Braz. j. . vol.83 número3

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Deep

neck

abscesses:

study

of

101 cases

夽

Thiago

Pires

Brito

∗

_,

_Igor

_Moreira

_Hazboun,

_Fernando

_Laffitte

_Fernandes,

Lucas

Ricci

Bento,

Carlos

Eduardo

Monteiro

Zappelini,

Carlos

Takahiro

Chone,

Agrício

Nubiato

Crespo

UniversidadeEstadualdeCampinas(UNICAMP),FaculdadedeCiênciasMédicas,DepartamentodeOtorrinolaringologia, Campinas,SP,Brazil

Received28October2015;accepted12April2016 Availableonline5May2016

KEYWORDS Neckabscess; Neckinfection; Neckspaces

Abstract

Introduction:AlthoughtheincidenceofDeepCervicalAbscess(DCA)hasdecreasedmainlyfor theavailabilityofantibiotics,thisinfectionstilloccurswithconsiderablefrequencyandcanbe associatedwithhighmorbidityandmortality.

Objective: This study aimed to present our clinical-surgical experience with deep neck abscesses.

Methods:A retrospectivestudy analyzed 101 patients diagnosed with deepneck abscesses causedbymultipleetiologies,assistedatamedicalschoolhospitalduring6years.One hun-dredonepatientswereincludedand27(26.7%)wereyoungerthan18yearsold(thechildren group),74patients(73.3%)wereolderthan18yearsold(theadultsgroup).Thefollowing clin-icalfeatureswereanalyzedandcompared:age,gender,clinicalsymptoms,leukocytecount, theaffectedcervicalarea,lifestylehabits,antibiotictherapy,comorbidities,etiology,bacterial culture,timeofhospitalization,theneedoftracheostomyandcomplications.

Results:There was predominanceinthemale gender(55.5%)andyoung people(meanage 28.1years).Allofthe51patientswithassociateddiseasecomorbiditywereadults.Themost frequentetiologieswerebacterialtonsillitis(31.68%)andodontogenicinfections(23.7%).The mostcommon cervicalareas affected were theperitonsillar (26.7%), submandibular/mouth floor (22.7%)andparapharyngealspaces (18.8%).Inchildren group,thesitemostcommonly involvedwas theperitonsillarspace(10patients, 37%).In adultsgroup,thesitemost com-monlyinvolvedwasmultispace(31patients,41.8%).Streptococcuspyogenes(23.3%)wasthe mostcommonmicroorganismpresent.Amoxicillinassociatedwithclavulanate(82.1%)wasthe

夽 _Please_cite_this_article_as:_Brito_TP,_Hazboun_IM,_Fernandes_FL,_Bento_LR,_Zappelini_CE,_Chone_CT,_et_al._Deep_neck_abscesses:_study_of

101cases.BrazJOtorhinolaryngol.2017;83:341---8.

∗_{Corresponding}_author.

E-mail:[email protected](T.P.Brito).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.

http://dx.doi.org/10.1016/j.bjorl.2016.04.004

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moreusedantibiotic.Themaincomplicationsofabscessesweresepticshock(16.8%), pneu-monia(10.8%)andmediastinitis(1.98%).Tracheostomywasnecessaryin16.8%ofpatients.The mortalityratewas1.98%.

Conclusion:TheclinicalfeaturesandseverityofDCAvariedaccordingtodifferentagegroups, perhapsduetothelocationoftheinfectionandahigherincidenceofcomorbidityinadults. Thus,DCAinadultsismorefaciletohavemultispaceinvolvementandleadtocomplications andseemstobemoreseriousthanthatinchildren.

© 2016 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

PALAVRAS-CHAVE Abscessocervical; Infecc¸ãocervical; Espac¸oscervicais

Abscessoscervicaisprofundos:estudode101casos

Resumo

Introduc¸ão:Emboraaincidênciadosabscessoscervicaisprofundos(ACP)tenhadiminuído prin-cipalmentepeladisponibilidadedosantibióticos,essainfecc¸ãoaindaocorrecomfrequência considerávelepodeserassociadaaaltamorbidadeemortalidade.

Objetivo:Esteestudotevecomoobjetivoapresentarnossaexperiênciaclínico-cirúrgicacom abcessoscervicaisprofundos.

Método: Um estudo retrospectivo realizado em um hospital universitário analisou 101 pacientes,duranteseisanos,diagnosticadoscomabscessoscervicaisprofundoscausadospor múltiplasetiologias.Foramincluídos101 pacientes,sendoque27 (26,7%)tinhammenos de 18 anos(grupo das crianças) e74 (73,3%)tinhammais de 18 anos(grupo dos adultos).As seguintescaracterísticasclínicasforamanalisadasecomparadas:idade,sexo,sintomas clíni-cos, área cervicalacometida, hábitos de vida, antibioticoterapia, comorbidades, etiologia, culturabacteriana,tempodeinternação,necessidadedetraqueotomiaecomplicações.

Resultados: Houvepredominânciadosexomasculino(55,5%)edejovens(idademédiade28,1 anos). Todosos 51 pacientescom comorbidade associada eram adultos. Asetiologias mais frequentesforamtonsilite bacteriana(31,68%) einfecções odontogênicas (23,7%).As áreas cervicaisacometidas mais comunsforama peritonsilar (26,7%), submandibular/assoalhoda boca(22,7%)eespaçosparafaríngeos(18,8%).Nogrupodascrianças,olocalmaiscomumente envolvidofoioespaçoperitonsilar(10pacientes,37%).Nogrupodosadultos,houvepredomínio deacometimento demúltiplosespaços (31pacientes,41,8%).Streptococcus pyogenes foio microrganismo presente mais comum(23,3%). A amoxicilina associadaao clavulanatofoi o antibióticomaisusado(82,1%).Asprincipaiscomplicaçõesdosabscessosforamchoqueséptico (16,8%),pneumonia(10,8%)emediastinite(1,98%).Atraqueostomiafoinecessáriaem16,8% dospacientes.Ataxademortalidadefoide1,98%.

Conclusão:AscaracterísticasclínicaseagravidadedoACPvariaramdeacordocomdiferentes faixasetárias,possivelmentedevidoàlocalizaçãodainfecçãoeàmaiorincidênciade comor-bidadesem adultos. Assim, oACP em adultos acomete mais facilmente múltiplosespaços, apresentamaiscomplicaçõeseparecesertambémmaisgravedoqueemcrianças.

© 2016 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob uma licença CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

Deep cervical abscesses (DCA)is definedby the presence of pus in the spaces and fasciae of the head and neck. DCA can be categorized into retropharyngeal, peritonsil-lar, masseteric, pteropalatine maxillary, parapharyngeal, submandibular, parotid and floor of mouth abscesses.1 Despite the improvements in diagnostic tests and the availabilityof modernantibiotic therapy, thoseinfections continuetocausesignificantmorbidityandmortalityrates, especiallywhenthereisnoearlytreatment.2_It_occurs_with

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anti-inflammatory drugs may mask presentations. It is sometimes difficult to findthe origin of DCA because the primarysourceofinfectionmayprecedeitbyweeks.5

DCA are potentially fatal and require an aggressive diagnostic and therapeutic management to avoid life-threatening complications, such as airway obstruction, cervical necrotizing fasciitis, jugular vein thrombosis, disseminatedintravascular coagulationempyema, medias-tinitis, aspiration pneumonia or thrombosis/aneurysm of the carotidartery. Usually polymicrobial,DCA occur from previous uncontrolled infections such as tonsillitis, den-tal infections, surgery, or trauma to the head and neck lymphadenitisafterupperairwaysinfection.2,6_It_is neces-sary toinvestigate risk factors such asinfections, foreign bodies,trauma,immunosuppressionandaddictionto intra-venousdrugs.Concomitantdiseasessuchascongenitalcysts andfistulas,TB,diabetesmellitus,HIV,tumors,deficiency statesandsoonshouldalsobetakenintoconsideration.7 Theclinical manifestationsarediverse anddepend onthe affected cervical area. Moreover,an inappropriateuse of antibiotics may change the clinical presentation of infec-tions of thiskind, making themelusive.4 _Patients_may _be mildly symptomatic and present with symptoms of fever and pain, or experience more severe or life threatening symptoms such as dyspnea airway obstruction and septic shock.

Thisstudyaimedtoreportourclinicalexperienceof sub-missionofdeepneckspaceinfectionsbythedescriptionof 101patientsdiagnosedinthelast6years.

Methods

Wereviewedthemedicalrecordsof101patientsdiagnosed with cervical infection spaces served by the Otolaryngol-ogy, Head and Neck surgery from a Brazilian Hospital of MedicalSchoolduringtheperiodfromJanuary2007to Jan-uary2013. Allpatientssigneda documentauthorizingthe useofdatafromtheirrecords(thatisastandard hospital procedure).

In all cases, the patients underwent a surgical proce-dure to drain pus. The diagnosis of deep neck abscess was suspected by clinical history and confirmed by Com-puted Tomography (CT)or surgery. This analysisexcluded patients with cervical infections who did not require surgery, such as cellulites, and superficial or limited infections. All patients were submitted to antibiotic therapy and, when possible, samples for culture and sensitivity.

We analyzed and compared the following clinical fea-tures:age,sex,clinicalsymptoms,leukocytecount,cervical area affected, lifestyle habits, antibiotic use, comorbidi-ties, etiology, bacterial culture, length of stay, need for tracheostomyandcomplications.

Alldescriptivedatawerereportedin percentages. Sta-tistical evaluationswere performed witha 2 sided t-test corrected for inequalityof variancesanddegreesof free-dom.Fisherexacttestand2testwereusedtocomparethe categoricalvariable.SPSS(13.0,SPSSInc,Chicago,IL)were usedtoanalyzethedataandap-value<0.05wasconsidered statisticallysignificant.

30

25

20

15

10

5

0

81-90

Age groups (years)

Number of patients (%)

0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80

Figure1 Subjectsdistributionaccordingtoage.

Results

Population

Ofthe101patients,56weremaleand45female,55.5%and 44.5%respectively.Theiragesrangedfrom1to81yearswith ameanageof28.1years.Mostpatientswereyoung,the2nd and4thagegroups.Amongchildren,themeanagewas8.4 years,witha slight male predominance (57% of patients) (Fig.1).

Symptomsandtimetodiagnosis

Themostcommonsymptomsatdiagnosiswerefever(86.1%) andneckpain(81.1%).Othersymptomswereodynophagia (75.2%),cervical edema(60.3%)andtrismus(47.5%). Thir-teenpatients(12.8%)hadsymptomsofairwayobstruction, eightmalesandfivefemaleswithameanageof31.3years. Fifteenpatients(14.8%)hadsignsofbacteremiaatthetime ofdiagnosis,andthosecollectedbloodcultures.Themean timefromsymptomonsettothedemandforhealthservices waseightdays(range2---20days).

Lifestyleandcomorbidities

Nineteenpatients(18.8%)weresmokers,24patients(23.7%) alcoholics and 10 patients (9.9%) drug users. The most prevalent comorbidities were hypertension (19 patients, 18.8%),diabetes mellitus(DM)(13patients,12.8%).Other less prevalent comorbidities were obesity (10 patients, 9.9%),hypothyroidism(4patients,3.9%)andhepatitisC(3 patients, 2.9%). In two patients there wasan association withHIV(%).Theadultpatientsexhibitmorecomorbidities thanchildren(p<0.01)(Table1).

Etiology

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Table1 Comparisonofchildrenandadults.

No.ofpatients No.ofmultispace No.ofcomplication Death No.ofcomorbidity

Children 27 2 8 0 0

Adults 74 31 40 2 51

p-Value <0.001 0.005 >0.10 <0.001

35

30

25

20

15

10

5

0

Number of patients (%)

Fasciitis Adenitis

Foreign body Lympadenitis Undeter mined

Odontogenic Tonsilite

Etiology

Figure2 Etiologyofdeepcervicalabscesses.

related to odontogenic infection there was a history of recentdentalmanipulation(Fig.2).

Spacesandcervicallymphnodes

Neck CT scan was performed to diagnose and assess the extent of infection in 71.2% of patients. The remaining patients had diseaseextension intraoperatively detected. Peritonsillarcervical areawasthemost affectedin 26.7% ofcases(27patients).Theotherareasaffectedin descen-dingorderwere:submandibular/floorofmouth(23patients, 22.7%),parapharyngeal (19 patients,18.8%), retropharyn-geal(18patients,17.8%),chewing(8patients,7.92%)and jugular-carotid(4patients,3.96%)(Fig.3).

AsTable2shows,thesitemostcommonlyinvolvedin chil-drengroup wasthe peritonsillarspace (10patients,37%), followedbyparapharyngealspace(9patients,33.3%),the

35 30 25

20

15 10

5 0

Affected area

Nu

mb

er

of p

a

tien

ts (%

)

Super ior mediastin

um

Jugular-carotid Masticator y

Retrophar yngeal

Paraphar yngeal

Submandib ular

Peritonsillar Multiple spaces

Figure3 Extentofinfeccionbydeepcervicalabscesses.

submandibularspacein4patients(14.8%)andthe retropha-ryngeal space in 4 patients (14.8%). In adults group, the sitemostcommonlyinvolved wasmultispace(31patients, 41.8%), followed by submandibular space in 19 patients (25.6%),theperitonsillarspacein17patients(22.9%).The adult patients developedmultispace infectionmore often thanthechildren(p<0.01)(Table1).

Therewastheoccurrenceofmultiplecervicalspacesin 33patients(32.7%).Whenpresent,lymphadenopathymost oftenreached levelsII andIII.Therewasextensiontothe superiormediastinumin2patients(1.9%).

Bacteriologyandleukogram

All patients received antimicrobial therapy. Amoxi-cillin+clavulanate was the most used antibiotics as first-line treatment (82.1% of cases), followed by cef-triaxone plus metronidazole combination. The change

Table2 Distributionofthesitesofdeepneckabscesses.

Childrenn(%)(n=27) Adults’n(%)(n=74) Total(n=101)

Multispace 2(7.4) 31(41.8) 33(32.6)

Parapharyngealspace 9(33.3) 10(13.5) 19(18.8)

PeritonsillarSpace 10(37) 17(22.9) 27(26.7)

Submandibularspace 4(14.8) 19(25.6) 23(22.7)

Retropharyngealspace 4(14.8) 14(18.9) 18(17.8)

Masticatorspace 0 8(10.8) 8(7.92)

Jugular-carotidspace 0 4(5.4) 4(3.96)

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Table3 Complicationsofdeepneckabscesses.

Childrenn(%)(n=8)a _Adults’_n_(%)₍_n₌₄₀₎a _All_patients₍_n₌₁₀₁₎a

Mediastinitis 0 2(5) 1.98%

Jugularveinthrombosis 0 1(2.5) 0.99%

Emergencytracheostomy 0 8(20) 7.92

Pneumonia 3(37.5) 8(20) 10.80%

Septicshock 3(37.5) 14(35) 16.80%

Surgicalrapprochement 2(25) 7(17.5) 8.90%

a _An_individual_patient_may_have₂_or_more_{complications.}

25

20

15

10

5

0

Microorganism

Nu

mb

er

of p

a

tien

ts (%

)

Neisser ia sp

S. pneumoniae S. vir

idans S. aureus

S. constelatusS. inter medius

S. p

yogenes Others Polymicrobial

Figure4 Bacterialgrowthcultureindeepcervical abscesses.

of antibiotic depended on the culture results or clinical outcome.

Material for culture was obtained in 76.2% patients. There wasnobacterial growth in 14.5%of cases. Polymi-crobial culture was detected in 18.8% of patients, being Streptococcus pyogenes+Streptococcus pneumoniae the mostfrequentassociation.S.pyogeneswasthemost com-mon microorganism present in 25 patients (23.3%). The prevalenceofotherorganismswasasfollows:Streptococcus intermedius(20patients,18.6%),Streptococcus constelat-tus(16patients,14.9%),Staphylococcusaureus(13patients, 12.1%), Streptococcus viridians (9 patients, 8.4%), Strep-tococcuspneumonia (8patients, 7.4%) and Neisseriaspp. (7patients,6.5%).Othermicroorganisms(Corynebacterium spp.,Eikenellacorrodens,Enterococcusfaecium,Klebsiella pneumoniae and other Streptococci) were less frequent, totaling12 patients (11.8%). Seventeen patientshad clin-icalsignsofsepsisonarrivalat theemergencyroom,and blood tests were made, resulting positive in 13 patients (12.8% oftotal), withthemost prevalentoccurrence also ofStreptococcuspyogenes(Fig.4).

Complications,tracheostomyandmortality

The complications of deep neck infection are shown in Table 3. Complicationswere found in 48 patients (8 chil-dren, 40 adults). Of the 8 patients of children with complications, 3 had pneumonia, 3 had Septic shock and 2 hadsurgical rapprochement. The main complicationsof cervical abscesses included sepsis (17 patients, 16.8%),

pneumonia(11patients, 10.8%),mediastinitis (2patients, 1.9%)andjugularveinthrombosis(1patient,0.9%).Surgical rapprochement was required in 9 patients (8.9%), proba-blybecauseofthereorganizationofinfectioninstores(%). Theadultpatientsdevelopedinfectiouscomplicationsmore oftenthanthechildren(p=0.005)(Table1).

The upper airway obstruction and the impossibility of intubationforcedthetracheostomyin17patients(16.8%). Of these, 8 (7.9%) underwent emergency tracheostomy becauseofrespiratoryfailure.

There were 2 deaths (1.9% mortality rate). The first casewasa19year-oldhealthyfemalewithextensive cer-vical abscess associated with descending mediastinitis of undeterminedetiology.Thedeathoccurredonthe3rd post-operativedayandshehadsepsiswithpositivebloodculture for Streptococcuspyogenes.The second case was ofa 49 year-olddiabetic malewithabscess of odontogenic etiol-ogy(Ludwig’sAngina)extendingtothesubmandibularneck spaces/floor of the mouth and parapharyngeal space. He presentedsepsiswithpolymicrobialbloodcultures( Strep-tococcusviridians+Neisseriaspp.).

Theaveragehospitalstaywas9.7dayswithavariation between 2:45 days. Abscess complications prolonged the hospitalstayin about fivedays(averagelength ofstay of 14.8days).

Discussion

Deep neck abscesses are diseases of major importance due to its frequency and severe complications. The inci-denceisestimatedataround10/100,000inhabitants/year, withatendencytoincrease,especiallyinchildrenunder5 years,1_in_whom_the_estimated_incidence_is_about_2/100,000 inhabitants/year.1_The_infections_have_no_preference_for_age orsexandcanaffectanyone.Inagreementwith Eftekhar-ianetal.studies,oursobserved ahigherincidenceinthe youngmalepopulationwithameanageof28.1years.8 How-ever, Huang et al. and other studies are also showing an upwardtrendintheincidenceofinfectionsinolderpatients andpatientswithsystemicdiseases.9_In_this_group,_defense mechanismswouldbeless efficient,recovery ratesslower andcomplicationswouldbemorefrequent.

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incidence,having odontogenicinfections asthe most fre-quentcause.6,10,11_In_our_study,_the_bacterial_tonsillitis_was themostcommoncause(31.68%),followedbyodontogenic infection(23.7%),totaling55.3%ofoursample.Other stud-ieshaveshownanincreaseassociatedwithintravenousdrug abuseand neck trauma infections, although we have not identifiedtheseetiologies.12

InastudybyCoelhoetal.,dentalfocuswastheoriginof abscessesin37%ofpatients,whereaspharyngealtonsiland disorderswerepresent in20%ofcases,notbeingpossible toidentifythesource ofinfectionin33%of patients.13 _To Sennesetal.,odontogenicinfectionwasthecausein42.1% ofpatients,tonsillitisin17.5%,postupperairwayinfections in15.8%andunknowncausein8.8%14_{lymphadenitis.}_Among other causes,post upper airways infection,lymphadenitis andforeignbodyingestionwerestillfoundin17.8%ofcases, adenitis(submandibular andparotid)at 7.8%and39.6%in thefasciitis. Otherauthorsalsoreportedasignificant pro-portionofDCAwithunknownprimaryorigin,reachingupto 50%ofcases.2,6,15,16 _In_14.8%_of_our_patients,_the_infection etiologycouldnotbedetermined,probablybecausethe ini-tialinfectionwasnotpromptlydiagnosed, althoughithas preceded the abscess for weeks. Thus, the average time fromsymptomonsettodiagnosis of DCAin ourstudy was 8days,butreachedupto20daysandthemainsymptoms werefeverandneckpain.

The knowledge of the anatomic relationships between neckspacesisimportantforthetherapeuticmanagement, sincethefascialimitingthesespacesareimportant anatom-icalbarriers tothe spread of infection,but also serve to directinfectiononceitsnaturalresistanceisovercome.17

Mostpreviousstudies1,18,19 _reported_that_children_are_a relatively low proportion of their patients with DCA. We found,however,thattheproportionofpatients whowere under18yearsofagewerehigh(27cases,26.7%),andnone of themhad DM or other associated diseases. Other indi-cators of health care utilization such asmedication used beforeandfrequencywerenotpossibletoobtain because mostpatientsreceivedtreatmentfor theiracuteepisodes at remote locations, either by their primary care physi-ciansorbythereferringotolaryngologist.However,probably thismaybecausedbythehistoryofantibioticsabuseand theantibioticresistanceexplainedbyindiscriminateuseof antibiotics, especially in colds and other viral infections, which are more prevalent in children than in adults.20,21 Previousantibioticuseiscorrelatedwithhigherrecoveryof resistantorganismsandincreasedincidenceof␤ -lactamase-producing bacteria.22,23 _Ultimately, _the _resistance _had _an effect on the incidence of deep neck infection.24 _Larger prospectivestudies areneeded to address many of these limitationsandtofurtherdelineatetherolefor understand-ingthedifferentcharacteristics betweenthechildrenand adultswithdeepneckinfection,helpinginaccurate evalu-ationandpropermanagement.

Most studies5,25 _reported _the _{retropharyngeal} _space _as the most common involved space in children, but we found the peritonsillar space the most common involved in children group (10---27 patients, 37%), closely followed byparapharyngealspace(9---27patients,33.3%).However, thereis onestudy4_showed_that_the_{parapharyngeal}_space was as the most common involved space in children. It mightbeexplainedbeacauseinfectionsintheperitonsillar,

submandibular, masticatory,andparotidspacecanusually spreadtotheparapharyngealspace.9 _Multispace_infection wasfoundin31patients(41.8%)inadultsandin2patients (7.4%)inchildren(p<0.001).Adultswereeasiertoget mul-tispaceinfectionthanchildren;thismightrelatetoahigher incidence of disease comorbidity in adults. Patients with disease comorbidity tend to have poorer defense against infections and thus result in higher rates of more severe infection in the form of multispace infections.18 _In _both deathstherewasinvolvementofmultiplecervicalspaces.

TheDCAmicrobiologyischaracterizedbygenerallybeing polymicrobialinfections, includingaerobicand anaerobic, gram positive particularly. Among the agents commonly found are: Streptococcus viridans, Streptococcus milleri, Prevotella spp., Peptosstreptococcus spp. and Klebisiella pneumoniae, the latter being more common in diabetic patients.26 _Sennes_found_{Streptococcus}_viridans_in_41.5%_of thecases,Staphylococcusaureusin20.7%ofthem,and3.8% withHaemophilusinfluenza.14 _In _our_study,_{Streptococcus}

pyogeneswasthemostfrequentlydetectedagent(23.3%), whichcanbeexplainedbythehigherincidenceof periton-sillarinfections.Fromallpatients,14.5%showednogrowth ofbacteriainculture,whichcanbeexplainedbytheuseof highdosesofintravenousantibioticsbeforeabscesssurgical drainage.27 _In _12.8% _of _patients, _it _was _detected _positive bloodculture,whichshowsthehighpossibilityofsystemic spreadofaninfectioninitiallyuncontrolled.

Many studies have shown the association of DM with DCA.9,28 _Huang_et_al.9,20 _and_Lee_et_al.18 _indicated_that_old patientswithDMweresusceptibletodeepneckinfection. In DMpatients,hyperglycemia mayimpairseveral mecha-nisms of humoral host defense, such asvariedneutrophil functions:adhesion,chemotaxisandphagocytosisandresult in predisposition to infection and complications.29 _Huang et al. found high rates of infection withKlebsiella pneu-moniae in diabetic patients.9 _The _prevalence _of _diabetic patientsinourstudywaslow(12.8%),withStaphylococcus aureus(5patients)andStreptococcuspyogenes(4patients) as the microorganisms most commonly found. In one of thelethaldevelopments,thepatientwithpoorlycontrolled diabetes had the blood culture positive for Streptococcus viridians+Neisseriaspp.

The management of DCA involves surgical drainage associated with use of intravenous antibiotics. Computed tomography withcontrastwasthetest ofchoicefor diag-nosingandassessingtheabscessextent.Althoughithashigh sensitivity,thetest specificityislow,for exampleincases of lymphnode clusters without associatedabscess, which canleadtounnecessarysurgicalprocedures.30_Oh_et_al._and otherresearchershavedemonstratedtheefficacyofneedle drainageofabscessguidedbyultrasound,withnoincrease incomplicationrates.27_In_general,_this_conservative treat-mentiseffectiveinsmallcollectionsandwithnoevidence ofimminentcomplications.Ourservicehaslittleexperience inthistreatment,preferringtheopensurgical drainagein allcases.

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empiricalcoverage,apenicillinwitha␤-lactamaseinhibitor combination(suchasamoxicillinandclavulanicacid),ora␤ -lactamantibiotic-resistant(suchascefuroxime,meropenem or imipenem) in combination witha drug,which is highly effectiveagainstmostanaerobes(suchasmetronidazoleor clindamycin).17,28 _Afebrile _after ₄₈_h, _the_patient _was dis-chargedwithaprescriptionoforalantibiotic.

Despitethewidespreaduseofantibiotics,several unde-sirableandlife-threateningcomplicationsofDCAareknown asdescendingmediastinitis, jugularveinthrombosis, peri-carditis, pleural empyema, arterial erosion,upper airway obstructionandsepsis.Inourstudy,thereweretwocases ofmediastinitis,bothinadultsandinvolvingmultipleneck spaces,anddeathinsepticshockinoneofthem(Table1). In mediastinitis,the patientoften complains of increased chest pain or dyspnea. The extent of disease occurs via anteriorvisceralspaceandmortalitycanreachhalfofthe cases,requiringcombinedthoracicdrainage.31_The obstruc-tionoftheupperairwayandconsequentrespiratoryfailure forcedtheemergencytracheostomyin7.9%ofpatients. Har-Eletal.describethatthe involvementofthefloorof the mouthandtheretropharyngealspacearemoreassociated withairwayobstructionandgreaterneedfortracheostomy, procedurenecessaryin75%ofthecases.10 _It_is _interesting tonote that in ourstudy,especiallyin patients with sec-ondary involvement of the masticatory muscles, trismus, tracheostomywasnecessarybecauseoftheimpossibilityof intubation, evenwithout the presenceof respiratory fail-ure.Ourmortalityratewas1.9%,similartothatdescribed byHuangetal.(1.6%).9

We presented here relevant information about clinical andsurgicalDCAoutcomes.However,thecourseand sever-ity of the same infection in different patients can vary widely,requiringanexperiencedteamtodealwithit.

Conclusions

Deepneckinfectionsconstituteamedicalandsurgical emer-gency. The clinical features and severity of DCA varied accordingtodifferentagegroups,perhapsduetothe loca-tionoftheinfectionandahigherincidenceofcomorbidity inadults.Thus,DCAinadultsismorefaciletohave multi-spaceinvolvementandleadtocomplicationsandseemsto bemoreseriousthanthatinchildren.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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