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Deep neck infections
Int. J. Oral Surg. 1979: 8: 407-411 Key words: infection. odolltogenic; tOllsiliitis; tOllsiliectomy; cyst. bronchiogenic; infectioll. spread of)
Deep neck infections E. VIROLAINEN, J. HAAPANIEMI, K. AITASALO AND J. SUONPAA Department of Otolaryngology, TlIrkli University Hospital, Finland
From January 1967 to August 1978, 65 patients with cervical abscesses were referred to the ENT Clinic of Turku University Hospital. The origin of these deep neck infections was odontogenic in 19, tonsillitis or tonsillectomy in 14, trauma in seven, salivary glands in five and branchiogenic cysts in five and other known causes in three cases. In 12 cases the origin was unknown. The cervical abscesses of odontogenic origin were located mostly in the submandibular space (11/19). The rest of the deep cervical infections were mostly found in the parapharyngeal space (25/46). Etiological factors and treatment of these severe infections are discussed. ABSTRACT -
(Received for publication 17 November 1978, accepted 17 April 1979)
The possibility of dangerous, life-threatening complications of deep neck infections emphasizes the need for early diagnosis and treatment. The origin of cervical abscesses may be an inflammation or a tonsil, mucosa of the mouth and throat or salivary glands. Also branchiogenic cysts and trauma in the head and neck region may be complicated by deep neck infections. Further, such a severe condition may develop after surgical procedures on the head and neck region. Occasionally a cervical abscess appears to have no specific etiology2,5,lo,11. In the visceral spaces, typical of the anatomy of the neck, the infection may easily extend through soft areolar tissues into the mediastinum or up to the intracranial spaces. The most serious complications of these cervical infections are thrombosis of the internal jugular vein, rupture of the
carotid artery, mediastinitis and septicemia. Sudden spontaneous rupture of the abscess into the throat may also produce fatal consequences 2,S,6,8.
Material The material of the present study consists of 65 patients referred to the ENT Clinic of Turku University Hospital from January 1967 to August 1978. All these patients had deep cervical abscesses that were incised and evacuated by an external route. General anesthesia was used in all operations. Pus was obtained for bacteriologic culture and sensitivity tests from every abscess. Also the wall of the abscess and the necrotizing cervical tissue were biopsied for histological diagnosis. The age of the patients varied from 1.5 to 64 years and the mean was 27 years (Table 1). The visceral space in which the abscess was located was determined by the surgeon (Fig. 1).
0300-9785/79/060407-05$02.50/0 © 1979 Munksgaard, Copenhagen
VIROLAINEN, HAAPANIEMI, AITASALO AND SUONPAA
408
Table 1. Deep neck infections treated at the ENT Clinic, Turku University Hospital, from January 1967 to August 1978 Localization (visceral space)
Total
Mean age (years)
19
Mean hospitalization (days)
9
Masticator Pharyngomaxillar Parapharyngeal Submandibular Sublingual
4 25 26 4
29
10
Total
65
27
11
6
34 28 26
Results The origin of deep cervical infection was odontogenic in 19 (29 %) cases: 10 dental granulomas, four infections following extraction, three cases with severe caries, one dental cyst and one gingival erosion caused by a poorly fitting prothesis. Eleven of these abscesses were located in the submandibular space, six in the masticator space, one in the sublingual, and one in the pharyngomaxillary space (Table 2). Acute tonsillitis had been diagnosed in nine patients shortly before the cervical infection. In six of these cases the abscess was found in the parapharyngeal space. The sublingual, submandibular and masticator
aUCCOPHAAY FASCIA - - - -
SUPUIOft CONS RICTIO
13
14
8
Seriousness of the disease lifeconthreatsevere trolled ening 1
7
8
6 1
2 2 1
16 25
5
52
4
spaces were each the site of one abscess. Five of the patients had undergone tonsillectomy about 2 weeks before hospitalization. In these patients the deep infection was found in the parapharyngeal space three times and in the pharyngomaxillary space twice. Seven abscesses originated from trauma to the head and neck region. Three assaulted patients had no external wounds or erosions on the skin of the head and neck. Two of these abscesses were found in the submandibular space and one was located in the parapharyngeal space. Three patients developed abscesses after bicycle accidents, two of which were in the parapharyngeal space and one in the submandibular space.
o. PHARYNX snR OMAS 010
.--_.-.I ,fXl',~:-- MUSCLE
CARO 10 5 EATH
PRE -VI: RTf BAAL SCLES
RfTROPHAAYNG£A
Fig. 1. Visceral paces of the neck.
Sl'ACl:
DEEP NECK INFECTIONS
409
Table 2. Etiology and localization of the deep neck infections Etiology
Localization (visceral space)
j .... 0 .....
rJ
.~
c.s
~
Odontogenic - extraction - granulomas - caries - cysts - erosions Tonsils - tonsillitis (acute) - tonsillectomy Trauma Salivary glands Branchiogenic cysts Tuberculosis Acne Ca with metastasis Unknown Total
5
~
S
g bl)
I'l
::l .0
:.ad
Cil
d
~ .Q §<
.g
~
al
P-<
1;1 P-<
S
U)
!-<
0
bl)
~ .Q 1
oj
U)
::l
bl)
'§
5
1
10 3 1 1
1
9
2
7 2
1
One parapharyngeal abscess originated from a piece of straw stuck in the mucosa of the throat. In the latter case radiographic investigation also revealed involvement of the mediastinum. Salivary glands seemed to be the primary source of the deep neck infections in five cases. Four abscesses were located in the submandibular space and one in the parapharyngeal space. Infection spread to the parapharyngeal space from four of the infected branchiogenic cysts. One sublingual abscess originated from an infected thyroglossal cyst. In 12 cases no sure etiologic factor could be found for the cervical abscess. However, in eight of these cases there was a history of previous upper respiratory infections
4 4
1
19
14 7 5 5 1
5
5
2
1 1 12
25
26
4
65
1
4
5
3
3 1 4
"0
4
3
1
6
....
~
1
with enlarged lymph nodes in the neck. Of these abscesses of unknown etiology, five were parapharyngeal, five submandibular and two sublingual. Other causes of the deep neck infections in the present material were tubercuiosis (one), metastasis of carcinoma (one) and infected acne (one). The survey of the 65 patients revealed that eight had been in a life-threatening condition during the course of the disease. Seven of these were found in the parapharyngeal space and one in the pharyngomaxillar space. In two cases the radiographic investigation revealed involvement of the mediastinum and a mediastinotomy was performed. However, suppuration was not found in the mediastinum in either case.
410
VIROLAINEN, HAAPANIEMI, AITASALO AND SUONPXA
The length of hospitalization was over 10 days in 22 cases and 6-10 days for 39 patients. The average length of hospitalization was 11 days.
Discussion Cervical infections of odontogenic ongIn are not uncommon. Fortunately, the thick fascia over the masticatory muscles may limit the spread of infection, although local swelling and pain is abundant. In the present material there was one pharyngomaxiIlary abscess which caused a life-threatening condition. This abscess developed after extraction of a tooth. Other odontogenic suppurative processes were limited to the submandibular and masticator spaces. The most common complication of acute tonsillitis is peritonsillar abscesso. However, infection may extend deeper in the neck without peritonsillar swelling. In this group the deep neck infections were most often found in the parapharyngeal space (7/9). After tonsillectomy the cervical abscess may originate from the infected tonsillar fossa. The five tonsillectomy patients in this series had undergone tonsillectomy with local anesthesia. It is possible that the needle puncture carried the bacteria to the deeper layers of the neck. In deep neck infections of traumatic origin there is usually a wound or laceration on the skin of head or neck7• However, a cervical abscess may also develop after trauma without any visible lesions on the skin. Three of our patients had such blunt trauma. This fact must be remembered in the diagnosis of traumatic cases with fever and persistent swelling. Idiopathic cervical abscesses originating from the degeneration of lymp nodes, secondary to upper respiratory infections may appear, especially in children. Usually these infections are in the submental or submandibular spaces. Although the etiology of
these infections remains unknown, the pathogen is most often a Gram-positive bacterium, usually a staphylococcus organism1 ,4,D. In our material there were 12 cases which did not appear to have a specific etiology. Staphylococcus aureus was cultured in five cases, Streptococcus hemolyticus in three cases and three cultures were negative. As a whole this group of abscess patients was younger than the others. Treatment of deep neck infections involves the removal of the causative agent, antibiotic therapy, incision and drainage. External incision and drainage under general anesthesia are preferred. The drainage of the pharyngomaxillar space may be difficult. During these operations the surgeon must be prepared for extensive hemorrhage. The cervical vessels may be weakened by a longlasting infection and could rupture after a sudden decrease in pressure. Antibiotic therapy alone is not sufficient in the treatment of the deep neck infections. Fifty-four of our 65 patients had received a course of antibiotics (penicillin in 45 cases) before they had been referred to the hospital. Bacteriological cultures were negative in 27 cases. This high percentage may be due to the wide preoperative treatment with antibiotics. Streptococcus hemo/yticus and Staphylococcus albus were the predominant organisms cultured. The hospitalization time of these patients is rather long and cervical abscesses cause a severe and often life-threatening disease. Early diagnosis is important, because there is usually no recourse except incision and drainage. The typical septicemia and pain provoked by turning of neck are diagnostic. Suspected cases must be referred to the hospital.
References 1. ADEKEYE, E. 0., BROWN, A. E. & ADEKEYE,
J.: Cervicofacial abscesses of unknown origin. Oral Surg. 1978: 45: 831-839.
DEEP NECK INFECfIONS 2. BECK, A. L.: Study of 24 cases of neck infection. Ann. Oto/. Rhinol. Laryngol. 1933: 42: 741-747. 3. BOEMER, L. C.: Great vessels in deep infections of the neck. Arch. Otolaryng. 1937: 25: 465--469. 4. BROOK, A. H. & WINT'ER, G. B.: Cervicofacial suppurative lymphadenitis due to staphylococcal infection in children. Br. J. Oral Surg. 1971: 8: 257-263. 5. FEDER, M. J., MARRA, L. M. & STRATIGOS, G. T.: Idiopathic submandibular and submental infections in children. J. Oral Surg. 1971: 29: 255-257. 6. JOKINEN, K., KAEJUAE, J. & NUUTINEN, J.: Nielun ja kaulan syvat tulehdukset. Duodecim 1975: 91: 1087-1091. 7. LIMONGELLT, W. A, OGLE, O. 0., CLARK, M. S. & WILLIAMS, A. C.: Fatal massive odema of the head and neck secondary to scalp laceration. J. Oral Surg. 1977: 35: 215-218.
411
8. NEW, G. B. & ERICH, J. B.: Deep infections of the neck. Surg. Clin. North Am. 1939: 18: 991-1003. 9. ROBBrNS, S.: Textbook of pathology. 2nd ed. Philadelphia, W. B. Saunders 1962, pp. 510-511, 10. SANDERS, B. G. & CROSTIlWATI'E, G.: Idiopathic cervical infections in children. J. Dent. Child. 1975: 42: 40--43. 11. WRIGHT, N. L.: Cervical infections. Am. J. Surg. 1967: 113: 379-389.
Address: J. SZlOnpiiii
Department of Otolaryngology Turku University Hospital KiinamyllYl1kalU 4 SF - 20520, Turku 52 Finland
Deep neck infections E. VIROLAINEN, J. HAAPANIEMI, K. AITASALO AND J. SUONPAA Department of Otolaryngology, TlIrkli University Hospital, Finland
From January 1967 to August 1978, 65 patients with cervical abscesses were referred to the ENT Clinic of Turku University Hospital. The origin of these deep neck infections was odontogenic in 19, tonsillitis or tonsillectomy in 14, trauma in seven, salivary glands in five and branchiogenic cysts in five and other known causes in three cases. In 12 cases the origin was unknown. The cervical abscesses of odontogenic origin were located mostly in the submandibular space (11/19). The rest of the deep cervical infections were mostly found in the parapharyngeal space (25/46). Etiological factors and treatment of these severe infections are discussed. ABSTRACT -
(Received for publication 17 November 1978, accepted 17 April 1979)
The possibility of dangerous, life-threatening complications of deep neck infections emphasizes the need for early diagnosis and treatment. The origin of cervical abscesses may be an inflammation or a tonsil, mucosa of the mouth and throat or salivary glands. Also branchiogenic cysts and trauma in the head and neck region may be complicated by deep neck infections. Further, such a severe condition may develop after surgical procedures on the head and neck region. Occasionally a cervical abscess appears to have no specific etiology2,5,lo,11. In the visceral spaces, typical of the anatomy of the neck, the infection may easily extend through soft areolar tissues into the mediastinum or up to the intracranial spaces. The most serious complications of these cervical infections are thrombosis of the internal jugular vein, rupture of the
carotid artery, mediastinitis and septicemia. Sudden spontaneous rupture of the abscess into the throat may also produce fatal consequences 2,S,6,8.
Material The material of the present study consists of 65 patients referred to the ENT Clinic of Turku University Hospital from January 1967 to August 1978. All these patients had deep cervical abscesses that were incised and evacuated by an external route. General anesthesia was used in all operations. Pus was obtained for bacteriologic culture and sensitivity tests from every abscess. Also the wall of the abscess and the necrotizing cervical tissue were biopsied for histological diagnosis. The age of the patients varied from 1.5 to 64 years and the mean was 27 years (Table 1). The visceral space in which the abscess was located was determined by the surgeon (Fig. 1).
0300-9785/79/060407-05$02.50/0 © 1979 Munksgaard, Copenhagen
VIROLAINEN, HAAPANIEMI, AITASALO AND SUONPAA
408
Table 1. Deep neck infections treated at the ENT Clinic, Turku University Hospital, from January 1967 to August 1978 Localization (visceral space)
Total
Mean age (years)
19
Mean hospitalization (days)
9
Masticator Pharyngomaxillar Parapharyngeal Submandibular Sublingual
4 25 26 4
29
10
Total
65
27
11
6
34 28 26
Results The origin of deep cervical infection was odontogenic in 19 (29 %) cases: 10 dental granulomas, four infections following extraction, three cases with severe caries, one dental cyst and one gingival erosion caused by a poorly fitting prothesis. Eleven of these abscesses were located in the submandibular space, six in the masticator space, one in the sublingual, and one in the pharyngomaxillary space (Table 2). Acute tonsillitis had been diagnosed in nine patients shortly before the cervical infection. In six of these cases the abscess was found in the parapharyngeal space. The sublingual, submandibular and masticator
aUCCOPHAAY FASCIA - - - -
SUPUIOft CONS RICTIO
13
14
8
Seriousness of the disease lifeconthreatsevere trolled ening 1
7
8
6 1
2 2 1
16 25
5
52
4
spaces were each the site of one abscess. Five of the patients had undergone tonsillectomy about 2 weeks before hospitalization. In these patients the deep infection was found in the parapharyngeal space three times and in the pharyngomaxillary space twice. Seven abscesses originated from trauma to the head and neck region. Three assaulted patients had no external wounds or erosions on the skin of the head and neck. Two of these abscesses were found in the submandibular space and one was located in the parapharyngeal space. Three patients developed abscesses after bicycle accidents, two of which were in the parapharyngeal space and one in the submandibular space.
o. PHARYNX snR OMAS 010
.--_.-.I ,fXl',~:-- MUSCLE
CARO 10 5 EATH
PRE -VI: RTf BAAL SCLES
RfTROPHAAYNG£A
Fig. 1. Visceral paces of the neck.
Sl'ACl:
DEEP NECK INFECTIONS
409
Table 2. Etiology and localization of the deep neck infections Etiology
Localization (visceral space)
j .... 0 .....
rJ
.~
c.s
~
Odontogenic - extraction - granulomas - caries - cysts - erosions Tonsils - tonsillitis (acute) - tonsillectomy Trauma Salivary glands Branchiogenic cysts Tuberculosis Acne Ca with metastasis Unknown Total
5
~
S
g bl)
I'l
::l .0
:.ad
Cil
d
~ .Q §<
.g
~
al
P-<
1;1 P-<
S
U)
!-<
0
bl)
~ .Q 1
oj
U)
::l
bl)
'§
5
1
10 3 1 1
1
9
2
7 2
1
One parapharyngeal abscess originated from a piece of straw stuck in the mucosa of the throat. In the latter case radiographic investigation also revealed involvement of the mediastinum. Salivary glands seemed to be the primary source of the deep neck infections in five cases. Four abscesses were located in the submandibular space and one in the parapharyngeal space. Infection spread to the parapharyngeal space from four of the infected branchiogenic cysts. One sublingual abscess originated from an infected thyroglossal cyst. In 12 cases no sure etiologic factor could be found for the cervical abscess. However, in eight of these cases there was a history of previous upper respiratory infections
4 4
1
19
14 7 5 5 1
5
5
2
1 1 12
25
26
4
65
1
4
5
3
3 1 4
"0
4
3
1
6
....
~
1
with enlarged lymph nodes in the neck. Of these abscesses of unknown etiology, five were parapharyngeal, five submandibular and two sublingual. Other causes of the deep neck infections in the present material were tubercuiosis (one), metastasis of carcinoma (one) and infected acne (one). The survey of the 65 patients revealed that eight had been in a life-threatening condition during the course of the disease. Seven of these were found in the parapharyngeal space and one in the pharyngomaxillar space. In two cases the radiographic investigation revealed involvement of the mediastinum and a mediastinotomy was performed. However, suppuration was not found in the mediastinum in either case.
410
VIROLAINEN, HAAPANIEMI, AITASALO AND SUONPXA
The length of hospitalization was over 10 days in 22 cases and 6-10 days for 39 patients. The average length of hospitalization was 11 days.
Discussion Cervical infections of odontogenic ongIn are not uncommon. Fortunately, the thick fascia over the masticatory muscles may limit the spread of infection, although local swelling and pain is abundant. In the present material there was one pharyngomaxiIlary abscess which caused a life-threatening condition. This abscess developed after extraction of a tooth. Other odontogenic suppurative processes were limited to the submandibular and masticator spaces. The most common complication of acute tonsillitis is peritonsillar abscesso. However, infection may extend deeper in the neck without peritonsillar swelling. In this group the deep neck infections were most often found in the parapharyngeal space (7/9). After tonsillectomy the cervical abscess may originate from the infected tonsillar fossa. The five tonsillectomy patients in this series had undergone tonsillectomy with local anesthesia. It is possible that the needle puncture carried the bacteria to the deeper layers of the neck. In deep neck infections of traumatic origin there is usually a wound or laceration on the skin of head or neck7• However, a cervical abscess may also develop after trauma without any visible lesions on the skin. Three of our patients had such blunt trauma. This fact must be remembered in the diagnosis of traumatic cases with fever and persistent swelling. Idiopathic cervical abscesses originating from the degeneration of lymp nodes, secondary to upper respiratory infections may appear, especially in children. Usually these infections are in the submental or submandibular spaces. Although the etiology of
these infections remains unknown, the pathogen is most often a Gram-positive bacterium, usually a staphylococcus organism1 ,4,D. In our material there were 12 cases which did not appear to have a specific etiology. Staphylococcus aureus was cultured in five cases, Streptococcus hemolyticus in three cases and three cultures were negative. As a whole this group of abscess patients was younger than the others. Treatment of deep neck infections involves the removal of the causative agent, antibiotic therapy, incision and drainage. External incision and drainage under general anesthesia are preferred. The drainage of the pharyngomaxillar space may be difficult. During these operations the surgeon must be prepared for extensive hemorrhage. The cervical vessels may be weakened by a longlasting infection and could rupture after a sudden decrease in pressure. Antibiotic therapy alone is not sufficient in the treatment of the deep neck infections. Fifty-four of our 65 patients had received a course of antibiotics (penicillin in 45 cases) before they had been referred to the hospital. Bacteriological cultures were negative in 27 cases. This high percentage may be due to the wide preoperative treatment with antibiotics. Streptococcus hemo/yticus and Staphylococcus albus were the predominant organisms cultured. The hospitalization time of these patients is rather long and cervical abscesses cause a severe and often life-threatening disease. Early diagnosis is important, because there is usually no recourse except incision and drainage. The typical septicemia and pain provoked by turning of neck are diagnostic. Suspected cases must be referred to the hospital.
References 1. ADEKEYE, E. 0., BROWN, A. E. & ADEKEYE,
J.: Cervicofacial abscesses of unknown origin. Oral Surg. 1978: 45: 831-839.
DEEP NECK INFECfIONS 2. BECK, A. L.: Study of 24 cases of neck infection. Ann. Oto/. Rhinol. Laryngol. 1933: 42: 741-747. 3. BOEMER, L. C.: Great vessels in deep infections of the neck. Arch. Otolaryng. 1937: 25: 465--469. 4. BROOK, A. H. & WINT'ER, G. B.: Cervicofacial suppurative lymphadenitis due to staphylococcal infection in children. Br. J. Oral Surg. 1971: 8: 257-263. 5. FEDER, M. J., MARRA, L. M. & STRATIGOS, G. T.: Idiopathic submandibular and submental infections in children. J. Oral Surg. 1971: 29: 255-257. 6. JOKINEN, K., KAEJUAE, J. & NUUTINEN, J.: Nielun ja kaulan syvat tulehdukset. Duodecim 1975: 91: 1087-1091. 7. LIMONGELLT, W. A, OGLE, O. 0., CLARK, M. S. & WILLIAMS, A. C.: Fatal massive odema of the head and neck secondary to scalp laceration. J. Oral Surg. 1977: 35: 215-218.
411
8. NEW, G. B. & ERICH, J. B.: Deep infections of the neck. Surg. Clin. North Am. 1939: 18: 991-1003. 9. ROBBrNS, S.: Textbook of pathology. 2nd ed. Philadelphia, W. B. Saunders 1962, pp. 510-511, 10. SANDERS, B. G. & CROSTIlWATI'E, G.: Idiopathic cervical infections in children. J. Dent. Child. 1975: 42: 40--43. 11. WRIGHT, N. L.: Cervical infections. Am. J. Surg. 1967: 113: 379-389.
Address: J. SZlOnpiiii
Department of Otolaryngology Turku University Hospital KiinamyllYl1kalU 4 SF - 20520, Turku 52 Finland