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Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2015 | Vol 33| Issue 1 | 61

ABSTRACT

The diagnosis and treatment of deep neckinfections is still an enigma for surgeons andphysicians. Because of the complexity and thedeep location of this region, the diagnosis andtreatment in this area is difcult. The anatomy ofdeep neck spaces is highly complex and therefore

precise localization of infections in this region isvery difcult. The diagnoses of deep neck spaceinfection (DNSI) are difcult because of the deeplocation of these spaces and are usually coveredby substantial amount of normal supercialsoft tissue. Access: To gain surgical access tothe deep neck spaces, the supercial tissuesmust be crossed with the risk of injury to theneurovascular structures in the neck. Neuraldysfunction, vascular erosion or thrombosis, andosteomyelitis are some of the complications ofDNSI because of the proximity of nerves, vessels,bones, and other soft tissues. Deep neck spaces

are communicated with each other and infectionsfrom one space can spread to adjacent space.DNSI, if not diagnosed early and promptly, mayresult in serious consequences even mortality. Thetreatment of DNSI with antibiotic therapy anddrainage is most often denitive and recurrenceof these cases is rare.

KEYWORDS: Deep neck space infections, incisionand drainage, submandibular space abscess

Bilateral deep neck space infection in pediatric patients:Review of literature and report of a case

Manish J Raghani, Nisha Raghani1

Department of Dentistry, Maxillofacial Surgery Services, All India Institute of Medical Sciences, 1Dental Surgeon, Raipur, Chhattisgarh, India

bilateral neck abscess in a 9-month-old male child isreported and the clinical presentation along with themanagement is discussed with a review of literature.

Case ReportA 9-month-old male child presented with a 3-4 dayshistory of fever, progressive swellings in both rightand left submandibular spaces and right buccal space.Clinical examination showed a non-toxic appearancewith a low-grade fever. The swelling was diffuse, softto rm in consistency, edematous red and tender,measuring 3 2 cms on left side, 4 3 cms on right,and a small 1 1 cms on right cheek besides the cornerof mouth. Mouth opening was adequate but no teethwere present (erupted) and no signicant nding whichcould relate to the swelling was found intraorally.Chest radiography revealed no abnormality, but thelaboratory studies showed a leukocyte count of 18,160/lwith neutrophil dominance and hemoglobin level of10 g/dl. Neck ultrasound identied bilateral abscessformation. Medicinal treatment started immediately inthe form of intravenous Ceftriaxone and Metronidazoleand hydration was maintained adequately. Butthere was no signicant clinical improvement withmedical management alone within rst 48 hours.Subsequently, incision and drainage of the bilateralsubmandibular abscesses was done extraorally. Feverand swelling subsided after surgical drainage and

Address for correspondence:Dr. Manish J Raghani,Department of Dentistry, Maxillofacial Surgery Services, AllIndia Institute of Medical Sciences, G. E. Road, Tatibandh,Raipur - 492 099, Chhattisgarh, India.E-mail: [email protected]

IntroductionDeep neck space infections (DNSIs) can occur at anyage but the pediatric deep neck infections requiremore intimate management because of their rapidlyprogressive nature.[1]Delay in diagnosis and treatmentmay lead to life-threatening complications. Theincidence and morbidity of DNSIs has been signicantlyreduced with the introduction of antibiotic therapy.Concurrent abscess in distinct neck spaces has rarelybeen reported in healthy children. Here, a rare case of

Case Report

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Raghani: Bilateral deep neck space infection in pediatric patients:Systematic review of literature and report of a case

Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2015 | Vol 33| Issue 1 |62

intravenous antibiotics. Due to uncommon occurrenceof such severe infection in infants, we tried to searchfor underlying etiology. According to the parents ofthe child, there was no history of any systemic illness.Peripheral blood lymphocyte subtypes and Ig A, Ig M,Ig G, Ig E levels were within normal limits. Serologicstudies for TOxoplasmosis, Rubella, Cytomegalovirusand Herpes (TORCH) simplex virus, Epstein-Barr

virus (EBV), hepatitis, and human immunodeciencyvirus (HIV) were negative. Evaluation for tuberculosisdid not show any abnormality. No clinical evidence ofan underlying immunocompromisation was detectedand the patient was discharged from the hospital withcomplete recovery after 2 weeks. Most likely, cause ofthe bilateral DNSI in this particular case could be theupper respiratory tract infection (Tonsillitis) because itis the most common etiology for DNSI in children.[2-5]

Discussion

DNSIs are infections in the potential spaces and facial

planes of the neck which could be lymphadenitis,cellulitis, necrotic node, or abscess in nature.[1,6]Beforethe advent of widespread use of antibiotics, 70% ofDNSIs were caused by spread from tonsillar andpharyngeal infections. Today, tonsillitis remains themost common etiology of DNSIs in children, whereasodontogenic origin is the most common etiology inadults.[2-5]

EtiologyCauses of deep neck infections include the following: Tonsillar and pharyngeal infections Dental infections or abscesses Oral surgical procedures or removal of suspension

wires Salivary gland infection or obstruction Trauma to the oral cavity and pharynx (e. g.,

gunshot wounds, pharynx injury caused byfalls onto pencils or popsicle sticks, esophageallacerations from ingestion of sh bones or othersharp objects)

Instrumentation, particularly from esophagoscopyor bronchoscopy

Foreign body aspiration Cervical lymphadenitis Branchial cleft anomalies Thyroglossal duct cysts Thyroiditis Mastoiditis with petrous apicitis and Bezold

abscess Laryngopyocele Intravenous (IV) drug use[7]

Necrosis and suppuration of a malignant cervicallymph node or mass

As many as 20-50% of deep neck infections have noidentiable source. Other important considerationsinclude patients who are immunosuppressed because ofHIV infection, chemotherapy, or immunosuppressant

drugs for transplantation. These patients may haveincreased frequency of deep neck infections andatypical organisms, and they may have more frequentcomplications.

Pathophysiology

DNSIs can arise from a multitude of causes. Whateverthe initiating event, development of a DNSI precedesby one of several paths, as follows: Spread of infection can be from the oral cavity,

face, or supercial neck to the deep neck space viathe lymphatic system.

Lymphadenopathy may lead to suppuration andnally focal abscess formation.

Infection can spread among the deep neck spacesby the paths of communication between spaces.

Direct infection may occur by penetrating trauma.

Once initiated, a deep neck infection can progress toinammation and phlegmon or to fulminant abscess

with a purulent uid collection.

The presenting symptoms and signs of the patientwith a DNSI, as well as the source of infection, willvary somewhat depending upon which of the spacesis involved. In a study reported by Coticchia et al.,the most commonly encountered sites of abscesses inthe head and neck region of pediatric patients wereretropharyngeal or parapharyngeal spaces, followedby anterior or posterior triangle and submandibularor submental regions, respectively. Retropharyngealor parapharyngeal involvement was more common in1-year-old children, or older, whereas submandibular orsubmental involvement was more common in children

younger than 1 year. However, there are differentresults, in different studies, in the literature regarding thedistribution of abscesses among the spaces of the neck.[8]

Ungkanont et al., reviewed 117 children treated fordeep neck infections during a 6-year period.[9]

The following distribution results were revealed: Peritonsillar infections (49%) Retropharyngeal infections (22%) Submandibular infections (14%) Buccal infections (11%) Parapharyngeal space infections (2%) Canine space infections (2%)

Abscesses of neck may involve many spacessimultaneously through the potential pathways ofextension as illustrated [Figure 1].

MicrobiologyThe microbiology of deep neck infections usuallyreveals mixed aerobic and anerobic organisms, oftenwith a predominance of oral ora. Both gram-positiveand gram-negative organisms may be cultured.Contemporary reports from different countries or


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areas may reveal different common pathogens.[1]Most studies have determined the predominance ofstreptococcus and Staphylococcusaureus as a causativeorganism although often infections are polymicrobial.On the other hand, the presence of anerobes may beunderestimated because of the difculty in culturingthem.[2] Streptococcus and normal oropharyngealora were more common in retropharyngeal and

parapharyngeal abscesses because these organismsare found in the oropharynx. Likewise, one wouldexpect Staphylococcus aureus to be more common inanterior and posterior triangle and submandibularand submental abscesses because this organism is acommon skin contaminant and these regions are moredistant from the oropharynx.[8]

Clinical PresentationA detailed history should be obtained from a patient ofdeep neck infection. Physical examination should focuson determining the location of the infection, the deepneck spaces involved, and any potential functional

compromise or complications that may be developing.A comprehensive head and neck examination should beperformed, including examination of the dentition andtonsils. The most consistent signs of a DNSI are fever,elevated white blood cell (WBC) count, and tenderness.Other signs and symptoms largely depend on theparticular spaces involved and include the following: Asymmetry of the neck and associated neck

masses or lymphadenopathy, which is present inalmost 70% of pediatric retropharyngeal abscessesaccording to a study by Thompson and colleagues

Medial displacement of the lateral pharyngealwall and tonsil caused by parapharyngeal spaceinvolvement

Trismus caused by inammation of the pterygoidmuscles

Torticollis and decreased range of motion of theneck caused by inammation of the paraspinalmuscles

Fluctuance that may not be palpable because ofthe deep location and the extensive overlying softtissueand muscles (e. g., sternocleidomastoid muscle)

Possible neural decits, particularly of thecranial nerves (e. g., hoarseness from true vocalcord paralysis with carotid sheath and vagalinvolvement), and Horner syndrome frominvolvement of the cervical sympathetic chain

Regularly spiking fevers (may suggest internaljugular vein thrombophlebitis and septicembolization)

Tachypnea and shortness of breath (may suggestpulmonary complications and warn of impendingairway obstruction)

Children with DNSIs have minimal signsand symptoms and also they do not verbalizetheir symptoms or cooperate with the physicalexamination.[8] The most common signs andsymptoms are a neck mass or swelling, fever,poor oral intake, and prior symptoms of an upperrespiratory infection such as rhinorrhea or cough.Other symptoms include: Neck pain, irritability,decreased neck mobility, sore throat, upper airway

obstructive symptoms, and febrile seizures. Inour case, the patient presented with bilateralsubmandibular soft swelling and low grade fever[Figures 2-4].

Computerized tomography (CT) scanning is themost widely used modality for diagnosing deepspace neck infections because it is less expensiveand readily available.[9]Although CT is helpful bothin determining the presence and location of neckinfections in children, it is less helpful in differentiatingabscess from lymphadenitis and cellulitis. On theother hand, use of magnetic resonance imaging(MRI) gives improved soft tissue denition without

the use of radiation but its use is limited due to thelack of availability and cost.[9,10] Ultrasonography isalso effective in identifying abscess versus cellulitis.The lateral neck plain X-ray lm has been used inthe past as a screening X-ray to look primarily at theretropharyngeal and prevertebral spaces.

Figure 1:Network of patterns of infectious extension within thepotential spaces of the neck (from Gadre et al., 2006 15)[13]

Figure 2:Bilateral submandibular swellings (abscess) also a smallswelling over right buccal region


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Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2015 | Vol 33| Issue 1 |64

TreatmentThe mainstays for successful management of deepneck infections are securing airway, antibiotics, andsurgical drainage. Antibiotics are not substitute forsurgery and incision and drainage are consideredthe gold standard for the majority of pediatric deepneck abscesses.[11] Because of the different causativeorganisms, broad-spectrum antibiotics are advocatedin treating deep neck infections.[1]Empirical parenteralantibiotics should be started before the culture resultsbecome available and then tailored to the culture resultswhen available. Fortunately, most pediatric DNSIs arelocated either in the anterior or posterior triangle of theneck or in the retropharyngeal area. Surgical drainageof these abscesses is usually direct and effective.[12]Needle aspiration of abscess can be used in some cases

but it is not much effective and may require recurrentaspirations. In my case, we there was no clinicalimprovement after antibiotics so I performed externalincision and drainage in which pus was evacuated anddiagnosis of abscess was conrmed. The postoperativerecovery was uneventful.

Conclusion

The treatment of DNSIs with antibiotic therapy anddrainage is most often denitive and recurrence ofthese cases is rare. The exception to this rule is thedeep neck infection that occurs in association with apre-existing congenital abnormality. So that, in thepatient that presents with a prior history of a similardeep neck infection or abscess, the level of suspicionshould be raised for an underlying lesion. Imaging,particularly CT scan, can be extremely helpful inmaking the diagnosis in these cases. In a review of12 cases of recurrent deep neck infection, Nusbaumet al., found the most common underlying congenitalanomaly to be a second branchial cleft cyst. Othercauses included rst, third, and fourth branchial cleftcysts, lymphangiomas, thyroglossal duct cysts, and acervical thymic cyst.

Bullet points

Why this paper is important to pediatric dentists?

This paper (article) describes the details of the deepneck infections in pediatric patients including variousetiologies, pathophysiology, clinical manifestations,and treatment of these patients. The etiology isfrequently from oral cavity (carious tooth) and thesubmandibular space is involved in most of the cases,so the pediatric dentist is usually the rst person to seethese patients. The purpose of writing this article inthis journal is that the pediatric dentist should be ableto diagnose the deep neck infections cases early andpromptly, so that proper treatment should be startedas early as possible to avoid dangerous consequencesand even mortality.

The case described here is a very small child (9 monthsold) for which a pediatric dentist or a maxillofacialsurgeon can be called upon in a hospital to attendand manage the case. In dentistry, we rarely see suchpatients, so I thought of worth mentioning it here.I think this would be of some help to our pediatricdentist friends.

References

1. Huang TT, Tseng FY, Yeh TH, Hsu CJ, Chen YS. Factors

affecting the bacteriology of deep neck infection: A retrospective

study of 128 patients. Acta Otolaryngol 2006;126:396-401.

2. Conrad DE, Parikh SR. Deep neck infections. Infect Disord

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3. Chang L, Chi H, Chiu NC, Huang FY, Lee KS. Deep neck

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4. Wang LF, Tai CF, Kuo WR, Chien CY. Predisposing factors

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5. Poeschl PW, Spusta L, Russmueller G, Seemann R, Hirschl A,

Poeschl E, et al. Antibiotic susceptibility and resistance of the

odontogenic microbiological spectrum and its clinical impact

Figure 3:The swelling was soft and tender with inammed, red, tense,shiny skin showing all signs of acute abscess Figure 4:Bilateral neck swellings (submandibular abscesses)


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How to cite this article:Raghani MJ, Raghani N. Bilateral deep

neck space infection in pediatric patients: Review of literature

and report of a case. J Indian Soc Pedod Prev Dent 2015;33:61-5.

Source of Support:Nil, Conflict of Interest:None declared.

on severe deep space head and neck infections. Oral Surg Oral

Med Oral Pathol Oral Radiol Endod 2010;110:151-6.

6. Courtney MJ, Miteff A, Mahadevan M. Management of

pediatric lateral neck infections: Does the adage ... never let

the sun go down on undrained pus ... hold true? Int J Pediatr

Otorhinolaryngol 2007;71:95-100.

7. Daramola OO, Flanagan CE, Maisel RH, Odland RM.

Diagnosis and treatment of deep neck space abscesses.

Otolaryngol Head Neck Surg 2009;141:123-30.8. Coticchia JM, Getnick GS, Yun RD, Arnold JE. Age-, site-,

and time-specic differences in pediatric deep neck abscesses.

Arch Otolaryngol Head Neck Surg 2004;130:201-7.

9. Osborn TM, Assael LA, Bell RB. Deep space neck infection:

Principles of surgical management. Oral Maxillofac Surg Clin

North Am 2008;20:353-65.

10. Caccamese JF Jr, Coletti DP. Deep neck infections: Clinical

considerations in aggressive disease. Oral Maxillofac Surg

Clin North Am 2008;20:367-80.

11. Meyer AC, Kimbrough TG, Finkelstein M, Sidman JD.

Symptom duration and CT ndings in pediatric deep neck

infection. Otolaryngol Head Neck Surg 2009;140:183-6.

12. Naidu SI, Donepudi SK, Stocks RM, Buckingham SC,

Thompson JW. Methicillin-resistant Staphylococcus

aureus as a pathogen in deep neck abscesses: A

pediatr ic case series. Int J Pediatr Otorhinolaryngol

2005;69:1367-71.

13. Gadre AK, Gadre KC. Infections of the deep spaces of theneck. In: Bailey BJ, Johnson JT, Newlands SD, editors. Head

and Neck Surgery: Otolaryngology. 4th ed. Philadelphia:

Lippincott, Williams and Wilkins; 2006. p. 668-82.

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