“THE STUDY OF ETIOPATHOGENESIS AND MANAGEMENT OF DEEP NECK SPACE INFECTIONS”
A DISSERTATION SUBMITTED TO THE TAMILNADU Dr. MGR MEDICAL UNIVERSITY
CHENNAI
In partial fulfilment of the Regulations
for the award of the Degree of
M.S. (OTO-RHINO-LARYNGOLOGY &HEAD AND NECK SURGERY) BRANCH-IV Registration No.: 221714302
DEPARTMENT OF E.N.T &HEAD AND NECK SURGERY
TIRUNELVELI MEDICAL COLLEGE
TIRUNELVELI
MAY 2020 CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “THE STUDY OF
ETIOPATHOGENESIS AND MANAGEMENT OF DEEP NECK SPACE
INFECTIONS” is a bonafide research work done by Dr. S.KOUSALYA DEVI,
Postgraduate M.S. student in Department of E.N.T & HEAD AND NECK
SURGERY, Tirunelveli Medical College & Hospital, Tirunelveli, in partial fulfilment of the requirement for the degree of M.S. in OTO-RHINO-
LARYNGOLOGY.
Dr. S.SURESHKUMAR MS(E.N.T) D.L.O, Professor and HOD of E.N.T, Date: Department of E.N.T & HEAD AND NECK Place: Tirunelveli SURGERY, Tirunelveli Medical College, Tirunelveli CERTIFICATE BY THE HEAD OF THE DEPARTMENT
This is to certify that the dissertation entitled “THE STUDY OF
ETIOPATHOGENESIS AND MANAGEMENT OF DEEP NECK SPACE
INFECTIONS” is a bonafide research work done by Dr. S.KOUSALYA DEVI,
Postgraduate student in M.S E.N.T in Department of E.N.T & HEAD AND
NECK SURGERY, Tirunelveli Medical College & Hospital, Tirunelveli, under the guidance of Dr.S.SURESHKUMAR, Professor and HOD, Department of
E.N.T & HEAD AND NECK SURGERY, Tirunelveli Medical College &
Hospital, Tirunelveli, in partial fulfilment of the requirements for the degree of
M.S in OTO-RHINO-LARYNGOLOGY..
Dr.S.SURESHKUMAR MS(E.N.T) Date: D.L.O, Place: Tirunelveli Professor and HOD of E.N.T, Department of E.N.T & HEAD AND NECK SURGERY, Tirunelveli Medical College, Tirunelveli CERTIFICATE BY THE HEAD OF THE INSTITUTION
This is to certify that the dissertation entitled “THE STUDY OF
ETIOPATHOGENESIS AND MANAGEMENT OF DEEP NECK SPACE
INFECTIONS” is a bonafide and genuine research work carried out by
Dr.S.KOUSALYA DEVI, post graduate student in M.S(E.N.T) under the guidance of Dr.S.SURESHKUMAR ,M.S(E.N.T) D.L.O.,Professor and HOD,
Department of ENT & HEAD AND NECK SURGERY, Tirunelveli Medical
College, Tirunelveli.
Date: Dr.S.M.KANNAN, MS., MCh., Place: Tirunelveli DEAN Tirunelveli Medical College, Tirunelveli COPYRIGHT
DECLARATION BY THE CANDIDATE
I hereby declare that dissertation entitled “THE STUDY OF
ETIOPATHOGENESIS AND MANAGEMENT OF DEEP NECK SPACE
INFECTIONS” is a bonafide and genuine research work carried out by me under the guidance of Dr.S.SURESHKUMAR M.S(E.N.T) D.L.O., Professor and
HOD, Department of E.N.T& HEAD AND NECK SURGERY, Tirunelveli
Medical College, Tirunelveli.
The Tamil Nadu Dr.M.G.R. Medical University, Chennai shall have the rights to preserve, use and disseminate this dissertation in print or electronic format for academic/research purpose.
Date: Dr. S.KOUSALYA DEVI, MBBS., Place:Tirunelveli Registration No.: 221714302 Postgraduate in ENT & HEAD AND NECK SURGERY, Department ENT & HEAD AND NECK SURGERY, Tirunelveli Medical College, Tirunelveli ACKNOWLEDGEMENT I am obliged to record my immense gratitude to Dr. S.M.Kannan MS., MCh,
Dean, Tirunelveli Medical College Hospital for providing all the facilities to conduct the study.
I express my deep sense of gratitude and indebtedness to my respected teacher and guide Prof.Dr. S.Suresh Kumar M.S ENT , HOD, Department of General
Surgery, Tirunelveli Medical College, Tirunelveli, whose valuable guidance and constant help have gone a long way in the preparation of this dissertation.
I Sincerely thank my Professors Dr. C. Ravikumar MS ENT, Dr. Senthil
Kanitha MS ENT, for his inspiring suggestions and valuable guidance at every stage of study.
I am also thankful to my Assistant Professors in the department,
Dr. C.Karuppasamy MS ENT, DLO, Dr. D.Rajkamal Pandian MS ENT DNB,
Dr. S.Ganapathy MS ENT DNB, Dr. A.Vijay Nivas MS ENT, Dr. Priya Dharshini
MS ENT., for their constant guidance and support throughout my study period.
I express my heartfelt thanks to my PG seniors &juniors and other friends for their help during my study and preparation of this dissertation and also for their co- operation.
I extend my thanks to my family, who supported and helped me a lot in completing the study.
Dr. S.KOUSALYA DEVI, MBBS., Date: Postgraduate in ENT, Place: Tirunelveli Department of ENT&HEAD AND NECK SURGERY, Tirunelveli Medical College, Tirunelveli
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OF ETIOPATHOGENESIS AND MANAGEMENT OF DEEP NECK
SPACE INFECTIONS” of the candidate Dr. . S.KOUSALYA DEVI,MBBS. with registration Number 221714302 for the award of M.S., (OTO – RHINO –
LARYNGOLOGY & HEAD AND NECK SURGERY) in the branch of IV. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion page and result shows 19 percentage of plagiarism in the dissertation.
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CONTENTS
SL. NO. TOPIC PAGE NO.
1. INTRODUCTION 1
2. AIM OF THE STUDY 3
3. MATERIALS AND METHODS 4
4. REVIEW OF LITERATURE 6
5. RESULTS 55
6. DISCUSSION 69
7. CONCLUSION 74
8. BIBLIOGRAPHY
9. ANNEXURE I - PROFORMA
10. ANNEXURE II - CONSENT FORM
11. ANNEXURE III - MASTER CHART ABBREVIATIONS
DNSI -Deep neck space infection
C&S -Culture and sensitivity
I&D -Incision and drainage
USG -Ultrasonography
CT -Computed tomography
MRI -Magnetic resonance imaging
NP -Neck pain
NS -Neck swelling
O -Odynophagia
D -Dysphagia
T -Trismus
TA -Tooth ache
AC -Airway compromise
VC -Voice change INTRODUCTION
Deep neck spaces are spaces situated between the 3 layers of deep cervical fascias of neck. There are 11 deep spaces in the neck formed by the facial planes, giving possible infection sites. According to their relationship with hyoid bone the spaces are divided into suprahyoid spaces [peritonsillar space, submandibular space, buccal space, parotid space, masticator space, parapharyngeal space], infrahyoid spaces [anterior visceral space or pretracheal spaces], spaces involving entire length of the neck [pre vertebral space, danger space, retropharyngeal space, carotid space]
DNSI are potentially lethal infection & need immediate appropriate treatment. Poor dental hygiene is responsible for the DNSI. Eventhough with the evolution of higher antibiotics they can still causes significant morbidity & mortality.
In Addition to dental infection, IV drug abuse, DM, HIV, surgical injuries, pharyngitis, tonsillitis are at risk of developing complications.
The common symptoms are fever, neck swelling, dysphagia, neck pain, sorethroat & other symptoms related to the neck spaces.
Present study is to find out etiology, risk factors, causative organism & management by appropriate antibiotics. Deep neck space infections are polymicrobial in nature. Peptostreptococci, streptococci, staphaureus and
1 anaerobes are the most common organisms causing deep neck space infections.
Treatment part consists of conservative management and surgical intervention.
The life threatening and common complications include airway obstruction, mediastinitis, jugular vein thrombosis, sepsis, respiratory distress, cavernous sinus thrombosis.
2 AIM OF THE STUDY
To evaluate the etiopathogenesis and management of deep neck space infections.
OBJECTIVES:
1. To evaluate the prevalence and various etiological factors associated with
DNSI.
2. To find out distribution of DNSI among sexes and various age groups.
3. To analyse the various clinical presentations and microbiological profiles
of DNSI.
4. To find out relevant investigation for early detection and effective
treatment.
5. To study about the management and its outcome.
6. To find out association of other systemic disease with DNSI.
3 MATERIALS AND METHODS
Cases with neck swelling =, neck pain, fever, sorethroat, dysphagia, odynophagia, change in voice were selected.
Patient attending or reffered to ENT OPD were included in this study. All patients underwent a thorough history taking and a detailed clinical examination. X-ray neck lateral and antero-posterior view, chest X-ray, Ultra
Sound neck, computed tomography scan neck and culture & sensitivity studies was done in selected individuals according to their findings.
Then the patients were started on broad spectrum antibiotics and converted to selective antibiotics based on culture report. Incision and drainage were done in patients with diabetes mellitus, patients with no improvement after 48 hours of parentral antibiotics, and patients with airway compromise. Management and the improvement were analysed.
INCLUSION CRITERIA:
- All ages
- Both sexes
- Patients with symptoms suggestive of deep neck space infections.
EXCLUSION CRITERIA:
- Patients not willing for the study.
- Patients with post traumatic infected wounds 4 - Wounds secondary to malignancy.
STUDY AREA:
Department of ENT, Tirunelveli Medical College Hospital.
STUDY PERIOD:
November 2017 to June 2019
METHOD OF STUDY
Prospective study
STUDY POPULATION
Average 40-80 (78 patients)
Patients attending TVMCH ENT Department
5 ANATOMY
one of the major consideration in the diagnosis and treatment of deep neck space infections is the ability of infections to travel from one anatomical region to another via planes or potential spaces created by the various fascias of head and neck .This arrangement is somewhat unique in the body and thorough understanding of their anatomy and the potential spaces they create is essential to the effective treatment of these serious infections.
THE SUPERFICIAL CERVICAL FASCIA
It is typically a thin layer of adipose tissue covering the platysma muscle and the muscles of Facial expression. It extends from epicranium of scalp down to thorax and axilla. The space between superficial fascia & deep fascia contains marginal mandibular nerve, adipose tissue, anterior jugular veins & superficial lymphatics. This potential space between the superficial cervical fascia and deep cervical fascia allows free movement of the skin and platysma over the deeper structure of the neck. This space also has the potential to allow spread of infections along its deeper border.
6 THE DEEP CERVICAL FASCIA
The deep cervical fascia is the most important determinant in the spread of cervical infections. Deep cervical fascia has 3 layer – the Superficial or investing layer of deep cervical fascia, the middle or Visceral fascia ,the deep or prevertebral fascia .These various fascias with their interconnecting septa, create potential spaces or compartments that tend to dictate the development and spread of infections.
THE SUPERFICIAL LAYER OF DEEP CERVICAL
FASCIA/INVESTING LAYER
This completely envelop the neck the skull to the chest. This has been called the mother of the cervical fasciae, since all other major deep cervical fascia develop as a septa from it. It surround the neck & splits to enclose 2 muscles sternocleidomastoid & trapezius, 2 glands parotid & submandibular gland, 2 spaces suprasternal & supra clavicular spaces. It extend from ligamentum nuche & cervical spine ,moving anteriorly to enclose the neck .Its bony attachments are superiorly the external occipital protruberance ,the mastoid process ,and the zygoma; anteriorly to hyoid bone and mandible; inferiorly to clavicle and sternum & acromian process of scapula. At mandible, it split into 2 layers. Its internal layer covers the medial surface of pterygoid muscle upto skull base. Its external layer covers masseter & inserts into
Zygomatic arch.
7 THE MIDDLE LAYER OF DEEP CERVICAL FASCIA:
This develops from extension of the superficial layer of deep cervical fascia and encircle the viscera of the neck, the pharynx, esophagus, larynx, trachea and thyroid gland. In addition the visceral fascia encloses the strap muscles and the neurovascular structure associated with the carotid artery. This large space enclosed by the visceral fascia is important because of potential communication of infections from the mouth, pharynx, esophagus ,larynx, trachea with the mediastinum.
This visceral fascia divided into three layers; the middle cervical fascia which encircle the strap muscles, the cervical visceral fascia and the carotid sheath. The cervical visceral fascia forms the capsule of the thyroid gland.
The buccopharyngeal fascia is the part of the cervical visceral fascia that coves the constrictor muscles of the pharynx and buccinator muscle, extending from the base of skull to the cricoids cartilage.
THE DEEP LAYER OF DEEP CERVICAL FASCIA OR
PREVERTEBRAL FASCIA
The prevertebral fascia lies anterior to the vertebral bodies medially, and covers paraspinous muscle laterally. Posteriorly attach to ligamentum nuchae
&cervical spine. At transverse process of cervical vertebra this fascia divided into 2 division anteriorly alar fascia & posteriorly prevertebral fascia.
8 Prevertebral fascia extend from skull base down the length of coccyx.
Laterally extend as axillary sheath. It splits to enclose the pectoral muscles, scalene muscle, vertebral & subclavian vessels, phrenic nerve & brachial plexus.
Alar fascia is the division between visceral layer of pretracheal fascia and prevetebral fascia. The f structures lie anterior to the prevertebral fascia, include the carotid sheath and its content, the pharynx, hypopharynx and esophagus.
9 THE CAROTID SHEATH
The carotid sheath is a circular condensation of connective tissue running vertically in the neck extending from the skull base to the level of clavicle. All three layers of deep cervical fascia forms the carotid sheath, deep to sternocleidomastoid muscle.
It contains internal jugular vein, common &internal carotid artery, Vagus nerve, 80% of lymphnodes of neck.
Cervical symphathetic chain lies deeper to carotid sheath. At the level of clavicle, the carotid sheath fuse with the covering of great vessels at the root of neck and the pericardium. Thus the carotid sheath is one of the main avenue for spread of infection from the neck into the chest and mediastinum.
10 POTENTIAL SPACES OF NECK
There are 2 types of fascial planes in the neck – those surrounding the muscles and those surrounding the viscera and vessels. Between the fascial layers in the neck, are spaces that may provide conduit for the spread of infections. They contain loose areolar tissue.
11 DEEP NECK SPACES ARE DESCRIBED IN RELATION TO THE HYOID BONE
Spaces involving Supra Hyoid Infrahyoid entire length of neck Peritonsillar space Pretracheal space
Parotid space (Anterior Visceral space)
Retropharyngeal space Masticator space
Danger space Sub mental space
Pre vertebral space Submanidubular space
Carotid space - sublingual space
- submaxillary
space
Parapharyngeal space
12 RETROPHARYNGEAL SPACE:
The retropharyngeal space lies between the alar fascia (a division of deep layer of deep cervical fascia) and the buccopharyngeal fascia covering the constrictor muscles of pharynx superiorly and the oesophagus inferiorly. It extends craniocaudally from the skull base to the tracheal bifurcation. It is divided into two lateral compartments, spaces of gillete by fibrous raphe. It has been estimated that 71% of head and neck infections involving the mediastinum spread via the retropharyngeal space or the danger space. Thus the retropharyngeal space is one of the main route of spread of infection from the head and neck to the mediastinum.
13 There are a group of nodes in retropharyngeal space known as Glands of
Henle which regresses by age of 5 yrs. Suppuration of these nodes result in
Acute retropharyngeal abscess in children. There is another group of nodes called the Rouvier’s nodes which are the first nodes to enlarge in case of nasopharyngeal & sinus malignancies.
DANGER SPACE:
It is a potential space situated between the prevertebral fascia and alar fascia, the two divisions of deep layer of deep cervical fascia. It extends from the skull base to the diaphragm. Retropharyngeal space proper is in front of alar fascia. This is called danger space because of easy route of mediastinitis.
PREVERTEBRAL SPACE:
This potential space lies between the cervical vertebra posteriorly and the prevertebral fascia anteriorly, extends from the base of skull to the coccyx.
Tuberculosis of spine, penetrating trauma are the chief source of infections.
CAROTID SPACE:
The carotid space is formed by the carotid sheath which is made up of all three layers of deep cervical fascia blending together. The content of carotid sheath include common carotid artery, the Internal jugular vein (IJV) and the vagus nerve.
14 It extend from the skull base to the mediastinum. Carotid space infections occur due to secondary spread from adjacent neck spaces, (or) by direct inoculation in IV drug abusers (or) by iatrogenic spread such as central venous catheterization.
PERITONSILLAR SPACE:
It is located lateral to the tonsils, lies between the capsule of tonsil and superior constrictor muscle. It contain loose areolar tissue and it is a site of accumulation of pus in quinsy. This space communicate with retropharyngeal and parapharyngeal spaces.
15 PAROTID SPACE:
This space lies between the superficial and deep capsule of the parotid gland, which is formed by the splitting of superficial layer of deep cervical fascia. It contains parotid gland, facial nerve, external carotid artery, retromandibular vein, and lymph node. Fascial layer is very thick superficially, very thin on deep side of gland, which is responsible for spread of infection into adjacent parapharyngeal space. From the lateral pharyngeal space ,infection may progress to the retropharyngeal space or carotid sheath and thus to the mediastinum. This is one of the feared complications of suppurative parotiditis.
SUBMENTAL SPACE:
This middle space lies between the anterior bellies of digastrics muscles.
The contents include areolar tissue, lymph node, anterior jugular vein.
SUBMANDIBULAR SPACE:
The submandibular space is composed of two spaces separated by mylohyoid muscle. The space below the mylohyoid muscle is called a submaxillary space. The space above the mylohoid muscle is termed as sublingual space and consist of loose connective tissue surrounding the tongue and sublingual gland.
It is bounded superomedially by oral mucosa and tongue, laterally with its tight attachment to the mandible and hyoid bone, inferiorly by the hyoid bone.
16 Submandibular infection readily communicate between the two subunits via the mylohyoid cleft (The space between the mylohyoid and geniohyoid muscle. The wartons duct, the lingual nerve, the hypoglossal nerve, branch of facial artery& lymphatics passing through this cleft. The submandibular space most commonly involved by primary infections of head and neck .Infections may arise from injuries to the floor of mouth, sublingual or submandibular gland sialadinitis ,or infections from the roots of mandibular teeth.
PARAPHARYNGEAL SPACE OR PHARYNGOMAXILLARY SPACE
OR LATERAL PHARYNGEAL SPACE
This lateral pharyngeal space shape compared to an inverted cone base is formed by the petrous portion of temporal bone, apex is at the level of hyoid bone. The posterolateral wall of lateral pharyngeal space contains the medial portion of the carotid sheath. The styloid process with its attachments, divide the space into two compartments.
The pre styloid compartment lies anterior to the styloid complex. It contains fat, connective tissue, the maxillary artery, the inferior alveolar nerve the lingual nerve. The post styloid compartment contains the carotid sheath, the
17 glossopharyngeal nerve, the hypoglossal nerve the sympathetic chain and associated lymphnode
The space communicate posteromedially to the retropharyngeal space, posterolaterally to the carotid space, anteroinferioly to the floor of mouth.
Because of its multiple connection ¢ral location it give access to spread of infection from one region to another .The most common route of infection to this space are lingual connections and lymphatics, submandibular gland infections, parotid and masticator space infections, and spread from peritonsillar abscess
MASTICATOR SPACE:
The masticator space is located between the superficial layer of deep cervical fascia and the muscles of mastication. It extends from base of skull to the lower border of mandible. It contain muscles of mastication, ramus and body of mandible, inferior alveolar nerve, mandibular division of trigeminal nerve. Infection to this space occur from trauma, surgery & post mandibular molar infections. Involvement of the deep compartment of masticator space results, if perforation of the lingual plate of the mandibular bone occurs.
Involvement of the superficial compartment produce extensive facial swelling and ,as a result of masseter muscle involvement severe trismus and pain occurs.
18 If left untreated infection may spread to the superficial portion of temporal space. Patients with deep masticator space infections will complaints of marked dysphagia, odynophagia and will exhibit swelling in the retromolar trigone, which is frequently mistaken for peritonsillar abscess. If the patient is unresponsive to initial antibiotic therapy surgical drainage may be required.
Drainage may be done through an intra oral or external incision depending on the space involved. The external incision usually employed is horizontal and is placed 2 to 3 cm below angle of mandible in the skin crease.
Intra oral incision placed along the inner margin of mandibular abscess
19 PRETRACHEAL SPACE:
The Pretracheal space lies between the middle layer of deep cervical fascia enclosing the trachea & thyroid, and deep layer of deep cervical facia.
The contents include the larynx, hypopharynx, cervical esophagus, thyroid, parathyroid, trachea.
Infection of this space usually result from contamination, as a result of trauma to the upper aero digestive tract or secondary to infection from surgical procedures such as thyroidectomy.
AETIOLOGY OF DEEP NECK SPACE INFECTIONS
In pre-antibiotic era, pharyngotonsillitis is the cause for 70% of DNSI.
But now the most common etiological factor is odontogenic infection. portal of entry in the pathogenesis of deep neck space infections
- odontogenic infections
- pharyngotonsillitis
- upper aero digestive tract trauma
- FB ingestion
- potts disease
- sialadenitis
- IV drug abusers.
20 CLINICAL MANIFESTATIONS
The clinical manifestation of deep neck space infection depends on the space involved .The symptoms include pain, fever, dysphagia, odynophagia swelling in the neck, trismus, torticollis. Pain is a constant finding in DNSI and gives a good idea about the primary source of infection. It may be used as a indication of extension or resolution of infection process.
Fever is also a constant finding of DNSI. Spiking temperature often indicate episodes of septicaemia and should raise concern about the possibility of internal jugular vein thromboplebitis and mediastinal extension. Trismus and torticollis are present in DNSI and are accompanied by swelling .The amount of swelling and trismus will vary depending upon the site of involvement.
Other symptoms the physician should aware of ,include progressive dysphagia, odynophagia, change in voice and dyspnea. Change in voice seen in lateral pharyngeal and retropharyngeal space involvement, with production of the so called hot pottato voice. Dyspnea can be occurred from airway encroachment caused by tongue swelling in ludwigs angina or from pharyngeal swelling in lateral pharyngeal and retropharyngeal abscess. Dyspnea is late finding indicating impending airway obstruction.
21 CLINICAL ASSESSMENT & INVESTIGATIONS
Assessment is done by taking a detailed history and performing a thorough physical examination. Airway assessment is important to findout whether the patient require emergency airway management.
HISTORY OF PATIENT
History about recent illness, dental caries, dental procedures, trauma to head and neck, i.v drug abuse should be asked.
Past history of diabetes, steroid therapy, HIV, CKD, and other immunocompromised conditions should be evaluated. History may prove invaluable in eliciting information that may lead to discovery of previously unsuspected portal of entry.
EXAMINATION
Patients should be examined for neck swelling, trismus, torticollis, dysphagia, odynophagia, fever, dyspnea. In pediatric populations in addition to these findings poor oral intake, drooling of saliva and lymphadenopathy should be examined. Physical examination is essential for determining the portal of entry and involvement of multiple spaces, and raise concern about development of complications.
22 LAB INVESTIGATIONS
Patients were investigated with routine blood examinations which includes
Total count, Differential count, Haemoglobin
Erythrocyte sedimentation rate, Platelets, coagulation profile
RBS, electrolytes, calcium
Blood culture if there is evidence of sepsis.
Screening for HIV, HBsAg, HCV, Pus for c/s.
Leukocytosis is an important feature of an abscess formation. Culture with
gram stain evaluation should be taken from any suspicious source of
infections.
DIAGNOSTIC IMAGING
PLAIN RADIOGRAPHY
Radiographic examination should be tailored to the individual patient and should include examination of the affected areas. Lateral neck films may be useful in demonstrating encroachment of the airway by floor of mouth infection
(ludwigs angina) or retropharyngeal abscess. Also they demonstrate widened retropharyngeal space which is suggestive of abscess formation. CXR are used to rule out complications like pleural effusion, pneumonia, and mediastinitis.
23 Soft tissue lateral view neck are useful for diagnosis of retropharyngeal and parapharyngeal abscess. Dental radiographs such as oral pantomogram are useful in identifying odontogenic source of infection
COMPUTED TOMOGRAPHIC SCAN
CT scans are useful to diagnose deep neck space infection and to find out the extent of disease. It also useful in early recognition of complications and planning the surgical treatment. Also identifies impending airway complications and can differentiate frank cellulitis from an abscess. CT scan with contrast enhancement is employed to determine the relationship of the infectious process to the cervical vasculature. It also demonstrates whether or not the internal jugular vein is patent.
24 ULTRASOUND
USG can differentiate frank cellulitis from drainable abscess. It helps to guide diagnostic and therapeutic needle aspiration. It is portable inexpensive and available in most of the institutions and avoid exposure to radiations.
MRI
MRI provides better soft tissue resolution and interference from dental filling avoid exposure to radiation.
Magnetic resonance angiography is used to rule out vascular complications including internal jugular vein thrombosis and carotid artery aneurysms.
.
25 SPECIFIC NECK SPACE INFECTIONS
LUDWIGS ANGINA
It is a gangrenous induration of connective tissues of neck. It is an acute infection of bilateral sublingual & submandibular spaces.
26 CRITERIA FOR DIAGNOSIS OF LUDWIGS ANGINA
Rapidly progressive cellulitis.
Develops along fascial planes with direct extension.
Does not involve submandibular gland (or) Lymphnode.
Involves both sublingual and submaxillary spaces and usually bilateral.
ETIOLOGY:
It occurs commonly in young adults with dental infection. Majority of the cases are result of abscessed 2nd (or) 3rd molar teeth. Which penetrate into submaxillary space below the mylohyoid ridge. Other causes parapharyngeal abscess penetrating injury, epiglottitis.
27 CLINICAL FEATURES:
Pain & swelling of the submandibular region which displace the tongue posteriorly and superiorly.
Trimus, dysphagia, odynophagia, fever.
Dyspnea and stridor signal the danger of airway obstruction.
On examination, submanidubular& submental regions are tense, swollen & tender. Floor of mouth is tense & indurated.
28 .
INVESTIGATIONS:
- Blood cell count is elevated.
- X-ray soft tissue neck.
- CT –Neck will show soft tissue oedema, gas, displacement of tongue.
TREATMENT:
Systemic Antibiotics- ceftriaxone / cefuroxime and Metroniadazole/
Clindamycin.
Tracheostomy – if airway is compromised.
29 Incision & drainage is the main component. Drainage material should be sent for culture and sensitivity.
Internal approach is for sublingually localised infection
External approach is for submaxillary infection
A transverse incision extending from one angle of mandible to the other is made, with vertical opening of the middle musculature.
PARAPHARYNGEAL ABSCESS
Parapharyngeal space infection can occur from
Pharaygitis, tonsillitis, adenoiditis, bursting of pertitonsillar abscess,
petrositis.
Dental infection (last molars)
Extension of parotid, retropharyngeal and submaxillary space infections.
Penetrating injuries
Iatrogenic
30 CLINICAL FEATURES:
Common Features: Fever, odynophagia, sorethroat, torticollis and
Toxemia.
If prestyloid compartment is involved, prolapse of tonsil, trismus,
swelling behind the angle of jaw and odynophagia.
If post styloid compartment is involved, pharyngeal bulging behind the
posterior pillar.
31 Cranial nerve palsies: IX, X, XI & XII may involved resulting in
dysphagia, horseness of voice, ipsilateral palsies of palate, larynx and
tongue.
Horners syndrome: Consists of anhidrosis, ptosis, miosis, enopthalmos,
loss of cilio spinal reflex due to involvement of sympathetic chain.
TREATMENT:
- Medical Treatment: aggressive antibiotic therapy, fluid replacement and
close observation.
- Surgical drainage usually done under general anaesthesia. Pre-operative
tracheostomy if trismus is marked. Drained by a horizontal incision made
2-3 cm below the angle of the mandible. Blunt dissection is done along
the inner surface of medial pterygoid.
32 COMPLICATIONS:
- Airway obstruction due to edema of Larynx.
- Thrombophlebitis of jugular vein
- Retropharyngeal abscess
- Infection of carotid sheath &mediastinitis
- Carotid artery bleeding
RETROPHARYNGEAL ABSCESS:
It is a life threatening infection of space between the buccopharyngeal fascia and alar fascia.
ACUTE RETROPHARYNGEAL ABSCESS:
It is commonly seen in children below 3 yrs of age. It occurs due to suppuration of retropharyngeal lymph nodes, secondary to infection from adenoids, nasopharynx, posterior group of sinuses. In adults it results from penetrating injury to pharynx and FB ingestion.
CLINICAL FEATURES:
- This abscess may obstruct the air & food passage resulting in Dysphagia,
Dyspnea.
33 - Stridor, croupy cough.
- Torticollis, bulge in the posterior pharyngeal wall.
X-ray soft tissue neck: CT Neck:
shows: widening of prevertebral soft tissue shadow, presence of gas, extent of abscess and straightening of cervical spine [Ramrod spine].
TREATMENT:
Incision and Drainage of abscess is done, usually without anaesthesia, as
there is risk of rupture during intubation.
34 The child is kept supine with head low and mouth opened with a mouth gag, a vertical incision is given in the most fluctuant area. Suction should always be kept available to prevent aspiration.
Broad spectrum systemic antibiotics
Tracheostomy in case of airway obstruction.
CHRONIC RETROPHARYNGEAL ABSCESS:
It occurs due to : (i) caries of cervical spine (ii) tubercular infection of
Retropharyngeal lymph node (iii) post traumatic vertebral fracture (iv) spread from parapharyngeal abscess.
CLINICAL FEATURES:
Throat pain, dysphagia, Fever and posterior pharyngeal wall swelling.
TREATMENT:
- I&D: Vertical incision along the anterior border of sternomastoid in low
abscess, along its posterior border in high abscess.
- Full course of anti tubercular therapy.
35 PERITONSILLAR ABSCESS (OR) QUINSY
It is defined as a collection of pus in the peritonsillar space. The space between the capsule of palatine tonsil and the superior constrictor muscle.
Usually it occurs as a complication of acute tonsillitis. Taking the advantage of the depth of crypta magna, infection reaches the peritonsillar space. Initially the infection may be non suppurative called peritonsillitis. Later due to high virulence of organism coupled, with low resistance of patients, suppuration occur.
CLINICAL FEATURES:
High grade fever, sore throat, dysphagia, dysphnea, a muffled hot potato voice.
Signs: Trismus, Torticollis, A large smooth surfaced globular fluctuant swelling near the upper pole of tonsil causing uvula to be pushed towards opposite side.
Diagnosis is based on presentation and clinical examination of the oropharynx.
36 TREATMENT:
In the stage of peritonsillitis, medical treatment which include hydrations, antibiotics, analgesics, local soothers.
Surgical treatment: instituted when abscess formation occur. I&D should be done in the most fluctuating (or) bulging point of abscess or at the junction of a horizontal line running through the base of uvula and a vertical line running along the anterior tonsillar pillar in sitting position without anaesthesia.
Interval Tonsillectomy should be done 4-6 weeks following the attack of quinsy.
37 COMPLICATIONS:
- Laryngeal edema
- parapharyngeal abscess
- Septicaemia
- Jugular vein thrombosis
- Spontaneous hemorrhage.
38 MICROBIOLOGY
Aspirates from deep neck space abscess are commonly poly microbial in nature. And reflect the odontogenic nature of these infections and the oropharyngeal flora. Most common organisms causing DNSI are aerobes like streptococcus viridians, staph aureus, klebsiella pneumonia, and less commonly streptococcus pneumonia, neisseria species and hemophilus influenza. Most common anaerobic isolates includes peptostreotococci, bacterioides, and fusobacterium species.
Methicillin resistant staph aureus causes deep neck space infections in i.v drug abusers, infants, young childrens and immuno compromised patients. It is an important pathogen in descending mediastinitis and necritizing fasciitis.
Klebsiella pneumonia is most common cause of deep neck space infections in patients who have uncontrolled diabetes mellitus
RISK FACTORS
DIABETES MELLITUS
Diabetes mellitus is the most common associated systemic disease in deep neck space Infection. Hyperglycaemia impairs neutrophil function and the complement pathway, and also increases the virulence of
39 certain pathogens. Uncontrolled diabetes impairs the immune function resulting in inability to confine an infection.
The most frequently isolated pathogen from deep neck aspirates in diabetic patients is Klebsiella pneumoniae .This infection is effectively treated by adding gentamicin to their empiric antibiotic therapy.
Diabetics have long hospital stay and mostly require surgical intervention because they respond poorly to conservative medical therapy and develop complications frequently compared with nondiabetic patients. It is also important to maintain the blood glucose levels below 200 mg/dl.
OTHER IMMUNOSUPPRESSION
Other causes of immunosuppression causing severe and atypical infections of the head and neck are HIV infection, chemotherapy, chronic renal failure, hepatic disease and chronic steroid therapy for autoimmune disease.
Immunocompromised patients are more likely to present with minimal signs and symptoms despite a greater risk for complications. The neutrophil count in AIDS patients may remain low inspite of an infection. Empiric antibiotic therapy used should cover all potential pathogens.
40 Intravenous drug abusers use the neck as an injection siteand increases the risk for carotid space infection. Pathogens are introduced through the skin and an abscess may form around a foreign body such as a broken needle.
Appropriate empiric antibiotic coverage should include vancomycin along with adequate anaerobic coverage that is also effective against Eikenella corrodens, such as ciprofloxacin or an aminoglycoside such as gentamicin, amikacin, kanamycin etc
Congenital cysts such as branchial cleft cysts, lymphangiomas, thyroglossal duct cysts and cervical thymic cysts should be suspected in any patient who has recurrence of deep neck space infection. Other less common causes include laryngocele, bronchogenic cyst, thyroid arch anomalies and thyroiditis.
Imaging is useful in early recognition and surgical planning.
Initially, infections within congenital cysts may respond well to antibiotic therapy. However, complete surgical excision of the cyst wall is absolutely necessary to prevent the recurrence.
41 MANAGEMENT
CONSERVATIVE TREATMENT
Uncomplicated deep neck abscess and cellulitis can be successfully treated with antibiotics without surgical drainage. Medical management for associated co morbidities such as diabetes, CKD, can improve the overall immune status of deep neck space infection patients
Initially patients started with empirical antibiotic therapy and later converted to appropriate antibiotics based on culture and sensitivity results.
Empirical therapy should be effective against aerobic and anaerobic bacteria that are commonly involved. Either penicillin with beta lactamase inhibitors
(amoxicillin or ticarcillin with clavulanic acid ) or cephalosporins (ceftriaxone, cefuroxime ) in combination with drugs active against anaerobes
(metronidazole, clindamycin) is recommended for optimal empirical therapy.
Vancomycin should be considered in i.v drug abusers, patients with profound neutropenia and immune dysfunction. The addition of gentamycin for effective gram negative coverage against klebsiella pneumonia is recommended for diabetic patients. Parenteral antibiotic therapy should be continued until the patient become afebrile for atleast 48 hours.
42 SURGICAL MANAGEMENT
Surgical management is the treatment of choice in complicated cases of deep neck space infections.
Indications for surgical management include airway compromise, septicaemia, critical conditions, diabetic mellitus, descending infections and no clinical improvement after 48 hours of initiation of parenteral antibiotics
Surgical drainage can be simple interval approach or external incision and drainage for superficial abscess and a more extensive external cervical approach for more extensive and complicated infections. Aspirated pus or debrided tissue should be collected and sent for gram staining and c/s test
Fluid resuscitation before surgery is important in deep neck space infections patients because these patients frequently present in a dehydrated state.
External cervical approach is used in draining anterior visceral, parapharyngeal, submandibular, retropharyngeal and carotid space abscess that cannot be fully drained by intra oral approach
Minimally invasive techniques can be preferred in unilocular well defined abscess and in patients who do not have airway compromise. USG
43 guidance and CT guidance is appropriate for locating and draining abscess accessible through the skin
AIRWAY MANAGEMENT
Acute airway obstruction is the commonest complication of deep neck space infections. It can be encountered in multiple space involvement,
Ludwig’s angina, retropharyngeal, parapharyngeal and anterior visceral space abscesses. Tracheostomy under local anaesthesia is the most effective method for managing airway compromise. Other methods of airway management are endotracheal intubation, fiber optic nasotracheal intubation, and cricothyrotomy.
Aggressive airway management is indicated if there is signs of respiratory distress (dyspnoea, stridor, chest retractions) or impending airway compromise. If there is airway compromise physical examination or diagnostic imaging shows severe swelling within the pharynx, upward displacement of the tongue, airway oedema or airway compression by an abscess. Swelling and the need for aggressive airway interventioncan be minimizedby use of intravenous steroids. Systemic steroids have hyperglycemic effects and should be avoided in patients with uncontrolled diabetes mellitus
TRACHEOSTOMY
In cases of severe respiratory distress or impending airway obstruction, tracheostomy is indicated. Tracheostomy and drainage procedures
44 needs separate incisions.Tracheostomy is relatively contraindicated in case of anterior visceral space / pretracheal space infection. The advantages of tracheostomy includes airway security, decrease sedation, short hospital stay and decrease mortality. The disadvantages are bleeding, pneumothorax, tracheal stenosis , mediastinitis , aspiration of pus , and death.
ENDOTRACHEAL INTUBATION
Endotracheal intubation can be attempted before tracheostomy for patients with milder degrees of respiratory distress. The advantages of endotracheal intubation are fast airway control and absence of risks associated with a surgical procedure. The disadvantages are difficult intubation in the cases with airway edema, patient discomfort, greater need for patient sedation and mechanical ventilation, potential for laryngotracheal stenosis.
45 FIBER OPTIC NASOTRACHEAL INTUBATION
Fiber optic nasotracheal intubation is performed under local anaesthesia. It is especially useful in patients without any airway compromise, but having severe trismus. Procedure is difficult in patients with laryngealedema, copious secretions, inadequate experience and improper application of topical anaesthetic.
CRICOTHYROTOMY
Cricothyrotomy can provide urgent airway access when there is a complete loss of the airway, but no facilities to perform a tracheostomy. The disadvantage of cricothyrotomy is that the rigid nature of the thyroid and cricoid cartilages limits the size of the tube that can be placed. Complications of cricothyrotomy are trauma to the posterior wall of the trachea and subsequent subglottic stenosis. Within 24 to 48 hours cricothyrotomy should be converted to a standard tracheostomy.
COMPLICATIONS
MEDIASTINAL COMPLICATION
Mediastinitis occurs when there is downward extension of an infection from the neck spaces or the anterior visceral space. The causative
46 organisms in most cases are polymicrobial and involve both aerobes and anaerobes.
The clinical symptoms of mediastinitis are increasing chest pain or dyspnoea. Chest radiography and computed tomography scan shows a widened mediastinum or pneumomediastinum . In patients with mediastinitis mortality rate is high.
VASCULAR COMPLICATION
Lemierre’s syndrome is the suppurative thrombophlebitis of internal jugular vein that results from extension of the infection into the carotid
47 space. The clinical features include swelling and tenderness at the angle of the jaw and along the sternocleidomastoid muscle. The signs of sepsis include spiking fever and chills. High resolution computed tomography scan and magnetic resonance imaging can be used to detect Internal Jugular Vein
Thrombus.
Treatment involves antibiotic therapy according to culture and sensitivity results and anticoagulation for 3 months when thrombus progression or septic emboli are present. Surgical ligation and resection of the internal jugular vein is indicated only when there is no resolution with antibiotic and anticoagulation therapy. If internal jugular vein thrombosis is recognized within
4 days of onset fibrinolytic agents may be tried.
48 CAROTID ARTERY ANEURYSM
Carotid artery aneurysm and its rupture may present with a pulsatile neck mass and often results in four cardinal signs:
• Recurrent sentinel haemorrhages from the pharynx or ear .
49 • Long clinical course.
• Hematoma of the surrounding neck tissues.
• Hemodynamic instability.
The treatment options include surgical intervention to gain proximal control of the common carotid artery and interventional radiologic procedures such as endovascular
Stenting.
OTHER COMPLICATIONS
Lung abscess
Empyema
Asphyxiation may result when an abscess ruptures into the larynx or
trachea
50 Horner’s syndrome
Cranial nerve IX to XII palsies result from infections that invade the
carotid space
Osteomyelitis can involve the mandible or cervical vertebral bodies and
can lead to vertebral subluxation
Sepsis is the direct cause of mortality in patients with deep neck space
infection
Potential complications include meningitis, intracranial abscess and
disseminated intravascular coagulation.
51 REVIEW OF LITERATURE
Burns described about the fascias of head and neck in 1811.
Mosher said that ‘ pus in the neck calls for the surgeons best judgement his best skill and for all of his courage’.
In 1836, Wilhelm friedrich von Ludwig described about ludwigs angina.
Beck studied about 50% of deep neck space infections involve lateral pharyngeal space before the advent of chemotherapy. The most common source of infection is peritonsillitis. According to the same author this figure has been reduced to less than 30% because of the advent of antibiotics.
In 1929, mosher described a T shaped inscision for submandibular fossa approach to carotid sheath and parapharyngeal space.
Barrett and associates recently suggested that the incidence of retropharyngeal abscess may be higher in adult population.
Dean described an anterior cervical approach for retropharyngeal abscess has extend to cause airway obstruction or if there is significant inferior extension.
Gaurav kataria et al. Reported deep neck space infections can be life threatening in diabetic patients, elderly, and immunocompromised patients. Special attention must be given to these groups.4
52 Kim hj et al studied about deep neck space infections in diabetic population in tertiary care centre. They reported deep neck space infections in diabetic patients are more likely to have complications and longer durations of hospital stay.3
Atishkumarbg et al7 studied odontogenic infections were the most common etiological factor for the development of deep neck space infections.
Varqalaravin et al. Reported deep neck space infections need early detection and aggressive management in order to prevent serious complications.8
Lawrence r et al studied controversies in the management of deep neck space infections in children, they suggested that the management of DNSI should be directed towards the patient as factors , age of the patient may influence the treatment conservative Vs surgical approach.18
Bing wang et al reported that CT and MRI plays a vital role in the diagnosis of
DNSI and guide in correct site for puncture or incision for drainage of DNSI.9
Mehmet mutlu et al. Reported deep neck space abscess is very rare in neonatal period.10
Peter d kalkos et al reported that skillfull airway management is critical in
DNSI.11
Weiquang yang et al studied DNSI in adults is prone to develop multi space involvement and complications than that of children.12 53 Parhiscar A et al studied about deep neck space abscess a, a retrospective review of 210 cases. This study shows intravenous drug abusers and mandibular fractures are no longer major etiological factors.17
Thiago PB et al studied main complication in DNSI includes septic shock, pneumonia, mediastinitis.34
54 RESULTS
1.SEX DISTRIBUTION
Male Female
41 (52.5%) 37 (47.4%)
Sex Distribution
37 [47.4,%] 41 [52.5%] Male Female
In our Study there were 78 patients in which 41 (52.5%) were male, 37 (47.4%) were female, with a male female ratio of 1:1.1
55 2.AGE DISTRIBUTION
Age No. of Patients Percentage
1-10 yrs 3 3.8%
11-20 yrs 8 10.2%
21-30 yrs 9 11.5%
31-40 yrs 21 26.9%
41-50 yrs 13 16.6%
51-60 yrs 8 10.2%
61-70 yrs 13 16.6%
71-80 yrs 3 3.8%
Age Distribution
26.90% 30.00% 25.00% 20.00% 16.60% 16.60% 15.00% 10.20% 11.50% 10.20% 10.00% 3.80% 3.80% 5.00% 0.00% 1-10 yrs 11-20 21-30 31-40 41-50 51-60 61-70 71-80 yrs yrs yrs yrs yrs yrs yrs
Minimum age – 5 yrs, Maximum age – 78 yrs, Majority 31-40 yrs.
56 The mean age of patients in our study was with minimum age of patients was 5 yrs and a maximum age was 78 yrs. Majority of patients were in the age group of 31-40 years followed by 41 - 50 yrs.
3. SYMPTOMS
Symptoms No. of Cases Percentage (%)
Neck Swelling 56 71.7%
Neck Pain 50 76.9%
Dysphagia 50 64.1% odynophagia 36 46.1%
Fever 66 84.6%
Toothache 30 39.7%
Trismus 19 24.3%
Airway Difficulty 7 8.9%
Torticollis 4 5.1%
Voice change 12 15.3%
57 SYMPTOMS OF DEEP NECK SPACE INFECTION
90 80 70 60 50 40 30 20 10 0
In this study the most common symptom was fever, Present in 66 Patients
(84.6%) followed by neck pain found in 60 Patients (76.9%), Neck Swelling in
56 Patients (71.7%), Dysphagia 50 Patients (64.1%), odynophagia in 36 Patients
(46.1%),Trismus in 31 Patients (39.7%), Tooth ache in 19 Patients (24.3%),
Airway Difficulty in 7 Patients (8.9%), Torticollis in 4 Patients (5.1%), Voice
Change in 12 Patients (15.3%).
58 4. LOCATION OF ABSCESS
Location of Abscess No. of Cases Percentage (%)
Ludwigs Angina 30 38.4%
Peritonsillar Abscess 16 20.5%
Submandibular Abscess 7 8.9%
Parotid Abscess 8 10.2%
Parapharyngeal Abscess 5 6.4%
Retropharyngeal Abscess 7 8.9%
Submental Abscess 3 3.8%
Anterior Visceral space abscess 1 1.2%
Masticator / Buccal space 1 1.2%
59 45 40 location of abcess 35 30 25 20 15 10 5 0
Among the 78 Patients of Deep Neck Space infections, Ludwigs Angina was the most common neck infection in 30 Patients (38.4%) followed by peritonsillar abscess in 16 Patients (20.5%), parotid abscess in 8 Patients
(10.2%), submandibular abscess in 7 Patients (8.9%), Parapharyngeal Abscess in 5 Patients (6.4%), Submental abscess in 3 % Patients (3.8%) and abscess anterior Visceral space in one patient (1.2%)
60 5.ETIOLOGICAL FACTORS
Etiology No. of Patients Percentage (%)
Odontogenic 38 48.7%
Tonsillopharyngitis 16 20.5%
Salivary Gland infections 1 1.28%
Foreign Body 3 3.8%
Idiopathic 20 25.6
Trauma 0 0
AETIOLOGICAL FACTORS OF DEEP NECK SPACE INFECTIONS 60 50 40 30 20 10 0
In our Study, the etiological factor in majority of cases was found to be, dental infections (38 Patients 48.7%) followed by Tonsillopharyngitis (16 Patients
20.5%). In 20 Patients the etiological factor was unknown.
61 6. RISK FACTORS / CO – MORBIDITY
Risk factor No. of Patients Percentage (%)
DM 20 25.6%
CKD 3 38.4%
HTN 5 6.41%
HIV 1 1.28
Anaemia 1 1.28%
RISK FACTORS 30
25
20
15
10
5
0 diabetes mellitus CKD hypertension HIV anemia
Among the various risk factors, diabetes mellitus was the common and found in 20 Patients (25.6%) and hypertension in 5 Patients (6.4%) one patients was found to be HIV Positive and one patient was severe anaemic with Hb
3.5% who was treated with blood transfusion.
62 7. DIAGNOSTIC TOOLS
DIAGNOSTIC TOOL NUMBER OF CASES PERCENTAGE
XRAY NECK 45 57.6%
CULTURE AND
SENSITIVITY 56 71.1%
CT SCAN 49 62.8%
DIAGNOSTIC TOOLS
XRAY NECK
CULTURE AND SENSITIVITY CT SCAN
In our study X-ray neck and CT SCAN was taken according to the clinical presentation and the spaces involved.
Pus for culture and sensitivity was sent for patients who underwent incision and drainage.
63 8. BACTERIOLOGY
Bacteriology No. of Patients Percentage (%)
Streptococcus Pyogenes 6 7.6%
Staph aureus 6 7.6%
Streptococcus 5 6.4%
Pseudomonas aeruginosa 9 11.5%
Bacteroides 2 2.56%
Klebsiella Pneumonia 3 3.8%
Peptostreptococcus 1 1.2%
E. Coli 2 2.5%
Negative Culture 20 25.6%
64 BACTERIOLOGY
streptococcus pyogenes staphylococcus aureus streptococcus viridans pseudomonasauroginosa bacteroides klebsiella pneumonia peptostreptococci e coli negative culture
Sample for pus Culture and Sensitivity were collected from 56 Patients.
Bacterial growth was found in 36 samples.
In this study pseudomonas aeruginosa species was found in 9 patients, followed by streptococcus pyogenes& Staph aureus in 6 patients. In 20 Patients the pus culture and sensitivity test was found to be negative.
65 9. TREATMENT
Treatment No. of Patients Percentage (%)
Incision and Drainage 56 71.7%
Wound Debridement 4 5.12%
Teeth Extraction 5 16.41%
Tracheostomy 6 7.6%
Conservative 22 28.2%
ATT 2 2.5%
MANAGEMENT OF DEEP NECK SPACE INFECTIONS
incision and drainage conservative management
All the 78 Patients were treated with IV antibiotics during admission.
Among this 78 Patients 56 underwent incision and drainage. 22 Patients were treated conservatively with IV antibiotics and other supportive measures.
66 10. ANTIBIOTIC USED
NUMBER OF
ANTIBIOTIC USED CASES PERCENTAGE
AMPICILLIN 3 3.8
CEFTRIAXONE 2 2.5
CIPROFLOXACIN 3 3.8
METRONIDAZOLE 4 5.1
CEFOPERAZONE-SULBACTAM 2 2.5
AMIKACIN 2 2.5
AMPI/CEFTRIAXONE+METRO+GM 62 79.4
ANTIBIOTIC USED
80 70 60 50 40 30 20 10 0
67 In our study a combination of drugs were used mostly.
Initially the patients with deep neck space infection were started on empirical antibiotics and later changed to appropriate antibiotics based on culture and sensitivity reports.
68 11. COMPLICATIONS
Treatment No. of Patients Percentage (%)
Airway compromise 7 8.97%
Septic Shock 4 5.125
Pneumonias 0 0
Mediastinitis 1 1.28%
Jugular vein thrombosis 1 1.28%
COMPLICATIONS OF DEEP NECK SPACE INFECTIONS
9 8 7 6 5 4 3 2 1 0 airway septic shock pneumonia mediastinitis jugular vein compromise thrombosis
In our study the most commonly encountered complication is airway compromise followed by septic shock.
Mediastinitis and jugular vein thrombosis occurred only in one patient each.
69 DISCUSSION
In our study 78 patients with DNSI were include and all were admitted to the hospital for treatment. In our study there was slight male predominance was seen which is consistent with studies by gauravkataria et al4 and parhiscar et al17. In our study the majority of patients were seen in the third to fourth decade. This correlate with the studies by gauravkataria et al4, parhiscar et al17, meher et al19 and gujarathi AB et al7.
The common symptom of presentation of our study was similar to other studies by meher et al19, gauravkataria et al4. The most common symptoms include fever, neck pain, neck swelling, dysphagia, odynophagia, trismus, and torticollis.
In a study by gauravkataria et al4, 24.07% of DNSI were caused by odontogenic diseases. In a retrospective study byparhiscar and har17, odontogenic infections were declared the most common cause of DNSI [43%].
Huang et al45, marchiori et al42 and eftekharian et al21 also reported that odontogenic problems were the common etiological factors for DNSI in 42%,
38.8%, and 49% cases respectively. In a study by mumtaz et al22 also showed the most common causative factor DNSI is dental infection. In our study also
70 the most common causative factor is odontogenic in origin and responsible for about 48.4% cases.
In our study, the most common presentation of DNSI was ludwigs angina[38.4%] followed by peritonsillar abscess [20.5%], parotid abscess[10.2%], submandibular abscess[8.97%] and retropharyngeal abscess[8.97%]. Ludwigs angina, peritonsillar abscess, submandibular abscess, parotid abscess accounted for approximately 56% of our cases which is consistent with the studies by afshin et al and khode et al52 with 60% cases with similar presentation. In astudy by gaurav kataria et al4ludwigs angina was the commonest presentation followed by peritonsillar abscess.
Diabetes mellitus was the most common co morbid condition associated with DNSI. In our study, 25.6% cases are diabetics which is somewhat high as compared to a study by gaurav kataria et al4 which reported
10.52% cases are diabetics. In a study conducted by huang et al45, 30.3% patients are diabetics which is consistent with our study.
Pseudomonas aerugenosa was the most common cultured organism in our study followed by streptococcus and staph aureus which is contrast to other
71 studies by parhiscar et al17, mumtaz et al22 and gauravkataria et al4 were the most common cultured organism is streptococcus species. In 20 patients
[25.6%] culture shows negative reports which was probably due to the initiation of antibiotic at the time the cultures were sent.
A contrast CT scan is the gold standard investigation for the early diagnosis of deep neck space infections and to show the extent of disease. CT scans are good in differentiating between cellulitis and abscess and plays an important role in the detection of serious complications.
CECT scan helps to decide whether the surgical intervention is needed or not. Patients with radiological evidence of abscess had an increased incidence of complicationsand they require surgical intervention due to aggressive nature of the condition.USG is also an important diagnostic tool in detection of abscess formation. In this study CT scan was performed in around
48 patients [61.5%], USG done in 12 patients [15.3%].
Usually the management of DNSI involves early drainage of abscess via external inscision or intraoral approach. In this study, all patients were initiated on appropriate i.v antibiotis with ampicillin or ceftriaxone and
72 metronidazole. Later this was changed according to c/s reports. In case if there is obvious abscess formation or pus collection in CT scan those patients treated with open surgical drainage. In our study 56 patients [71.7%] underwent surgical intervention which is consistent with the studies by gauravkataria et al4, eftekharian et al21, parischar et al17, mumtaz et al22 with surgical intervention required in approximately 89.4%, 79%, 100%, 78% cases respectively. In our study, 22 patients were treated with medical management alone which is contrast with the study by gaurav kataria et al4 in which only 8 patients were treated conservatively.
Complications were occurred only in few patients. 7 patients had upper airway obstruction, 4 patients had septic shock, 1 had mediastinitis. 4 patients died during hospital stay due to co morbidities and development of complications.
Airway management is challenging in cases with DNSI .Usual causes of airway compromise include laryngeal edema and pushing of the tongue upwards and backwards in ludwigs angina. In our study tracheostomy was done in 76% cases, which is consistent with the study by Eftekharian et al.and in which tracheostomy was performed in 8.8% cases.
73 CONCLUSION
Patients with DNSI were evaluated and managed according to their etiology and clinical presentation.Infections of the deep fascial spces of the head and neck were fairly common and were a source of considerable morbidity and mortality.
DNSI are most common in the age group of 31-40 years. Males are most
commonly affected than females.
The most common cause of DNSI is odontogenic infections. Therefore
prevention of DNSI can be achieved by making population aware of oral
and dental hygiene and encouraging regular checkups for odontogenic
infections.
Patients with DNSI with diabetes are more prone to develop
complications. It is very important to give special attention to high risk
groups such as diabetic, elderly and patients with systemic diseases as
these patients may progress to life threatening complications.
Early diagnosis and treatment is essential in DNSI. All patients should be
started on empirical antibiotics and later changed as per c/s reports.
Therapeutic needle aspiration and conservative medical management are
effective in selective patients such as those with minimal abscess
formation.
74 Surgical intervention is indicated in a patient who shows significant
abscess formation on CT scan.
Tracheostomy should be considered if airway protection is needed.
Lack of adequate nutrition, poor oral hygiene, tobacco chewing,
smoking, betel nut chewing lead to dental and periodontal infections
causing increased prevalence of DNSI.
75 PATIENT WITH LUDWIGS ANGINA
Pre operative clinical picture
Post operative clinical picture PATIENT WITH PARA PHARYNGEAL ABSCESS
Pre operative clinical picture CT Neck
Post operative clinical picture PATIENT WITH RECURRENT PARAPHARYNGEAL ABSCESS
Pre operative clinical picture CT Neck
Post operative clinical picture PATIENT WITH PAROTID ABSCESS
Pre operative clinical picture
Post operative clinical picture PATIENT WITH RETROPHARYNGEAL ABSCESS
Picture shows bulge in the posterior pharyngeal wall
CT NECK SHOWS ABSCESS COLLECTION IN THE RETROPHARYNGEAL ABSCESS PATIENT WITH LUDWIGS ANGINA
Pre operative clinical picture
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Name : IP / OP No. :
Age : Sex :
Occupation :
Address :
Presenting Complaints :
History of presenting illness
S. Complaints Yes No Duration No. 1. Fever 2. Fever with chills 3. Sore throat 4. Tongue pushed back 5. Neck pain 6. Neck stiffness 7. Ear pain 8. Neck Swelling 9. Change in Voice 10. Body ache 11. Painful swallowing 12. Difficulty in Swallowing 13. Difficulty in breathing 14. Difficulty in talking 15. Noisy difficulty in breathing 16. Cough with expectoration 17 Chest Pain
Past History : Diabetes Mellitus / Tuberculosis / Hypertension /
Epilepsy / Jaundice / Asthma
Personal History : Diet, Appetite, Smoking, Alcohol, Tobacco Chewer,
Bladder and Bowel habits.
Family History : Married / Unmarried :
Number of Children :
Socioeconomic Status : Low Middle High
General Examinations:
Appearance :
Temperature :
Pallor :
Cyanosis :
Jaundice :
Pedal edema :
Lymphadenopathy :
Thyroid Swelling :
Pulse Blood Pressure Respiratory Rate Temperature
Systemic Examination: Cardiovascular system Respiratory system
Examination of abdomen Central nervous system
Local Examination: Throat:
ORAL CAVITY ;
Lips :
Teeth :
Gingivo buccal sulcus and labial sulcus:
Oral Mucosa :
Tongue anterior 2/3rd of tongue :
Floor of mouth :
Hard and soft palate :
Retromolar Trigone :
OROPHARYNX ;
Tonsils and pillars :
Posterior pharyngeal wall and lateral Pharyngeal wall :
Indirect Laryngoscopy:
Posterior 1/3 rd of Tongue :
Vallecula :
Epiglottis :
Aryepiglottic folds :
Arytenoids :
Ventricular Bands :
Both Vocal cords and mobility :
Subglottis :
Hypopharyngx : Posteriorpharyngeal wall
Pyriform fossa
Postcricoid region
Neck:
Inspection
Skin :
Laryngeal contour :
Thyroid :
Tracheal Position :
Abnormal Veins, Sinus, Scar :
Laryngeal crepitus :
Palpation
Warmth :
Tenderness :
Nodes :
Carotid Pulsations :
Ear : Right Left
Tympanic Membrane :
External Auditory Canal. :
Nose :
Cranial nerves :
Investigations:
Blood : Hb :
TC :
DC :
ESR :
Platelet :
aPTT :
PT :
BT & CT :
Urine : Albumin :
Sugar :
Throat Swab Culture and sensitivity :
Culture and sensitivity of aspirate :
X-ray Chest :
X-ray Neck AP / Lateral :
X-ray Neck Soft Tissue AP / Lateral :
Computed tomography scan :
Patient Name :
Diagnosis :
Procedure :
Anaesthesia : GA / LA
Positions :
Final Diagnosis :
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MASTER CHART S.N NAME AG SE IP.NO CLINICALFEATURES RISKFACTORS DIAGNOSIS C/S TREATMENT COMPLICATIO O E X NS N N D O F T T A T V S P A C C 1 RAJENDRAN 53 M 43799 + + + + - + + - - - - LUDWIGS ANGINA - CONSERVATIVE - 2 KAVITHA 19 F 89024 - - + + + ------PERITONSILLAR - CONSERVATIVE - ABSCESS 3 PAVITHRA 12 F 4624 - - + + + ------PERITONSILLAR - CONSERVATIVE - ABSCESS 4 BALAGANESH 7 M 12278 + + - - + ------SUBMENTAL ABSCESS NO I&D - GROWTH 5 AARTHI 22 F 62724 + + - - + ------PAROTID ABSCESS STAPH I&D - AUREUS 6 KARUTHA 55 M 73872 + + - - + + - - - - - LUDWIGS ANGINA CONSERVATIVE - PANDI 7 PANDARAM 60 M 73641 + + + + + + + - + - DM LUDWIGS ANGINA STREPT I&D - PYOGENES 8 MAHESHWARI 48 F 6181 + + - - + ------RT PAROTID ABSCESS - CONSERVATIVE -
9 SUBRAMANIAN 67 M 57220 + + ------DM LT PAROTID ABSCESS NO I&D - GROWTH 10 SARASWATHI 45 F 18418 - - + + + + - - - - DM/ HTN RETROPHARYNGEAL PSUDOMONAS I&D - AERUGIONOSA ABSCESS 11 SHANTHI 28 F 32084 + + - - + ------LT SUBMANDIBULAR - CONSERVATIVE - ABSCESS 12 PETCHIMUTHU 30 M 52308 - - + + + + - + - - - RETROPHARYNGEAL STAPH I&D WITH AIRWAY ABSCESS AUREUS EMERGENCY COMPROMISE TRACHEOSTOM Y 13 JENISHA 15 F 78707 + + + + + - + - - - - LT SUBMANDIBULAR - CONSERVATIVE - ABSCESS 14 MUPPIDATHY 37 F 54675 + + + + + ------LUDWIGS ANGINA - CONSERVATIVE -
15 BALA 58 M 53492 + + ------DM RT PAROTID ABSCESS KLEBSIELLA I&D - SUBRAMANIAN 16 SHAMEELA 38 F 54219 + + + + + + + + - - - LUDWIGS ANGINA STAPH I&D WITH AIRWAY AUREUS EMERGENCY COMPROMISE
TRACHEOSTOM Y 17 MUTHAIH 70 M 52549 + + + + ------DM LUDWIGS ANGINA KLEBSIELLA I&D - DEVAR 18 PALAVESAM 78 M 33834 + + ------DM LUDWIGS ANGINA STREPT I&D - VIRIDANS 19 RAJAMANI 36 M 36571 - - + + + + - - - + DM LT PERITONSILLAR STAPH I&D - ABSCESS AUREUS 20 GURUVAMMAL 60 F 37787 + + - - + - + + - - - RT SUBMANDIBULAR STREPT I&D - ABSCESS VIRIDANS 21 MARIAMAL 44 F 38690 - - + + + - - - - + - RT PERITONSILLAR - CONSERVATIVE - ABSCESS 22 ARUN 22 M 36556 + + - - + - - - - - RT SUBMANDIBULAR - CONSERVATIVE - ABSCESS 23 VEERAPPAN 49 M 43965 + + + + + ------PARAPHARYNGEAL STEPT I&D - ABSCESS PYOGENES 24 ARUN 27 M 67526 - - + + + - - - - + - LT PERITONSILLAR - CONSERVATIVE - ABSCESS 25 GOVINTH 45 M 74823 - - + + + + - - - - - BUCCAL ABSCESS - CONSERVATIVE - 26 SUDALAI 36 M 85473 + + + + + + + - - - DM LUDWIGS ANGINA PSEUDOMONA I&D - S AERUGINOSA 27 MUKESH 15 M 51452 + + + ------PARAPHARYNGEAL NO I&D - ABSCESS GROWTH 28 SUYAMBU 64 M 29838 + + + + + - - - - - HTN LUDWIGS ANGINA E COLI I&D - 29 BOOBATHY 39 M 87040 - - + + + + - - - + - LT PERITONSILLAR - CONSERVATIVE - ABSCESS 30 JEYAKUMARI 64 F 2117 - - + + + ------LT PERITONSILLAR - CONSERVATIVE - ABSCESS 31 RAMALAKSHMI 33 F 5480 - + + + + ------RETROPHARYNGEAL STAPH I&D - ABSCESS AUREUS 32 ROOTH 42 F 8061 - - + + + - - - - + - LT PERITONSILLAR NO I&D - ABSCESS GROWTH 33 SUBBAMMAL 65 F 12703 + + - - + - - - - - DM RT SUBMANDIBULAR BACTEROIDES I&D - ABSCESS 34 ANANDAPAN 48 M 19913 + + + + + + + + - - DM PARAPHARYNGEAL PSEUDOMONA I&D WITH AIRWAY ABSCESS S AERUGINOSA EMERGENCY COMPROMISE TRACHEOSTOM
Y 35 PARVATHY 63 F 44842 + + + + ------LUDWIGS ANGINA STREPT I&D - VIRIDANS 36 ISAKKIAMMAL 35 F 49057 + + - - + ------LT PAROTID ABSCESS PSEUDOMONA I&D - S AERUGINOSA 37 APPADHURAI 43 M 39022 - - + + + + - - - + - LT PERITONSILLAR - CONSERVATIVE - ABSCESS 38 ABDHULLA 63 M 70432 + + + + + ------LUDWIGS ANGINA NO I&D - GROWTH 39 SYED IBRAHIM 50 M 61995 + + + + + + - - - - DM PARAPHARYNGEAL STEPT I&D - ABSCESS PYOGENES 40 PETCHITHAI 29 F 63881 + + - - + ------RT SUBMANDIBULAR - CONSERVATIVE - ABSCESS 41 SORNAMUTHU 40 F 24017 - - + + + ------RETROPHARYNGEAL PSEUDOMONA I&D - ABSCESS S AERUGINOSA 42 ROSELIN 45 F 54532 - - + + + + - - - + DM LT PERITONSILLAR NO I&D - ABSCESS GROWTH 43 FATHIMA 70 F 11688 + + + + + - + + - + DM/HTN/CK LUDWIGS ANGINA KLEBSIELLA I&D WITH SEPSIS AND BEEVI D EMERGENCY DEATH TRACHEOSTOM Y 44 SOLAIAMMAL 26 F 6547 + + - - + + - - - - - LUDWIGS ANGINA - CONSERVATIVE -
45 VIDHYA 9 F 53825 - - - + + + - - - - - LT PERITONSILLAR - CONSERVATIVE - ABSCESS 46 SUBRAMANIAN 58 M 65694 + + + + + ------LUDWIGS ANGINA NO I&D - GROWTH 47 MURUGESAN 48 M 66011 - + + + + + - - - - - LT PERITONSILLAR STEPT I&D - ABSCESS PYOGENES 48 JUSTIN 13 M 66098 + + + + ------LUDWIGS ANGINA NO I&D - GROWTH 49 INDUMATHI 32 F 67211 - - + + + + - - - + - RT PERITONSILLAR NO I&D - ABSCESS GROWTH 50 SELVI 50 F 69538 + + - - + + - - + - - ANTERIOR VISCERAL STREPT I&D - SPACE ABSCESS VIRIDANS 51 BALA 5 M 12278 + + _ - + + + - - - - LUDWIGS ANGINA - CONSERVATIVE 52 ANSARY 34 M 4735 + + - - + - - - - - LT PAROTID ABSCESS NO I&D
GROWTH 53 VELAVAN 36 M 8929 + + - - + - - - - - RT PAROTID ABSCESS NO I&D GROWTH 54 KANAGAMAL 32 F 15516 + + + - + + + - - - LUDWIGS ANGINA PSEUDOMONA I&D S AERUGINOSA 55 RAMALAKSHMI 29 F 21483 + + - - + - - - - - SUBMENTAL ABSCESS NO I&D GROWTH 56 SEENIAMMAL 75 F 23495 - + + + + - - - - - DM RETROPHARYNGEAL STAPH I&D ABSCESS AUREUS 57 RAZULMYDEEN 30 M 25364 - - + + + - - - - - PERITONSILLAR NO I&D ABSCESS GROWTH 58 MARIAPPAN 36 M 29363 + + - - + - - - - - HIV LT PAROTID ABSCESS BACTEROIDES I&D 59 ARUNACHALAM 67 M 34026 + + + + + + + - - - DM LUDWIGS ANGINA NO I&D GROWTH 60 BENSIYA 16 F 43530 + + - - + ------SUBMENTAL ABSCESS NO I&D GROWTH 61 SAMEELA 38 F 54219 + + + + + + + + - + DM/HTN/ LUDWIGS ANGINA PEPTOSTREP I&D WITH DKA/SEPSIS/A CKD TOCOCCUS EMERGENCY C/DEATH TRACHEOSTOMY 62 MUPPIDATHY 37 F 54674 + + - - + - - - - - RT SUBMANDIBULAR - CONSERVATIVE ABSCESS 63 RAMASUBBU 45 F 66676 - - + + + - - - - + PERITONSILLAR STEPT I&D ABSCESS PYOGENES 64 THANGADURAI 58 M 54202 + + + - + - - - - - LUDWIGS ANGINA - CONSERVATIVE
65 MURUGESAN 46 M 60432 + + + + + - + - - - LUDWIGS ANGINA PSEUDOMONA I&D S AERUGINOSA 66 MUTHAIH 70 M 52519 + + - - + - + - - - LUDWIGS ANGINA I&D 67 CHANDRA 52 F 27719 + + + + + + + - - + DM LUDWIGS ANGINA I&D 68 VASANTHA 34 F 20427 + + + + + + + - - - DM/HTN/ RETROPHARYNGEAL PSEUDOMONA I&D SEPSIS/DEATH CKD ABSCESS S AERUGINOSA 69 MALATHI 26 F 18291 + + + + + + + - - - LUDWIGS ANGINA NO I&D GROWTH 70 ISAKKIAMMAL 35 F 83420 + + ------LT PAROTID ABSCESS NO I&D GROWTH 71 AKILA 20 F 54301 - + + + + - - - - - RETROPHARYNGEAL NO I&D ABSCESS GROWTH 72 RAMALAKSHMI 66 F 70839 + + - + + + - - - - ANEMIA LUDWIGS ANGINA NO I&D
GROWTH 73 SARASWATHY 39 F 68124 + + - - + + - - - - LUDWIGS ANGINA - CONSERVATIVE
74 SEETHALAKSHMI 64 F 70075 + + + + + + - - - - DM LUDWIGS ANGINA E COLI I&D 75 ARUNACHALAM 32 M 65536 + + + + + + + + - - DM LUDWIGS ANGINA STEPT I&D WITH SEPSIS/DEATH PYOGENES EMERGENCY TRACHEOSTOMY 76 MUKESH 15 M 4310 + + - - + - - - + - PARAPHARYNGEAL NO I&D ABSCESS GROWTH ATT 77 LAKSHMANAN 58 M 43042 + + + + - + + - - - LUDWIGS ANGINA PSEUDOMONA I&D S AERUGINOSA 78 JOTHIKUMAR 26 M 62153 - - + + ------PERITONSILLAR NO I&D ABSCESS GROWTH