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

Eur Arch Otorhinolaryngol (2012) 269:1241–1249

Treatment

Overall, 226 patients (61.9%) responded effectively to intravenous antimicrobial therapy only. Sixty-five patients (17.8%) underwent tooth extraction. On discharge, tonsillectomy was proposed to all patients treated for DNI secondary to pharyngotonsillitis.

All patients received empirical broad-spectrum intravenous antimicrobial therapy on admission in order to eradicate both aerobic and anaerobic microorganisms. The first-line therapy was later modified according to microbiological findings if the isolated microorganisms revealed resis- tance towards the empiric therapy. The most frequently provided treatment regimens, alone or in combination, were amoxicillin/clavulanate potassium (58.9%), second- and third-generation cephalosporins (37.3%), ampicilline/ sulbactam (12.9%), clindamicyn (11.4%), metronidazole (3.6%), and vancomycin (2.4%). Patients who were clinically unstable (airway obstruction, signs and symptoms of sepsis); patients with descending infection; patients with anterior visceral space involvement, with abscess involving more than two deep neck spaces; and patients with abscess larger than 3.0 cm, underwent imme- diate surgical drainage. Gas-forming infections were not in itself an absolute indication for immediate surgery unless large amount of tissue were involved. In all the other cases, patients were observed for 48 h. If the patient’s symptoms and signs worsened or if no clinical improvement was noted after 48 h, surgical drainage was performed. On the other hand, if clinical response was seen, a radiographic study was repeated to confirm clinical judgment. If the repeat imaging did not confirm a regression of collection of pus, surgical intervention was anyway considered. In selected cases, therapeutic needle aspiration of abscess was considered an alternative to conventional open surgery. One-hundred and thirty-nine patients (38.1%) under- went surgical drainage. Of the abscess group ( n = 213), 111 patients (52.1%) underwent surgical drainage. Of the cellulitis group ( n = 152), 28 patients (18.4%) underwent surgical drainage. In 112 cases (30.7%), an open surgical drainage was performed under general anesthesia. An exclusively transoral approach was used in 21 cases. An external or combined approach was necessary in 91 patients. In all cases, a wide exposure of the abscess cavity was performed including blunt avulsion of any loculations, the devitalized tissue was de´brided, and the wound was irrigated with half- strength hydrogen peroxide. In patients with extensive tissue necrosis, the cervical incision was packed with plain gauze and left open to allow oxygenation of the tissue and daily irrigations with antiseptic solutions. In other cases, wounds were closed after placement of large-bore drains for irrigation. Twenty-seven patients (7.4%) underwent needle aspiration of abscess, with CT-scan guidance in five cases. Intraoperative findings confirmed the CECT diag- nosis of abscess in 87.1%. Duration of symptoms ( \ 5 days vs. C 5 days) was not found to be predictive of necessity of surgical drainage ( P = 0.566).

Complications

There were 67 patients (18.4%) developing life-threatening complications (Table 3 ). Forty-three were men (64.2%) and 24 were women (35.8%) with a median age of 59 years (range 18–89 years). Diabetes mellitus occurred in 27 patients (40.3%). An abscess was present in 54 patients (80.6%) and a multiple-space involvement was diagnosed in 52 cases (77.6%). Sixteen patients (4.4%) developed descending necrotiz- ing mediastinitis with a median of 6 days (range 3–12 days) after onset of first symptoms of cervical infection. Most common symptoms and signs included neck and/or upper aero-digestive tract swelling ( n = 16), dysphagia ( n = 10), throat pain ( n = 11), neck stiffness ( n = 5). Acute onset of dyspnea and thoracic pain were seen in three and four patients, respectively. Neck swelling was the only clinical finding in five patients. In most cases ( n = 10), the diag- nosis of mediastinitis was made on the basis of CECT findings in absence of clinical signs of mediastinum involvement. Twelve patients underwent external drainage of the cervical abscess in conjunction with posterolateral thoracotomy, four patients with infection limited to the upper mediastinal spaces above the tracheal carina under- went transcervical thoracic drainage. Among patients with descending mediastinitis, a microbiological diagnosis was obtained from 10 patients (62.5%). A polymicrobial infec- tion was identified in six patients. The isolated aerobic bacteria were Streptococcus spp ( n = 5), Coagulase-nega- tive staphylococcus ( n = 3), Acinectobacter baumanii ( n = 1), Gemella morbillorum ( n = 2), Stenotrophomonas maltophilia ( n = 1), and Klebsiella pneumoniae ( n = 1). Bacteroides spp ( n = 3), Fusobacterium spp ( n = 2),

Table 3 Life-threatening complications

No. deaths

Complications

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

Airway obstruction

31 (8.5)

0

Sepsis

22 (6.0)

1

Descending mediastinitis

16 (4.4)

0

Pneumonia

12 (3.3)

0

Jugular vein thrombosis ± septic embolism 11 (3.0)

0

Pleural effusion

4 (1.1)

0

Disseminated intravascular coagulation

1 (0.3)

1

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