Analytical Study on Deep Neck Space Infections

Copyright © Arun O
Arun O* and George MV
Department of ENT, Jubilee Mission Medical College, India
*Corresponding author: Arun O, Department of ENT, Jubilee Mission Medical College, India
Submission: June 08, 2018; Published: July 19, 2018
Analytical Study on Deep Neck Space Infections
Background
Deep neck infections are frequently accompanied with
localized aerodigestive tract compromise and sometimes by life
threatening sequelae like severe airway obstruction, mediastinitis,
pericarditis, internal jugular vein thrombosis and carotid artery
erosion [1]. Failure to recognize deep neck space infections (DNSI)
early may be due to an altered clinical practice resulting from
the misuse of antibiotics, increasing prevalence of patients with
immunodeficiency and changes in the origins of deep neck space
infections and its bacteriology.
Dental infections and regional trauma are now more common
causes of deep neck infections.Clinical examination alone seems to
underestimate the extent of disease in 70% of cases, appropriate
radiological imaging can reveal infection spreading between the
spaces [2]. Decision making between conservative versus surgical
management are very important in the management of DNSI.
Methods
Source of Data
Primary source of information method was used on the
patients admitted in the Department of Otorhinolaryngology
with clinically diagnosed cases of deep neck space infections in
Jubilee Mission Medical College, Thrissur, Kerala, which is a 1800
bedded tertiary care hospital providing medical services to mixed
population of 3 districts. The study was conducted for a period of 2
years commencing from December 2012 to November 2014.
Method of Data Collection
Primary source data collected from a specially designed case
recording proforma pertaining to the selected patients. Prior to
selection, they had to undergo routine history taking, physical
examination and investigations. Informed written consent and
Ethical committee approval were taken prior to the study. Follow
up of the patients during hospital stay were done.
Sample Size
We included 40 cases of deep neck space infections admitted in
our department during this study period.
Design of Study
Prospective study design
Inclusion Criteria
Only clinically or radio logically confirmed cases of deep neck
space infections of all age groups and both sexes were included in
the study.
Research Article
1/5Copyright © All rights are reserved by Arun O.
Volume 2 - Issue 1
Abstract
This study was performed Department of Otor hinolaryngology, Jubilee Mission Medical College, thrissur, Kerala for a period of 2 years commencing
from December 2012 to November 2014. To review our experience with deep neck space infections and to study changing trends. The objectives were
to study clinical presentation, etiology, associated systemic diseases, bacteriology, radiology, management and outcome of deep neck space infections.40
Patients coming from both urban and rural areas irrespective of age and sex admitted in department of ENT with deep neck space infections which was
confirmed either clinically or radiologically. Superficial skin abscesses and abscesses due to infections of external neck injuries were excluded from the
study rn.
Result: rthe commonest infections leading to deep neck infection were dental infections and tonsillitis. Commonest symptom was pain
odynophagia/dysphagia. Bacteria most often isolated were staphylococcus aureus. Gram negative organisms like klebsiella and pseudomonas were
also isola ted. One of our patients underwent tracheostomy. Complications were seen in 12.5% of cases of which 2 patients died.rn.
Conclusion: rnThe deep neck space infection is still a challenging disease in otolaryngology. Its presentation may be masked and bacterial
culture might not be conclusive but it still needs early diagnosis and prompt management either conservative or surgical. Most of our patients needed
surgical intervention, especially the pediatric cases. Early surgical intervention can reduce the complications. Tracheotomy should be considered if air
way protection is neededrn
Keywords: Deep neck space infection; Peritonsillar abscess; Retropharyngeal abscess; Diagnosis; Surgical management
Experiments in
Rhinology & OtolaryngologyC CRIMSON PUBLISHERS
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ISSN 2637-7780

Exp Rhinol Otolaryngol
2/5How to cite this article: Arun O, George MV. Analytical Study on Deep Neck Space Infections. Exp Rhinol Otolaryngol. 2(1). ERO.000528.2018.
DOI: 10.31031/ERO.2018.02.000528
Volume 2 - Issue 1
Copyright © Arun O
Exclusion Criteria
Superficial skin abscesses, abscesses due to infections of the
external neck wounds (surgical / traumatic) were excluded from
the study. Each patient detailed history was taken followed by
detailed general and local examination to determine the extent
and cause of the deep neck space infections. They were subjected
to baseline investigations. It includes hemoglobin, TC, DC, ESR,
Random Blood Sugar, urea/creatinine, urine- albumin, sugar,
and microscopy. In cases where clinical diagnosis was uncertain,
radiological investigations were done to confirm the diagnosis.
Needle aspiration or incision and drainage (I&D) was done at
the earliest stage in majority of the patients, pus was sent for culture
and sensitivity analysis. All patients were initially started on a
combination of third generation cephalosporin and metronidazole.
The antibiotics were modified based on culture sensitivity reports
or clinical unresponsiveness. Supportive therapy, in the form of
intravenous fluid, analgesics, antipyretics, mouth washes etc. were
given. Descriptive and inferential statistical analysis has been
carried out in the present study.
Result
It was observed that the maximum number of cases was seen
in the age group of 40-50 years (22.5%). Youngest patient seen
was 45 days old and the oldest patient was 70 years old. Among
40 patients, 32 (80%) patients were adults and 8 patients (20%)
were among pediatric age group (≤12 years). 18 (45%) were male
and 22 (55%) were female. 33 (82.5%) patients belong to low
socioeconomic status. The most common symptom with which the
patients presented was odynophagia/dysphagia (38 patients 95%)
followed by fever (34 patients 85%), pain in throat (27 patients
67.5%), neck Swelling (27 patients 67.5%), halitosis (21 patients,
52.5%), difficulty in opening the mouth (20 patients 50%) and
difficulty in breathing (7 patients, 17.5%).10 patients (25%) had
history of DM and were on irregular treatment. 6 patients (15%)
were on treatment for HTN and 2 patients(5%) had history of
seizure disorder, on treatment. 4 patients (10%) had history of
foreign body ingestion, following which symptoms started. On
removal of foreign body and subsequent antibiotic treatment,
symptoms relieved.
Most common clinical finding was fever among 34 patients
(85%) followed by neck swelling 23 patients (57.5%) and
lymphadenopathy 23 patients (57.5%). Etiology was unknown
in 15 patients (37.5%), dental infections in 12 patients (30%)
and tonsillitis in 6 patients (15%). Most common infection was
peritonsillar abscess (12 patients-26%) and retropharyngeal
abscess (12 patients-26%) followed by parotid abscess (9patients-
20%), parapharyngeal abscess (5 patients-11%), Ludwig’s
angina (4 patients- 9%), submandibular abscess (2 patients-4%).
Masticator abscess (2 patients-4%). Peritonsillar abscess occurred
in 12 patients (26%) and it didn’t progress to other neck spaces. In
32 patients (80%) single space was involved. In 8 patients (20%)
more than one space was involved, of these 3 patients (7.5%) had
Ludwig’s angina.
As clinical diagnosis was certain in 12 cases (30%) and
patients improved symptomatically, no radiological investigation
was carried out. In the remaining 28 cases (70%), diagnosis was
confirmed radio logically. Ultrasound was done in 16 cases (40%),
CT scans (20%), x-rays were taken for 4 patients (10%). Thus out
of the 28 cases where radiological investigations are done, 16 cases
( 40%) diagnosed with USG itself. I &D of the abscess done in 22
patients (55%), needle aspiration 8 patients(20%), both Needle
aspiration and I & D in 4 patients( 10%) and conservative treatment
with intravenous antibiotics in 6 patients(15%).
In 36 out of 40 cases where there was no airway obstruction,
no death happened and out of 4 cases where there was airway
obstruction, 2 patients died. P value = 0.00013 which shows
statistically significance. In pediatric cases where 8 (100%) out of
8 (20%) were treated with non conservative (surgical) methods. In
adults out of 32(80%); 26 (81.25) treated with surgical methods
and were 6 (18.75%) treated with conservative methods; The
P value = 0.184 which was not statistically significant (Table1).
Surgical Vs Non surgical treatment
Table 1: Surgical Vs Non surgical treatment
AGE group
Surgical
TotalYes No
Pediatric 8(20) 0(0) 8(20)
Adult 26(65) 6(15) 32(80)
Total 34(85) 6(15) 40(100)
Figure 1: Pus being taken for culture and sensitivity in patient with submandibular abscess

3/5
How to cite this article: Arun O, George MV . Analytical Study on Deep Neck Space Infections. Exp Rhinol Otolaryngol. 2(1). ERO.000528.2018.
DOI: 10.31031/ERO.2018.02.000528
Volume 2 - Issue 1
Copyright © Arun O
Pus was sent for culture and sensitivity in 40 patients (Figure
1). It was sterile in 16 samples (40%).Organisms were isolated in 24
samples (60%). Culture yielded growth of polymicrobial organisms
in 1 sample (2.5%). Due to the unavailability of the facilities in our
settings, anaerobic culture was not done.
Most people spent 1-5 days in hospital, minimum duration was
1 day. That patient came with breathing difficulty and sepsis and
died within few hours itself. Maximum duration of hospital stay
was 19 days. That patient was admitted with parotid abscess and
Ludwig’s angina. Symptoms relieved at discharge. Average duration
of hospital stay was 6.78 ± 3.9 days.
Discussion
Spaces Involving the Entire Length of Neck
A. Anterior visceral (pretracheal or previsceral) space.
It is the anterior portion of the visceral compartment that
surrounds the trachea, is located against the anterior wall of
the oesophagus, its superior limit is the hyoid bone.
B. Posterior visceral (retropharyngeal, retrovisceral or
retroesophageal space). It lies anterior to the alar fascia. This
space extends from the skull base to the tracheal bifurcation
(T1), where the alar fascia fuses with the middle layer of deep
cervical fascia.
C. Prevertebral space. It lies immediately anterior to the
spinal column and the anterior longitudinal ligament. It is
bounded anteriorly by the prevertebral layer of the deep layer
of the cervical fascia and it extends from the base of skull to
coccyx.
D. Danger Space
E. Suprahyoid Spaces. Submandibular space2. Peritonsillar
Space3. Parotid Space4. Lateral pharyngeal space (peripharyn-
geal, parapharyngeal,pterygopharyngeal,pterygomandibular,
pharyngomaxillary space)
F. Infrahyoid spaces
G. Pretracheal (anterior visceral) space
H. Suprasternal space Of Burns
In our study the youngest patient was 45 days old child
presented with retropharyngeal abscess and oldest was 70 year old
male presented with parotid abscess. 45 days old child presented
with stridor, prompt diagnosis of retropharyngeal abscess made
with the help of CT scan Figure 2. hild improved after I&D of the
abscess.
Figure 2: CT scan of 45 days old child showing retropharyngeal abscess.
Clinical Presentation
The most common presenting complaints in our series was
odynophagia/dysphagia. This was followed by fever, throat pain
and neck swelling. DS Sethi, P. Kamath and Gino Marioni studies
have also shown odynophagia, neck swelling and fever to be the
commonest presenting complaints [2-4].
Associated systemic disease
In our series of 40 patients, 10 patients had diabetes mellitus
(DM) and were on irregular treatment. Out of the two patients who
died due to DNSIs, one had both DM and hypertension (HTN) on
irregular treatment; other patient had DM and seizure disorder.
Etiology of Deep Neck Infections
Previously established risk factors for DNSIs included
peritonsillar infections, upper respiratory tract infections, poor
oral health, odontogenic infections, intravenous drug use or other
substance abuse, immunocompromised states, and diabetes [5].
More recent trends have demonstrated an overall increase in the
prevalence of causes related to odontogenic infection [4].
In our study, in majority of the cases, etiology was unknown
followed by dental infections and tonsillitis. This could be a result
of the infections being caused by more virulent bacteria, which
may be more resistant to standard dental practices. Secondly, the

4/5How to cite this article: Arun O, George MV. Analytical Study on Deep Neck Space Infections. Exp Rhinol Otolaryngol. 2(1). ERO.000528.2018.
DOI: 10.31031/ERO.2018.02.000528
Volume 2 - Issue 1
Copyright © Arun O
patient population may have reflected a cohort less likely to present
to a health practitioner at an earlier stage of infection. Tonsillar
infections could be a result of an increased bacterial load harbored
within the tonsillar crypts. Presence of foreign body was identified
in 10% of the patients. In our study, a 19 yr old girl admitted with
odynophagia, on examination diagnosed to have peritonsillar
abscess. Further blood evaluation revealed WBC counts above 1
lakh and peripheral smear examination showed the presence of
leukemia.
Location of Deep Neck Space Infection
In our study, most common infection was retropharyngeal
abscess (26%) and peritonsillar abscess (26%) followed by parotid
abscess (20%) and parapharyngeal abscess (11%).
Bacteriological study
In our study culture was negative in 16 cases (40%), it may be
because of improper use of antibiotics prior to presenting to our
centre. Staph. aureus was the most commonly isolated organism
(22.5%), followed by beta hemolytic streptococci (12.5%) and
klebsiella (10%). The organisms isolated were similar across the
different weight percentile groups Coticchia et al. [6]. Reported
that the organisms isolated from an anterior or posterior triangle
abscesses (35%) and submandibular abscess (42%) were mostly
S. aureus. Similarly, Dodds and Maniglia [7] noted that the most
commonly isolated organism was S. aureus in their study. Most of
the organisms isolated in our study showed good susceptibility
to cephalosporins, amoxicillin+ clavulinic acid, ciprofloxacin,
gentamycin and amikacin.
Management
I &D of the abscess done in 22 patients, needle aspiration 8
patients, both needle aspiration and I & D in 4 patients. Studies
comparing needle aspiration and incision drainage in the treatment
of peritonsillar abscess have shown no statistical significance
John et al. [8]. In their study concluded that a trial of intravenous
antibiotic therapy could be considered before immediate surgical
intervention is performed in patients who are clinically stable [9].
Nagy et al also considered medical line of treatment as the first line
of management especially in those with abscess volumes estimated
to be less than 2000mm and if no clinical improvement occurs after
24 to 48 hrs, surgical exploration may be indicated [10].
In our study early surgical intervention was the mainstay of
treatment.
Complications
Complications developed in 5 patients( 12.5%) of which 4
patients (10%) developed airway obstruction, 2 patients( 5%) died
and1patient(2.5%)developedmediastinitis.Deathinboththecases
was due to respiratory obstruction due to delayed presentation and
unwillingness of the patients to undergo tracheotomy. One patient
with airway obstruction who was diagnosed to have Ludwig’s
angina underwent tracheostomy + I&D and symptoms relieved
afterwards.
Radiological Investigations
In 28 cases (70%), diagnosis was confirmed radiologically.
Ultrasound was used in 16 cases (40%), CT scan (20%), x-rays
were taken for 4 patients( 10%) In rural setting like ours where
all patients cannot afford contrast enhanced CT(CECT), ultrasound
can be used effectively in cases like Ludwig’s and submandibular
abscess. CECT is currently considered the radiologic investigation
of choice in deep neck infections. In cases where parapharyngeal
and retropharyngeal abscess are suspected CECT not only helps
in diagnosis but also helps in identifying impending airway
complications before they are clinically detectable, thereby
reducing the complications.
Miller et al have concluded in their study that CECT has a high
sensitivity and low specificity, which may lead to needless surgery
for some patients if used in isolation. Clinical examination and
CECT together are the most accurate test to determine the extent
of DNSI [11]. There are recent reports of successfully treating small
abscesses (< 2000mm on CECT) with intravenous antibiotics alone
[12].
Length of Hospital Stay
In terms of length of hospital stay, this study demonstrated that
presentation with airway compromise, mediastinitis and diabetes
are associated with a prolonged course in hospital, as is consistent
with the findings of previous studies [13]. Maximum hospital stay
was for 19 days (patient with Ludwig’s angina/DM/HTN) followed
by 17 days (patient who developed mediastinitis following
retropharyngeal abscess subsequent to accidental foreign body
ingestion)
Socio Economic Status
In our study, 33 out of 40 (82.5%) belong to low socio economic
status according to the revised Kuppuswamy scale [14]. Lack of
awareness of complications and poor health seeking behavior
with low literacy rates are responsible for these cases, measures
directed towards these issues should be initiated and continued for
the prevention of DNSIs.
Conclusion
Our study revealed that deep neck space infections are common
in female in the age group 40-50 years. Majority presented with
complaints of odynophagia/dysphagia. Etiology found to be dental
infections and tonsillitis. Most common infections are peritonsillar
abscess and retropharyngeal abscess. Radiological investigations
were required in 28 patients. Surgical interventions were done
in 34 patients. Staphylococcus aureus isolated in 10 cases, which
were 100% sensitive to ciprofloxacin. 2 patients died following
respiratory obstruction. Complications were more in patients
having systemic disease. Early surgical intervention is important to
reduce complications.
Recommendations
A. Foreign bodies in the throat are to be removed without
delay especially in patients having systemic diseases, also

5/5
How to cite this article: Arun O, George MV . Analytical Study on Deep Neck Space Infections. Exp Rhinol Otolaryngol. 2(1). ERO.000528.2018.
DOI: 10.31031/ERO.2018.02.000528
Volume 2 - Issue 1
Copyright © Arun O
chronic tonsillitis have to be treated without much delay.
B. Dental infections are still a major factor in deep neck space
infections. Proper oral hygiene can prevent these infections up
to a certain extent.
C. CECT is essential in appropriate management of deep
neck infections especially in those involving parapharayngeal
and retropharyngeal spaces. Needle aspiration in the treatment
of peritonsillar abscess is successful and cost effective.
D. Antibiotic coverage should include gram negative, gram
positive and anaerobic micro organisms. A combination of
third generation cephalosporins and metronidazole are given
as empiric antibiotic coverage.
Health education in rural areas can make people aware of
complications of deep neck space infections and need for seeking
treatment in time. Early diagnosis, aggressive management with
surgical intervention and proper airway management decrease the
complications and mortality associated with deep neck abscesses.
References
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12. Nagy M, Backstrom J (1999) Comparison of the sensitivity of lateral neck
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