of an air-fluid level, subcutaneous air, or
rim enhancement of the cavity.17,19 We selectively used CECT for our patients with clinical
suspicion of having an abscess. Of those 134
cases (including some cases of peritonsillar
abscess) with CECT, 114 cases had an abscess.
The accuracy rate in defining an abscess was
85.1%, and this was similar to that of other
reports.15 Miller et al18 also suggested that
hypodensities of less than 2 mL in volume
with no ring enhancement were less likely to
yield pus at the time of surgery.
As to the treatment of deep neck infections,
there is no place for outpatient care. In our
department, the strategies of treatment can be
divided into 2 aspects based on the radiologic
finding: cellulitis only or nonnecrotizing infections can be treated with antibiotic therapy
alone, whereas abscess in deep neck infection
are mandated with surgical exploration and
debridement. In our series, there were 144
cases operated on, including repeated aspiration in 91 cases (more than half were used for
those with peritonsillar abscess) and surgical
drainage in 53 cases. The operation rate
(73.5%) was not very high in comparison to
that of Har-El et al1 (87.3%) and Parhiscar and
Har-El4 (88%). This was probably because the
medical referral systems in Taiwan were not
fully developed; most patients would go di-
116
rectly to ear, nose, and throat specialists
rather than primary physician, and, therefore,
their diseases were not advanced when being
diagnosed. Although Mayor et al20 claimed
that medical treatment could be as successful
as open surgical drainage in most cases with
abscesses, the risk of progression and potentially fatal complications was still too high;
therefore, surgical drainage became the preferred method.
After the patient is admitted, initial antibiotics should be administered before the culture results are available. Penicillin should be
the drug of choice for aerobic Staphylococcus
pyogenes (groups A, B, C, G, H), S viridans,
and most Clostridial species. Clindamycin
provides adequate therapy against anaerobes
that are resistant to penicillin G, whereas gentamycin provides therapy against most aerobic gram-negative bacilli, including members
of the Enterbacteriaceae group and Pseudomonas aeruginosa, which might contribute to
the septic process, especially in the immunocompromised host. Some authors argued that
penicillin derivatives and clindamycin were
the key to successful therapy and avoidance of
complications.1,4,10 We suggest that gentamycin should also be included in the regimen
because Klebsiella pneumoniae often predominate the culture results. Besides, according to
the present study, aerobic gram-negative bacilli account for 50% of the positive cultures
and were often sensitive to gentamycin. In our
hospital, we usually use penicillin and gentamycin initially, and clindamycin is reserved
for those with severe infections or with odontogenic origin. The second- or third-generation antibiotics are used instead if poor clinical response is noted or when complications
have developed. Under such protocol, our patients could recover as quickly as those reported in other reports,1,4,19 based on the duration of hospitalization.
The most fearful complications are airway
obstruction, vascular rupture, and descending
mediastinitis. These complications may
present and proceed with amazing speed, but
they can generally be avoided by early recognition and aggressive treatment. In our study,
5 cases got descending mediastinitis (all of
them got mixed spaces infection). We conducted combined surgery with a chest surgeon in 2 of them, but 1 case died within 24
WANG ET AL
hours after operation because of septic shock.
In reviewing of this dead patient, we found
the origin of infection arose from peritonsillitis. From the onset of a sore throat to death,
there were only 48 hours. The remaining 3
patients recovered uneventfully simply under
close observation and effective intravenous
antibiotics. Upper airway obstruction was
noted in 15 cases, and an emergent tracheostomy was performed ultimately in 8 (4.34%)
of them. Endotracheal intubation is not advised at this time because it may further jeopardize the already compromised airway. Because published data dictated that airway
obstruction to a sufficient degree to warrant
tracheostomy for airway support was identified in 12% to 16% of the patients who had
deep neck abscesses,1,2,9 and the need for tracheostomy was common in retropharyngeal
abscess (33.3%) and Ludwig’s angina (75%).1
The reported percentage was much higher
than that in our study. This is probably because we routinely used intravenous steroid
for patients with impending airway obstruction. Their strong anti-inflammatory effect
might slow the swelling speed, prevent those
cases with cellulites from becoming abscesses, and help pain control in all cases.
However, we need a controlled study for further verification. There were 6 patients acquiring sepsis, and 4 of them recovered uneventfully with high-dose intravenous antibiotics
either with or without surgical drainage. The
remaining 2 cases died of septic shock (both
had severe liver cirrhosis). The mortality rate
was 1%, which was quite close to that of
Har-El et al1 (0.91%).
CONCLUSION
With the introduction of antibiotics and the
improvement in dental care and oral hygiene,
the incidence of deep neck infections had
decreased significantly today, but they continue to be a cause of morbidity and mortality.
In general, the combination of early radiologic
diagnosis, intravenous antibiotic therapy,
drainage of pus and appropriate culture, and
maintenance of airway will lead to the good
prognosis. Complications remain potentially
fatal, but it can be successfully avoided if
doctors pay more attention to those patients at
higher risk of developing complicated deep
CERVICAL SPACE INFECTIONS
neck infections, such as female patients, patients with neck swelling, and patients with
complaint of respiratory difficulty.
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