2018-19 Section 7-Neoplastic and Inflammatory Diseases of the Head and Neck eBook

Eur Arch Otorhinolaryngol (2012) 269:1241–1249

Diagnostic investigations

Table 1 Site and character of deep neck infections

Involved spaces

No. of patients (%) ( N = 365)

No. cellulitis

No. abscess

All patients underwent otolaryngological examination with fiber-optic, b-mode ultrasonography of the neck and/or contrast-enhanced computed tomography (CECT)/mag- netic resonance imaging (MRI) of the neck. CECT and MRI were performed in 321 (87.9%) and 23 (6.3%) patients, respectively. 3-mm slides from skull base to the superior mediastinum were obtained before and after con- trast injection using either the spiral or multi-slice tech- nique. The CECT scan was interpreted as demonstrating an abscess in presence of the enhancing rim around non- enhancing central density consistent with fluid. The initial CECT scan was extended to include the chest in cases of suspected descending infection. Acquisition of high-reso- lution axial scans of the jaw together with curved and or- thoradial multiplanar reconstructions was performed in patients with submandibular space infections and/or sus- pected odontogenic infection. Follow-up CECT was the diagnostic procedure of choice to evaluate response to medical and/or surgical treatment and was performed in 286 cases (78.3%). Overall, the median number of imaging examinations was two per patient (range 1–9). No signifi- cant differences were found in number of imaging proce- dures between patients who were immediately operated and in patients selected for observation ( P = 0.670). On the other hand, a higher number of imaging procedures, particularly CECT, was performed in patients developing complications (median 4, range 3–9). The source of infection was identified in 297 patients (81.4%): the most common cause was a pharyngitis ( n = 119; 32.6%), followed by dental infection ( n = 102; 27.9%), submandibular sialadenitis ( n = 39; 10.7%), par- otitis ( n = 23; 6.3%), cervical lymphadenitis ( n = 7; 1.9%), otitis ( n = 4; 1.1%), epiglottitis ( n = 2; 0.5%). One patient developed deep neck abscess with descending mediastinitis secondary to cervical intravenous drug abuse. The pathogenesis of DNI was not determined in 69 patients (18.9%). According to the source of infection, the most common primary site of DNI was submandibular space followed by parapharyngeal space (Table 1 ). In 191 cases (52.3%), a multiple space involvement was observed. An abscess was present in 213 patients (58.4%), a cellulitis in 152 patients (41.6%). Source, site, and character of DNIs

Submandibular

220 (60.3)

108

111

Parapharyngeal

211 (57.8)

88

123

Parotid

48 (13.1)

8

40

Retropharyngeal

36 (9.9)

10

26

Visceral anterior

29 (7.9)

7

22

Visceral vascular

12 (3.3)

0

6

Masticatory

11 (3.0)

3

8

Prevertebral

9 (2.4)

1

8

Temporal

3 (0.8)

3

0

Table 2 Isolated pathogens from 177 patients with deep neck infections

No.

Aerobic/facultatives Streptococcus viridans not typed

37

Coagulase-negative staphylococcus

33

Staphylococcus aureus

23

Klebsiella pneumoniae

18

Staphylococcus epidermidis

11

Haemophilus influenzae

11

Streptococcus pneumoniae

6

Streptococcus, b -hemolytic, group A

5

Streptococcus constellatus

5

Proteus mirabilis

4

Streptococcus group F

3

Pseudomonas aeruginosa

3

Acinectobacter baumanii

2

Gemella morbillorum

2

Stenotrophomonas maltophilia

1

Streptococcus oralis

1

Anaerobic

Bacteroides spp

19

Peptostreptococcus spp

15

Fusobacterium spp

5

Prevotella melaninogenica

4

Propionibacterium acnes

2

Veillonella spp

2

Others

Candida spp

4

Aspergillus spp

2

obtained from the primary source of infection, the neck or the mediastinum, using either a sterile swab or suction trap. Microbiological diagnosis (Table 2 ) was successful in 177 patients (48.5%); 15.8% positive cultures were polymicrobial.

Microbiology

Microbiological analysis included aerobic ± anaerobic cultures and were performed from blood samples, material

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