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

Eur Arch Otorhinolaryngol (2012) 269:1241–1249

Peptostreptococcus spp ( n = 2), and Veillonella spp ( n = 1) were detected in anaerobic cultures. Among patients with critical airway narrowing, 15 patients (48.4%) had a bilateral diffuse gangrenous cellu- litis of the submandibular and sublingual spaces (‘‘Lud- wig’s angina’’) with or without extension to the visceral anterior space. In order to resolve airway obstruction, 8 patients underwent emergency tracheostomy, 17 patients underwent fiberoptic guided awake endotracheal intuba- tion, and 6 patients achieve relief after successful treatment by intravenous corticosteroids. Eleven patients developing visceral vascular space infection with jugular vein thrombosis secondary to oro- pharyngeal infection, underwent long-term antibiotic ther- apy in association with anticoagulant therapy (enoxaparin 100 IU/kg twice daily for 3 months). All patients with jugular vein thrombosis complained of neck stiffness. Positive blood cultures for Fusobacterium spp. and Strep- tococcus constellatus were documented in four and one patient, respectively. Septic embolization to multiple sites (lung, liver, spleen, and joints) was observed in five cases (Lemierre’s syndrome). Two patients with associated pa- rapharyngeal abscess—one of those with concomitant descending mediastinitis—underwent surgical drainage of the pus collection. No patients underwent ligation of the internal jugular vein. Less severe complications account for osteomyelitis ( n = 2) and vocal cord palsy ( n = 2). In univariate logistic-regression analysis, we assessed fac- tors associated with life-threatening complications. The strongest predictor of life-threatening complications was diabetes mellitus [odd ratio 7.37 (95% CI 3.90–13.94); P \ 0.001]. Other variables significantly associated with complications are shown in Table 4 . Factors that were independently associated with life-threatening complica- tions on the basis of a multinomial regression model, are shown in Table 5 : diabetes mellitus [odd ratio 5.43 (95% CI 2.56–11.53); P \ 0.001] and multiple deep neck spaces Predictors of complications

Table 5 Factors associated with life-threatening complications in the stepwise multivariate model

P value

Factor

Odds ratio (95% CI)

Body temperature: per increase of 1 C 1.49 (1.09–2.04)

0.012

White blood cell count: per increase of 1 9 10 3 /mm 3

1.09 (1.02–1.17)

0.005

5.43 (2.55–11.53) \ 0.001

Diabetes mellitus

Evidence of colliquation

2.51 (1.22–5.15)

0.012

4.92 (2.38–10.16) \ 0.001

Multiple space involvement

involvement [odd ratio 4.92 (95% CI 2.38–10.16); P \ 0.001] were the strongest independent predictors of complications.

Outcome

One patient with diabetes mellitus and liver dysfunction who have developed sepsis and disseminated intravascular coagulation died from severe hepatic insufficiency 16 days after successful drainage of bilateral submandibular abscess with extension to the anterior visceral space. All other patients were discharged in stable condition after a median length of inpatient stay of 11 days (range 6–73 days).

Discussion

This is the largest series of DNIs reported in Western lit- erature. Although DNIs can affect all age-group, most of cases in the present series were concentrated between the fifth and seventh decade of life. About one-fourth of patients have relevant associated comorbidities with dia- betes mellitus being the most frequent. Diabetes mellitus is commonly reported in patients with DNIs [ 5 ]. Several authors have identified diabetes mellitus as a significant risk factor for infection-related morbidity and mortality [ 5 , 6 ]. The results of our study confirmed diabetes mellitus as the strongest independent predictors of complications. Peripheral vascular disease in diabetics may predispose patients to anaerobic infection [ 7 ]. Furthermore, patients with a hyperglycemic state have functional leukocyte, macrophage, and fibroblast impairments that increase their susceptibility to serious infections [ 8 , 9 ]. Therefore, opti- mal control of diabetes mellitus play a critical role in DNIs management: insulin use is the best option due to flexibility of timing and dose. Most DNIs are mixed polymicrobial infections includ- ing aerobes and anaerobes. Bacteroides fragilis , Prevotella , Porphyromonas , and Fusobacterium spp resist penicillin through the production of beta-lactamase. Overall, more

Table 4 Univariate associations with life-threatening complications

P value

Factor

Odds ratio (95% CI)

Sex: male vs. Female

1.50 (0.87–2.60)

0.145

Age: per 10-year increase

1.20 (1.04–1.39)

0.012

Body temperature: per increase of 1 C 1.41 (1.10–1.80)

0.006

\ 0.001

White blood cell count: per increase of 1 9 10 3 /mm 3

1.11 (1.05–1.17)

7.37 (3.90–13.94) \ 0.001

Diabetes mellitus

\ 0.001 \ 0.001

Evidence of colliquation

3.63 (1.90–6.93)

Multiple space involvement

3.96 (2.14–7.36)

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