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Otolaryngology–Head and Neck Surgery (2009) 141, 123-130

ORIGINAL RESEARCH–GENERAL OTOLARYNGOLOGY

Diagnosis and treatment of deep neck space abscesses

Opeyemi O. Daramola, MD, Carrie E. Flanagan, MD, Robert H. Maisel, MD, and Rick M. Odland, MD, PhD, Milwaukee, WI; and Minneapolis, MN

No sponsorships or competing interests have been disclosed for this article.

ABSTRACT

OBJECTIVE: To review our experience with deep neck ab- scesses and identify unique trends in our patient population. STUDY DESIGN: Case series with chart review. SUBJECTS AND METHODS: Evaluation of patients with deep neck space abscesses between 2001 and 2006. Peritonsillar abscess, superficial craniocervical infection, and salivary gland infections were excluded from selection of study population. A total of 106 cases were reviewed. RESULTS: Dental infections were the most common cause of deep neck abscesses (49.1%). Comorbidities included substance abuse (53.7%), psychiatric illness (10.4%), hypertension (9.4%), head and neck cancer (6.6%), and diabetes mellitus (5.7%). All patients received systemic antibiotics, eight patients required tra- cheotomy, 85 patients underwent surgical drainage in the operating room, and 11 had bedside drainage. Median and lower quartile of time in hospital was 2 and 3 days, respectively, whereas upper quartile was 4 days (range, 1 to 27 days). Patients with comor- bidities or concurrent illness tended to stay longer ( P 0.05, Mann-Whitney test). There were six complications and no mortality. CONCLUSION: Substance abuse and poor orodental hygiene are important predisposing factors to deep neck abscesses. Appro- priate management continues to favor a combination of early surgical drainage and systemic antibiotics.

© 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

D eep neck space abscesses (DNSA) continue to pose a diagnostic and treatment challenge. What initially be-

gins as a common upper respiratory tract or simple dental infection may ultimately progress to an abscess of the deep neck spaces, with the potential for complications such as descending mediastinitis, internal jugular vein thrombosis, airway embarrassment, sepsis, disseminated intravascular

coagulation, and death. 1-7 Despite the increasing use of antibiotics and improved diagnostic modalities, DNSA con- tinue to cause significant morbidity and mortality, with associated mortality ranging from 1.6 to 40 percent. 1-3

These observations highlight the importance of expeditious and appropriate management decisions when treating pa- tients suspected with DNSA. In order to successfully diagnose and treat patients with DNSA, the clinician must have an understanding of neck anatomy, common etiologies, typical presentation, major predisposing comorbidities, clinical course, bacteriology, and potential complications. The mainstay treatment of DNSA has been antibiotic therapy with surgical drainage, with the clinical picture dictating the aggressiveness of treatment. 1,8,9 Successful conservative measures that use bedside procedures or sole antimicrobial therapy for small abscesses have been reported as well. 2,3,9 This study represents a six-year experience of DNSA management at our institution. Primary objectives included identifying predisposing characteristics and evaluating the role of selected therapeutic interventions in limiting mor- bidity and mortality.

METHODS

Cases were selected from medical records of patients diag- nosed with DNSA between February 2001 and December 2006 at Hennepin County Medical Center (HCMC), Min- neapolis, MN. The study was conducted with approval from the HCMC Human Subjects Research Committee, which serves as the institutional review board. Selection of charts was based on codes from the ninth revision of International Statistical Classification of Diseases (ICD-9). The following ICD-9 codes were used to identify patients: 682.0 (cellulitis and abscess of the face), 682.1 (cellulitis and abscess of the neck), 528.3 (cellulitis and abscess of oral soft tissue, Lud- wig’s angina), and 519.2 (mediastinitis). Six hundred patients were identified on initial review. Patients with superficial craniocervical cellulitis and iso- lated salivary gland infection without objective evidence of deep neck space involvement were excluded. Uncompli- cated peritonsillar abscesses, localized buccal abscesses, and deep neck cellulitis were also eliminated. The final

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study population consisted of 106 cases, and these records were studied in detail. Information reviewed included: pa- tient age and gender, location of infection, cause, signs, symptoms, concurrent illnesses or existing comorbidity, du- ration of hospitalization, intensive care unit (ICU) manage- ment, treatment course, and complications. Information that characterized a patient’s infection was determined by anal- ysis of radiographic imaging, operative records, and micro- biology and histopathology reports. Statistical Package for Social Sciences (SPSS Statistics 17.0, Chicago, IL) was used to obtain descriptive statistics and to perform Mann- Whitney U test.

RESULTS

Demographics

There were 67 male and 39 female patients with the major- ity of patients between ages 21 to 50 years (74%) ( Fig 1 ). The mean age was 35 16 years (3 months to 86 years) for male patients and 31 16 years (2 months to 72 years) for female patients.

Etiology and Presentation

Dental infections were the most common cause of DNSA (52 cases). However, the cause was not determined in 32 cases ( Fig 2 ). Most patients presented with neck swelling, craniocervical pain, fever, and facial swelling ( Table 1 ).

Comorbidities

Table 2 summarizes comorbidities encountered with respec- tive implicated spaces. Substance abuse was identified in 57 patients (53.7%). Substance abuse in this study included documented tobacco abuse, alcohol abuse, chronic mari- juana use, and habitual injection of cocaine and heroine. Psychiatric illness (10.4%) was the second most common comorbidity. Patients with multiple comorbidities were ac- counted for only once in statistical tests.

were ac- counted for only once in statistical tests. Figure 1 Distribution of age and gender

Figure 1 Distribution of age and gender in 106 patients with deep neck abscesses.

of age and gender in 106 patients with deep neck abscesses. Figure 2 Etiology of deep

Figure 2 Etiology of deep neck abscesses in 106 patients. (H&N CA, head and neck squamous cell carcinoma; IVDU, in- travenous drug use directly into the neck at the site of deep neck abscess; postoperative infxn, postoperative infection.)

Radiology and Microbiology

Eighty-four patients (79.2%) had computed tomography (CT) scans. An orthopantomogram (OPG) was requested by the oral maxillofacial surgery service in 11 patients (10.4%). The submandibular space was the most common space involved ( Table 3 ). The parapharyngeal, submandib- ular, pretracheal, and deep posterior neck spaces were sta- tistically more involved in odontogenic versus nonodonto- genic DNSA ( P 0.05 by 2 analysis). OPG was useful when suspected dental caries or other dental pathoses were not readily identified by physical examination. Purulent fluid or tissue samples were obtained from 84 patients. Thirty infections were polymicrobial, 13 speci- mens had no growth, three revealed normal oral flora, and one patient had DNSA secondary to dipterous fly larvae infestation ( Table 4 ). Among the 52 odontogenic cases, Streptococcus spp were the most common pathogens (44.4%).

Table 1 Patient presentation (n 106)

Number of patients

Symptoms Craniocervical pain

23 (21.7%)

Dysphagia

10 (9.4%)

Odontalgia

6 (5.7%)

Odynophagia

6 (5.7%)

Dysphonia

2 (1.9%)

Headache

2 (1.9%)

Signs Neck swelling

52 (49.1%)

Fever

12 (11.3%)

Facial swelling

12 (11.3%)

Airway problems

3 (2.8%)

Torticollis

3 (2.8%)

Orocutaneous fistula

2 (1.9%)

Trismus

2 (1.9%)

Cervical emphysema

2 (1.9%)

Emesis

1 (0.9%)

Daramola et al

Diagnosis and treatment of deep neck

125

Table 2 Cormorbidities with spaces implicated

Space(s) implicated*

Description

Number of patients

S

MP

T

D

UW

Tobacco abuse Alcohol abuse Cocaine and heroine† Chronic marijuana use Psychiatric Illness Diabetes mellitus Hypothyroid SCC-neck SCC-mouth Other neoplastic disease Hepatitis C infection Liver cirrhosis Non alcoholic steatohepatitis Diverticulosis Ulcerative colitis Renal failure Polycystic kidney disease Hypertension Pulmonary tuberculosis Other cardiopulmonary disease Anemia Pancytopenia Orocutaneous fistula Laryngeal chondritis Morbid obesity Chronic steroid therapy AIDS Infectious mononucleosis Human immunodeficiency virus Gout

38 (35.8%)

15

3

1

3

2

4

10

14 (13.2%)

5

3121

2

14 (13.2%)

5 (4.7%)

5

4

— —————

1

6

2

1

11 (10.4%)

4

1

1

3

2

6 (5.7%)

1

1

3

1

1 (0.9%)

1

1

————

6 (5.7%)

1 (0.9%)

2 (1.9%)

5 (4.7%)

1 (0.9%)

1 (0.9%)

1 (0.9%)

1 (0.9%)

2

1

4

— ———— — — —————— — — — —————— —

1

1

1

4

1

1

1

1

1

1

1

1

1

————

————

————

4 (3.8%)

1 (0.9%)

10 (9.4%)

5

2

1

2

2 (1.9%)

1

2

————

2

1

1

— —

5 (4.7%)

2 (2.8%)

————

1

1

1 (0.9%)

—————

1

4 (3.8%)

2

1

————

1

3 (2.8%)

3

3 (2.8%)

1

—————

2

2 (1.9%)

1

1

2 (1.9%)

————

1

1

1 (0.9%)

————

1

1 (0.9%)

1

—————

1 (0.9%)

1

——————

S, submandibular space; M, masticator space; P, parapharyngeal space; T, pretracheal space; D, deep posterior neck; U, unspecified; W, widespread infection; SCC, squamous cell carcinoma; AIDS, acquired immune deficiency syndrome. *Sum of spaces implicated in all columns exceed 106 because of multiple space infections. In addition, some patients with multiple comorbid conditions also presented with multiple space infections. †Patients with chronic injection of cocaine and heroine.

There was no significant difference in microbiology be- tween patients with drug or alcohol abuse and the rest of the population. Furthermore, there was no difference in the causative organisms between patients who were dependent on alcohol versus tobacco users. Information with respect to pediatric patients (n 15) is summarized in Table 5 . The cause of DNSA in children below the age of 10 years was often unknown, and a small number were due to trauma. Pediatric patients 12 years and older were all diagnosed with odontogenic DNSA.

Treatment

All 106 patients were hospitalized. Range of time in hospital was 1 to 27 days with the lower quartile, median, and upper quartile stay of 2, 3, and 4 days, respectively, (interquartile range or IQR 2 days). With the use of a Mann-Whitney U test, patients with comorbidities tended

to stay longer (median of 3 days) compared with those without associated comorbidities or systemic illness (me- dian of 2 days, P 0.047). Seventeen (16%) patients were treated in the ICU with a median course of 3 days (IQR 4.25 days). Diabetic patients had a median stay of 2 days (range, 2 to 6 days). Surgical procedures were performed in 97 (91.5%) pa- tients. Others were managed conservatively with antibiotics and supportive care. Among the 97 patients, 85 patients were taken to the operating room (OR) for incision and drainage (I&D). Surgery was performed on 65 of these patients in less than 24 hours. Tracheotomy was performed in eight patients and 44 patients underwent dental extrac- tions in addition to I&D. Bedside I&D was performed in 11 patients and one abscess was aspirated. Nine (8.5%) patients were managed with antibiotics alone. Review of antibiotic treatment revealed that 50 patients were treated with oral or intramuscular antibiotics as an

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Table 3 Location of deep neck abscesses in 106 patients

Number of patients

Anatomic space

Odontogenic

Nonodontogenic

Total (%)

Single space Submandibular* Masticator Pretracheal* Parotid Carotid Retropharyngeal Prevertebral Parapharyngeal Multiple space Parapharyngeal-submandibular* Parapharyngeal-masticator Temporal-masticator Retropharyngeal-parotid Submandibular-masticator Other spaces Unspecified Deep posterior neck*

25

12

37 (34.9%)

5

2

7 (6.6%)

0

5

5 (4.7%)

0

3

3 (2.8%)

0

1

1 (0.9%)

0

1

1 (0.9%)

0

1

1 (0.9%)

1

0

1 (0.9%)

12

1

13 (12.3%)

2

2

4 (3.8%)

1

0

1 (0.9%)

0

1

1 (0.9%)

0

1

1 (0.9%)

7

12

19 (17.9%)

0

7

7 (6.6%)

*Significant at P 0.05 by 2 analysis.

outpatient by their primary care doctor before hospital pre-

sentation ( Table 6). Empiric antibiotic therapy was initiated

in all patients on diagnosis at HCMC. Oral or intravenous

clindamycin was the most frequently used antibiotic (56 patients, Table 6 ). The antimicrobial therapy was subse- quently modified based on culture results and sensitivity testing. Combination antimicrobial therapy was used in 50 patients.

Outcome and Complications

There was no mortality. There were five cases of mediasti- nitis and one postoperative large bowel obstruction. Medi- astinitis cases were treated with antibiotics and supportive care. One of the patients with mediastinitis received prior outpatient penicillin therapy.

DISCUSSION

A deep neck abscess often starts as an isolated area of

cellulitis in the soft tissues adjacent to the source of infec- tion. 4,5 The fascial layers of the neck and the body’s natural defense mechanisms help to prevent further spread of in- fection. Consequently, widespread progression is not typi- cally seen. 6 However, if the infection is not adequately treated, it may develop into a purulent fluid collection. This collection may track along fascial planes deeper into the neck and potentially extend into the mediastinum. 2,3,5,6 The results from this study are consistent with similar DNSA reviews that show a predominance of male patients primarily in an age range of 21 to 60 years old. 1,3,7,9 Pre-

senting signs and symptoms vary and are dependent on the time at which a patient seeks medical attention. In this study, there is no specific examination finding or symptom for a DNSA and patients may present several days after onset of symptoms. The lack of one or two specific signs and symptoms is also in agreement with other studies where pain, fever, facial and neck swelling, and trismus have been reported to be the most common presenting signs and symptoms 3,4,9,10 Additional signs and symp - toms include odynophagia, otalgia, dysphagia, oral swell- ing, and dyspnea. The majority of patients with an odontogenic source in our study had poor oral hygiene with recent history of dental procedures. Before the antibiotic era, DNSA often origi- nated from the tonsillar and pharyngeal areas. Today, sia- loadenitis and dental infections are considered more com- mon causes of DNSA. 3,4,6,7,11 An odontogenic deep neck abscess is principally associated with disease in the second and third mandibular molars. 6 The root apices of these molars extend below the mylohyoid muscle, thus establish- ing a pathway for spread to the submandibular and submen- tal spaces. Untreated infection in these spaces may spread to other adjacent neck spaces. Etiology was unidentified in 32 cases. A majority of published reviews acknowledge the fact that many patients with DNSA do not report an inciting event or obvious cause, as was consistent with our data. 2,9,12 It is possible that the inability to detect an obvious cause may be due to prior outpatient treatment of dental infections, upper respiratory tract infections, or other diseases with antibiotics. This may obliterate or mask the source of infection. 2,3,9,12

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127

Table 4 Isolated pathogens from 84 patients with deep neck abscesses

Frequency or percentage

 

Number of

Percentage with

Immunocompromised

 

Organism

N

diabetic patients

substance abuse

patients

Aerobic/facultative Streptococcus sp Staphylococcus aureus

21

4.7%

33.3%

19.0%

14

2.14%

21.4%

42.9%

Staphylococcus sp Streptococcus viridans MRSA GABHS Streptococcus milleri Enterobacter sp Haemophilus sp Lactobacillus sp

14

14.3%

28.6%

10

10.0%

10.0%

8

12.5%

38.0%

6

33.3%

16.7%

5

20.0%

40.0%

2

50.0%

3

1

100%

S

maltophilia

1

100%

100%

Pseudomonas aeruginosa

1

100%

Anaerobic Peptostreptococcus sp Prevotella sp Eikenella corrodens

1

100%

2

50.0%

1

100%

F

necrophorum

1—

Veillonella sp Miscellaneous No growth Physiologic flora Diphtheroid bacillus Candida albicans Actinomyces sp Larva infestation

1

13

15.4%

38.4%

23.1%

4

4

25.0%

2

50%

1

100%

1

100%

N, total number of isolates positive with respective pathogen; MRSA, methicillin-resistant Staphylococcus aureus ; GABHS, group A beta hemolytic Streptococus sp; S maltophilia, stenotrophomonas maltophilia; F necrophorum, Fusobacterium necrophorum.

Chronic alcohol consumption damages the oropharyn- geal mucosa and enhances permeability to carcinogens and microbes. 13 It is also associated with depressed immune function. In addition, undesirable quantitative and qualita- tive changes have been demonstrated in the oral microflora of alcoholics who also smoke. Finally, it has been suggested that individuals who abuse alcohol and tobacco tend to adopt poor oral hygiene, which subsequently predisposes them to odontogenic neck infections. 13 Clinicians should be cognizant of these observations and must adopt a high index of suspicion for DNSA in frequent users of alcohol and tobacco who present with concerning symptoms. Notable psychiatric diseases in this study included major depressive disorder (MDD), schizoaffective disorder, schizo- phrenia, and bipolar disorder. The role of psychiatric illness in the pathogenesis of DNSA is not easily explained by a single objective measure. These patients are prone to adopt- ing poor dental hygiene secondary to disabling mental ill- ness. Antidepressants and psychoactive drugs also have side effects such as stomatitis, sialoadenitis, gingivitis, and xe- rostomia. 14 Furthermore, patients with MDD have been reported to have cravings for sweets because of dysgeusia induced by antidepressant medication. These trends, cou-

pled with low interest in the maintenance of optimal oral hygiene and a propensity to abuse tobacco, puts these pa- tients at a high risk for dental infections that may progress into DNSA. 14 Diabetes mellitus (DM) is commonly reported in patients with deep neck infections. 11,15 Existing literature suggests that diabetic patients who develop DNSAs have more se- vere infections, greater incidence of complications, and higher mortality. 11 However, the six diabetic patients in this study did not have protracted illness or a higher rate of complications. Although our findings do not fully support a conclusion of increased illness severity in diabetic patients, DM is a well-established risk factor for a DNSA. The majority of DNSA are polymicrobial. 1,5,7,16 Patho- gens involved in DNSA are often part of the normal flora of the oral cavity, oropharynx, or skin. The results from this review revealed a low level of anaerobic bacteria when literature seems to suggest otherwise. 1,5,12,15 Detailed re- view of laboratory and operative reports showed that sam- ples from abscesses were not automatically considered for anaerobic, fungal, or mycobacterial pathogens unless spec- ified by the physician performing the procedure. Thus, these specimens may not be placed in appropriate media condu-

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Table 5 Summary of deep neck space infections in pediatric patients (n 15)

Age and sex

Cause

Space

Microbiology

CT Findings

Therapy

H

0.16

F

Unknown

Parotid

S aureus

Abscess

I&D, A

5

0.25

M

Unknown

Posterior neck

S aureus

MNNA

I&D, A

5

0.33

F

Unknown

Parotid

S aureus

Abscess

I&D, A

4

0.58

F

Unknown

Submandibular

S aureus

MNNA

I&D, A

5

1

F

Unknown

Posterior neck

No growth

MNNA

I&D, A

2

2

M

Trauma

Retropharyngeal

NP

Abscess

A

6

2

M

Unknown

Posterior neck

S aureus

MNNA

I&D, A

4

3

M

Tuberculoid adenitis

Submandibular

S aureus,

MNNA

I&D, A

3

6

M

Unknown

Pretracheal

P acnes, DB Streptococcus sp MNNA

I&D, A

2

7

F

Trauma

Parotid

S aureus

Abscess

A

4

12

M

Odontogenic

Submandibular

S viridans

NP

I&D, A

2

12

M

Odontogenic

Submandibular

S viridans

Abscess

I&D, A

1

14

F

Odontogenic

Submandibular

S viridans

Abscess, gas

I&D, A

3

17

F

Odontogenic

Submandibular masticator

S aureus

Abscess, tracheal

I&D, A

4

deviation

H, hospitalization in days; F, female; S aureus, Staphylococcus aureus; I&D, incision and drainage; A, antibiotics; M, male; MNNA, multiple necrotic lymph nodes surrounded by abscess; NP, not performed; P acnes, Propionibacterium acnes ; S viridans, Streptococcus viridans .

cive for isolating anaerobic organisms. This inconsistency in specimen sampling, coupled with prior use of outpatient antibiotics may be responsible for the low yield of anaerobic organisms. Specimens from deep neck space abscesses should be immediately collected at the time of surgical drainage, transported in appropriate vessels that will op- timize growth of aerobic and anaerobic organisms in selected media. Technique of sample collection is also important as studies have suggested that aspiration of pus may yield more comprehensive results in comparison to swabs. 5,17 Empiric antibiotic coverage for DNSA must consider aerobic and anaerobic pathogens that synthesize beta-lacta- mase. 3,5,15,17 Second or third generation cephalosporin drugs such as cefoxitin or ceftriaxone are effective. Alter- natively, a penicillin and beta-lactamase inhibitor combina- tion such as ampicillin-sulbactam also provides adequate coverage. 5,17 Clindamycin may be used as an alternative and is preferred in those allergic to penicillin. Suspicion or confirmation of methicillin-resistant Staphyloccocus aureus warrants the use of effective antibiotics such as vancomy- cin, rifampin, or sulfamethoxazole-trimethoprim. Therapy may be changed as required by culture results. Gram negative rods such as Klebsiella pnuemoniae and Neisseria sp are uncommon in healthy individuals diag- nosed with DNSA, but they have been found in diabetic patients and those who are debilitated or immunocompro- mised. 2,11,15 Although there was no specific difference in DNSA microbiology between diabetic and nondiabetic pa- tients in this study, there was a trend for patients who were considered to be immunocompromised due to acquired im- munodeficiency syndrome, renal or liver disease, cancer, and chronic steroid use to have a DNSA caused by less

common organisms. In addition to a penicillin or cephalo- sporin, immunocompromised patients should also be treated with a fluoroquinolone or an aminoglycoside. In our pediatric population, the primary offending organ- ism in children under 10 years of age was Staphylococcus aureus . Beyond this age, infections were similar to adult DNSA profiles with respect to pathogen and neck space involvement. The change is most likely from eruption of permanent dentition, which subsequently establishes a con- duit for spread of dental infection into deep neck anatomy. There was no predilection for retropharyngeal space ab- scesses in our pediatric population, as has been noted in other studies. 10 Studies have lent support to the notion that limited pediatric neck abscesses commonly arise from ne- crotic lymph nodes, and small uncomplicated DNSA may respond to intravenous antibiotics alone or antibiotics with needle aspiration. 5,10 Two of 15 pediatric patients in this study were successfully managed with antibiotics alone. Contrast-enhanced computed tomography (CT) scanning is the radiologic evaluation of choice in the study of deep neck infections. It has been shown to have a sensitivity ranging from 95 to 100 percent in identifying and charac- terizing deep neck infections. 3,18 CT is instrumental in dis- tinguishing cellulitis from DNSA, localization of DNSA, identification of airway deviation, and involvement of the carotid sheath or major blood vessels. 4,6,15,18 CT imaging should be extended below the neck to survey the thorax when mediastinitis is suspected. Mediastinal involvement in one patient in this study was solely identified by CT scan. Signs and symptoms that raise concerns for mediastinitis include dyspnea, chest pain, widened mediastinum on chest roentgenograph, pneumomediastinum, and deterioration of clinical status. 4,12

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129

Table 6

Antibiotic usage

Number of patients.

Antibiotic

Inpatient

Treatment*

Prior

treatment†

Clindamycin

56

11

Ampicillin/sulbactam

31

Augmentin

29

7

Metronidazole

17

3

Penicillin

13

14

Vancomycin

8

Imipenem

7

Cephalexin

7

5

Linezolid

5

Ceftriaxone

4

1

Azithromycin

4

Levofloxacin

4

2

Cefproxil

4

1

Piperacillin/tazobactam

3

Ciprofloxacin

3

2

Cefazolin

3

1

Doxycycline

1

Amikacin

1

Cefadroxil

1

Ertapenemn

1

Erythromycin

1

1

Moxifloxacin

1

Rifampin

1

Cefotaxime

1

Amoxicillin

2

*For preoperative or inpatient treatment, 50 patients re- ceived multiple antibiotics thus the total number under fre- quency column exceeds 106. †Fifty patients received oral or intramuscular antibiotic ther- apy for outpatient treatment. They subsequently presented to the hospital or emergency department when symptoms persisted. None of these patients was treated with more than one antibiotic.

Loss of the airway represents the most common cause of death in patients with complicated DNSA. 19 Airway obstruction may be a consequence of mass effect from large DNSA, neck edema, and necrosis. Asphyxiation from sudden abscess rupture and hemorrhage is also possible. 5 Control of the airway via endotracheal tube (ETT) intubation or tracheotomy should be a priority in the management plan. 3-5,15,19 The choice between trache- otomy and ETT intubation depends on several factors such as spaces involved, illness severity, emergent need for air- way control, and institutional preference. Among the eight patients that received tracheotomy, three had widespread infection, and two had Ludwig’s angina. Current policy at HCMC is to perform tracheotomy on patients with Lud- wig’s angina. Prompt and aggressive surgical drainage is the appropri- ate treatment for DNSA. However, preparations for surgery should not delay initiation of broad spectrum antibiotics. Antimicrobial therapy may be adjusted, as indicated, by

sensitivity results. In this review, conservative treatment was defined as sole antimicrobial treatment, needle aspira- tion, and bedside I&D. These were used in patients with small abscesses with limited infection and without major health comorbidities. This is consistent with the litera- ture. 3,4,9 These criteria may not be generalized across pa- tient populations and are not typically applicable to patients with multiple DNSA or those with signs and symptoms indicating impending airway compromise. A combination of surgical and antimicrobial therapies should remain the standard modality of treatment in the majority of patients with DNSA.

CONCLUSION

DNSA is a common complication of dental or pharyngeal infections. Chronic alcohol and tobacco consumption and psychiatric illness should also be considered with diabe- tes mellitus as important predisposing factors for DNSA. Most patients require intravenous antibiotics and expedi- tious surgical debridement. Immunocompromised pa- tients require broad spectrum antibiotics. Extension of CT scans to the thorax is prudent in the context of clinical signs that indicate mediastinum involvement or worsen- ing clinical status. Despite treating a population with significant comorbidities, the combination of early diag- nosis, initiation of empiric antimicrobial therapy, and prompt and aggressive surgical intervention resulted in resolution of all cases and no mortality.

AUTHOR INFORMATION

From the Department of Otolaryngology and Communication Sciences (Dr Daramola), Medical College of Wisconsin, Milwaukee; the University of Minnesota Medical School (Dr Daramola); and the Department of Otolar- yngology–Head and Neck Surgery (Drs Flanagan, Maisel, and Odland), University of Minnesota, Minneapolis; and the Department of Otolaryn- gology–Head and Neck Surgery (Drs Flanagan, Maisel, and Odland), Hennepin County Medical Center, Minneapolis.

Corresponding author: Opeyemi Daramola, MD, Department of Otolaryn- gology and Communication Sciences, Medical College of Wisconsin, 9200 West Wisconsin Ave, Milwaukee, WI 53226.

E-mail address: odaramol@mcw.edu.

AUTHOR CONTRIBUTION

Opeyemi O. Daramola , study design, study coordinator, data acquisition, data analysis, data interpretation, writer; Carrie E. Flanagan , concept, study design, data interpretation, writer; Robert H. Maisel , study design, manuscript review; Rick M. Odland , study design, data interpretation, manuscript preparation, mentor.

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Otolaryngology–Head and Neck Surgery, Vol 141, No 1, July 2009

DISCLOSURES

Competing interests: None.

Sponsorships: None.

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