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

Eur Arch Otorhinolaryngol (2012) 269:1241–1249

approach is justified, even if areas of colliquation are not usually evident [ 6 ]. No correlation was found between duration of symptoms and the necessity of surgical drainage. Considering that a short duration of symptoms may correlate with a more aggressive infection, one should have expected a higher prevalence of surgical drainage in these patients. On the other hand, an inappropriate antibiotic therapy and anaerobic infections may be responsible for a slow course of disease and longer duration of symptoms in patients who finally develop complications requiring surgical procedures. About 7.5% of patients were successfully drained by needle aspiration. Minimally invasive techniques are attractive options in patients with well-defined, unilocular abscess without airway compromise. Draining an abscess by needle aspiration reduces the morbidity of open surgery by limiting surgical trauma, reducing healing time, minimizing the risk of contaminating the surrounding healthy tissue. CT or ultrasound guidance may improve the efficacy and safety of percutaneous abscess drainage. In selected retro- and parapharyngeal abscesses without involvement of visceral vascular space, endo-oral aspiration and/or incision should be considered in order to reduce patient morbidity, economic burden and avoid aesthetic complications. About 18% of patients developed life-threatening com- plications. Diabetes mellitus was confirmed to be the strongest predictor of life-threatening complications [ 5 ]. Airway obstruction and spread of infection to the medias- tinum are the most troublesome complications in patients with deep neck space infections. In our study population, most patients with mediastinitis had not shown any symptoms and signs of mediastinum involvement with symptoms of neck infection being common. Therefore, prompt diagnosis of descending mediastinitis may be missed in the absence of a high index of suspicion and routine CECT through the mediastinum. On the basis of our multivariate analysis, patients with diabetes mellitus, multiple space involvement, evidence of colliquation, high WBC, or high body temperature should be considered to potentially have a descending mediastinitis until proven otherwise. Descending necrotizing mediastinitis requires an aggressive multidisciplinary management. Delay in diagnosis as well as inadequate drainage of the mediasti- num are considered to be the most significant factors responsible for mortality [ 22 ]. Transcervical drainage of the mediastinum should be reserved for patients with infection limited to the upper mediastinal spaces above the tracheal carina. On the other hand, cervicotomy along with posterolateral thoracotomy incision is the standard of care in patients with inferior mediastinum involvement. Lemierre’s syndrome is an uncommon seen and often forgotten complication of acute oropharyngitis affecting healthy adolescents and young adults. Central to the

Fig. 5 A case of Ludwig’s angina

Macrolides or ketolides plus metronidazole should be considered in patients with a penicillin allergy. Clinda- mycin resistance among strains of Bacteroides fragilis has increased over 10 years, and current resistance rates reach 20–50% or more worldwide [ 24 ]. Take into account that in the present and other series [ 22 ] Bacteroides spp were among the most frequently isolated anaerobic pathogens both in uncomplicated and complicated DNIs, clindamycin may no longer be considered a first-line antibiotic in DNIs. First intention antibiotic therapy should be reviewed 48 h later and potentially adjusted according to the microbio- logical- and drug-resistance patterns. A prolonged antibi- otic therapy should be advisable as anaerobic infections are frequently chronic. After resolution of clinical signs of DNIs, oral therapy can replace parenteral one. Open surgical incision and drainage are considered the mainstay of treatment for deep neck abscesses. Almost two-third of the patients responded satisfactorily to medical therapy only. We and several authors have demonstrated previously that a trial of intravenous antibiotic treatment associated with an aggressive CECT-based wait-and-watch policy may result in a significant number of selected patients (patients with cellulitis, abscesses \ 3 cm not involving ‘‘danger spaces’’ or more than one space, stable general condition) avoiding an unnecessary surgical drainage [ 15 , 17 , 25 ]. This policy did not result in significantly higher number of imaging procedures in patients selected for observations mainly because imaging investigations were routinely performed also after surgical drainage of deep neck abscess in order to confirm the resolution of the infections. In the present series, about one-fourth of patients required an extensive external cervical approach. This approach is mandatory for drainage of large abscesses, multiple space abscesses, and impending complications. In patients with Ludwig’s angina, an external surgical

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