By Brett A. Miles, DDS MD
Larry Myers, MD, faculty sponsor
“The management of infection in the neck continues to call for the surgeon's best judgment, his best skills, and often all his courage.”
~Harris B Mosher - 1929 address to the American Academy of Otolaryngology
INTRODUCTION
The management of deep cervical infections continues to challenge surgeons despite the progress of medicine over the last 100 years. Historically, these infections were notoriously difficult to treat and frequently lethal. Advances in diagnostic imaging, antimicrobial therapy, surgical techniques, and the emergence of intensive care units have lead to decreased morbidity and mortality from head and neck infections. Unfortunately however, these severe infections remain lethal today and continue to be a significant source of morbidity to the afflicted patient.
DIAGNOSTIC CONSIDERATIONS
The history and physical examination remains an integral part of the evaluation of the patient when an infection is suspected in the head and neck region. Commonly reported signs and symptoms include sore throat, odynophagia, dysphagia, neck swelling, neck pain, fever, and general malaise. Ominous signs include severe trismus, drooling, hoarseness, neck stiffness or immobility, and stridor or frank airway obstruction. Systemic toxicity or sepsis with spiking fevers, tachycardia and hemodynamic instability may ensue. Suspicion of infection within the soft tissues of the head and neck should prompt appropriate radiographic evaluation, often plane radiographs followed by computed tomography with IV contrast, provided that the patient is stable enough to undergo imaging procedures. Radiographic imaging is critical for accurate localization of involved areas as a significant proportion of patients with infection in the soft tissues of the head and neck have multiple space involvement at the time of presentation.1-3 Proper imaging also allows for surgical planning and provides a baseline study to monitor improvement after the selected treatment is initiated. Other imaging modalities such as, MRI, or ultrasound may be considered for special situations.4-9
ETIOLOGY
There are numerous reported etiologies of infection afflicting patients in the head and neck region. Cutaneous flora, mucosal flora, oral flora/dental pathogens, salivary gland pathogens, malignancy, foreign body, contaminated traumatic injuries are common sources of infection. Various congenital anomalies such as brachial cleft cysts or fistulae are additional sources. The most common etiologies of infection in the head and neck in an adult patient are odontogenic sources and sequelae to upper respiratory infections. In pediatric patients upper respiratory pathogens are the predominate source of infection.1, 3, 10, 11 Paramount to effective surgical therapy and empiric antimicrobial selection is determining the source of the infection. Historical data such as recent upper respiratory tract infections, sore throat, recent dental work/surgery, acute/chronic sinusitis, or traumatic injury should be elicited from the patient in order to pinpoint possible infectious sources.
MEDICAL MANAGEMENT
Approximately 35-62% of infections of the deep spaces of the neck are polymicrobial in nature. Common pathogens include Streptococcus viridans, B-hemolytic streptococcus, Staphylococcus, Klebsiella pneumoniae, Bacteroides, and Peptostreptococcus.12, 13 Additionally, antibiotic resistance is often seen associated with infection of the deep cervical spaces.14 Therefore, empiric antibiotic regimens should be broad-spectrum and include clindamycin, ampicillan/metronidazole, ampicillan/sulbactam, piperacillin/tazobactam, or second/third generation cephalosporins such as cefuroxime or cefotaxime. Appropriate culture and sensitivity should be obtained and additional agents such as vancomycin, gentamycin, imipenim, ertapenim, etc. may be added to the regimen if necessary. Additional laboratory studies such as WBC count, blood cultures, ESR, and sedimentation rate may be obtained but often do not alter management strategies and have limited utility in most cases.3, 12, 13, 15, 16 Appropriate medical consultation should be obtained for patients who have medical co-morbidities complicating their disease state such as diabetes, malignancy, immunosuppression, uremia, or other chronic disease states. Medical diseases of this type have been shown to lead to increased morbidity and mortality when associated with deep cervical infection and the appropriate management of these illness is critical.15, 17-19
SURGICAL MANAGEMENT
Surgical therapy remains one of the key components of successful treatment of surgical infections. The importance of adequate drainage of infected spaces and debridement of infected tissue cannot be overstated. Appropriate surgical management of deep neck infections is predicated on a comprehensive understanding of the anatomy of the head and neck. Deep cervical infections have potentially devastating consequences due to the ability of infection to spread rapidly within the spaces of the neck. This fact is facilitated by contiguous anatomical planes, known as fascial planes, which lead to rapid spread of infection from an involved space to an adjacent space within the soft tissues of the neck. Additionally, these potential spaces limit antimicrobial penetration and availability during treatment. Fascial planes are defined, anatomical, potential spaces dictated by the connective tissue and surrounding musculature within the neck and mediastinum. Anatomical spaces within the neck include the sublingual, submental, submandibular, submasseteric, pterygomandibular/masticator, infratemporal/temporal, lateral and retropharyngeal, and prevertebral spaces. A thorough anatomical understanding of these spaces is paramount to the appropriate surgical therapy of infections within the head, neck, and mediastinum. Surgical drainage of the involved as well as adjacent spaces is required for adequate surgical therapy.2, 10, 12, 20 Generally, surgery consists of skin incisions placed within cosmetically acceptable locations followed by blunt dissection and drainage of the infected space as well as adjacent spaces which may be potentially involved. When the infection is especially complicated the techniques of formal neck dissection may be employed to avoid damaging critical structures and allow appropriate drainage of the affected area. Irrigating drains are placed which are subsequently removed when the patient is improving clinically and the drainage is no longer significant. Repeat imaging with computed tomography should be considered in all cases which do not respond to initial therapy as expected, or if suspicion exists that the abscess has re-accumulated or was inadequately drained initially. Additional surgical explorations should be performed as needed if the clinical condition of the patient continues to worsen.
SPECIAL SITUATIONS
Ludwig's Angina
Ludwig's angina is a severe, life threatening infection characterized by bilateral submandibular and sublingual space involvement with airway compromise. Originally described by Von Ludwig in 1836 as “cellulitis and soft tissue infection surrounding the mandibular glands...” the term angina refers to the choking sensation related to impending airway obstruction. Clinical characteristics of Ludwig's angina include cellulitis of the neck, trismus, inability to handle secretions, floor of mouth elevation, and eventual airway compromise. Management of the airway continues to be a significant challenge when treating patient's with Ludwig's angina. In a study examining tracheostomy and intubation in the treatment of Ludwig's angina approximately 55% of attempted intubations failed requiring “slash” tracheostomy. Overall, 75% of cases of Ludwig's angina required tracheostomy including emergent procedures.13 While traditional anesthesia airway management techniques may be utilized in selected cases, formal awake local tracheostomy remains the airway management technique of choice and should be considered early in the algorithm when treating patients with this condition. Incision and drainage of infected fascial spaces in Ludwig's angina follows the surgical principals of all cervical infections as noted above. The etiology of Ludwig's angina is an infected tooth in nearly 90% of cases, therefore dental evaluation and extraction of the offending tooth is an important part of appropriate therapy.21 Other causes include submandibular sialadenitis or cervical lymphadenitis. Bilateral submandibular and sublingual spaces should be explored as well as all adjacent involved spaces. It should be noted that despite current management the diagnosis of Ludwig's angina continues to carry a reported mortality rate of approximately 60% in the literature.10, 11, 17, 21, 22
Necrotizing Fasciitis
Although more commonly involving the abdomen, groin/perineum or distal extremities, necrotizing fasciitis is a devastating disease when manifested within the head and neck region. Necrotizing fasciitis is characterized by severe, rapidly spreading soft tissue infection with extensive necrosis of the subcutaneous tissue and underlying fascia and muscle. The widespread soft tissue infection is often quickly followed by systemic toxicity and septic shock. Necrotizing fasciitis is extremely difficult to treat effectively due to the rapid progression of disease and is frequently fatal. Early in the disease process, patients often present with seemingly innocuous findings on clinical exam and in fact the disease is characterized by significant pain and systemic signs such as fever and tachycardia which are elevated out of proportion to the clinical examination findings. Due to the rapidity of the soft tissue involvement, the zone of infection/inflammation is often poorly defined, with lack of traditional manifestations of infection such as necrosis, erythema, or purulent drainage. As the soft tissue involvement progresses however, distinct zones of extremely tender erythematous tissue, followed by frank necrosis, are hallmarks of this disease. Multiple aerobic/anaerobic microbial pathogens have been implicated in the literature regarding necrotizing fasciitis. Group A beta-hemolytic streptococcus, Viridans streptococcus, and Staphylococcus aureus are commonly isolated pathogens, as well as various other species including Clostridium perfringens, Eikenella, Bacteroides, Pseudomonas, Enterobacter, and Prevotella. The extensive dermal, fascial, and myonecrosis are thought to be related to bacterial pathogenicity from production of streptococcal mucopeptides, hyaluronidase, collagenases which lead to small vessel thrombosis and tissue destruction.14, 16, 23-26 27 Necrotizing fasciitis has been reported after odontogenic infections/dental extractions, tonsillectomy, incision and drainage of tonsillar abscess, facial fractures, lacerations, insect bites, and various surgeries/traumatic injuries. Several cases have been reported with no inciting event or discoverable source leading to the disease.28-36 Necrotizing fasciitis is often complicated by medical co-morbidity with chronic alcoholism, diabetes, malignancy, and immunocompromised states being the most prominent.23, 32, 35, 37 The diagnostic workup of necrotizing fasciitis is primarily clinical. Cultures and gram stain are of limited utility due to the polymicrobial nature of the infection and the rapid progression. Surgical therapy should not be delayed pending culture results when the diagnosis of necrotizing fasciitis is suspected. If the patient is stable, computed tomography with intravenous contrast should be obtained early in the course of the disease to evaluate the extent of the infectious process. Often soft tissue involvement will be underestimated clinically and accurately diagnosing involved tissues is critical in the treatment of this disease. Repeat CT scanning is often necessary to ensure adequate surgical debridement.38 Approximately 50-73% will have gas present in the soft tissues on examination or CT scan.26, 27, 39-41 Radiographic features of necrotizing fasciitis include diffuse thickening and infiltration of the dermis and subcutaneous tissue, diffuse enhancement and/or thickening of the superficial and deep cervical fasciae(fasciitis), enhancement and thickening of the platysma, sternocleidomastoid muscle, or strap muscles(myositis), and fluid collections in multiple neck compartments. Other commonly observed CT findings include, mediastinitis, and pleural or pericardial effusions. Computed tomography of the chest is indicated in all cases of cervical necrotizing fasciitis as approximately 50% of patients may exhibit thoracic involvement.26, 34, 36, 42 Involvement of the lower cervical region or chest should prompt immediate consultation with general/thoracic surgeon. Wide surgical excision of all affected soft tissues is the primary treatment modality for necrotizing fasciitis. Extensive cutaneous, fascial, and muscular structures often require excision resulting in reconstructive challenges. Sacrifice of involved vessels, nerves and other critical structures may be required during surgery in order to halt disease progression.40 More often than not, multiple surgical interventions are required to adequately treat necrotizing fasciitis.43, 43, 44 It has been suggested that frozen section analysis be utilized to ensure adequate excision of involved tissue.45 Mortality with necrotizing fasciitis has been reported to range from 12-30% with current therapy.27, 40, 41, 46, 47 Further, delay in diagnosis or treatment is statistically associated with increased mortality.26, 31, 39, 43, 43, 47 Some authors have suggested a slight decrease in mortality when multiple/staged surgical procedures are performed.26, 41 Broad spectrum antibiotic therapy such as the extended spectrum penicillins (i.e. ticaricillan, piperacillin) in combination with an aminoglycocide and metronidazole should be instituted immediately when the diagnosis of necrotizing fasciitis is suspected. Formal culture results indicating a specific organism may drive changes in antimicrobial selection however necrotizing fasciitis is generally polymicrobial in nature.43 23, 32, 35, 37 26, 31, 39, 43, 47 Control of co-existing medical disease during treatment is also a priority.23, 32, 35, 37 Some authors have reported on the use of hyperbaric oxygen therapy for necrotizing fasciitis with promising results.26, 26, 27, 34, 36, 39, 40, 42, 48, 49 HBO may offer enhanced oxygen delivery to affected tissues and promote host responses which are beneficial for healing. HBO is often difficult to obtain emergently at most medical centers however and at the current time this therapy has not been completely accepted due to lack of controlled evidence showing a clear benefit in the treatment of necrotizing fasciitis.
COMPLICATIONS
Descending Mediastinitis
Descending mediastinitis is a dreaded complication of cervical space infection. Infection from the neck may rapidly penetrate the cervical or prevertebral fascial planes allowing infection to spread to the mediastinum. Evaluation with computerized tomography is critical to assess extent of infection as nearly 40-50% of patients with mediastinitis are the result of extension of cervical infection.44, 49-51 Recognition and prompt therapy for this condition is extremely important as involvement of this space is ominous and associated with a mortality rate approaching 31-50%.26, 34, 36, 42 Interestingly, there exists a disproportionate number of males afflicted with descending mediastinitis (6:1 according to some authors) the cause of which remains unknown.44, 49-51 Consultation with the general/thoracic surgeon is often warranted in the management of cervical infections and is paramount if the diagnosis of descending mediastinitis is suspected. In a meta-analysis, Langford et al. distinguished between mediastinitis (i.e. esophageal perforation) and descending necrotizing mediastinitis related to cervical infection. In this report the authors found cervical drainage alone was associated with a mortality of 47% as compared to 19% when mediastinal drainage was added.<.05). The authors stated “Although transcervical drainage is usually effective in the treatment of acute mediastinitis due to a cervical esophageal perforation, this approach in the patient with descending necrotizing mediastinitis fails to provide adequate drainage and predisposes to sepsis and a poor outcome. In addition to cervical drainage, aggressive, early mediastinal exploration--debridement and drainage through a subxiphoid incision or thoracotomy is advocated to salvage the patient with descending necrotizing mediastinitis”.44, 49, 52 Mediastinal/thoracic extension of cervical infection may result in empyema or pericarditis. Pericarditis associated with descending mediastinitis was associated with a mortality approaching 100%. Imaging of a suspected empyema/pericarditis includes chest radiographs and computed tomography of the chest. Some authors have utilized Indium labeled WBC scans adjunctively. Consultation with the thoracic surgeons should be obtained. Generally, empyema may be treated with formal thoracotomy.53 Surgical interventions include neck drainage, tracheostomy, thoracotomy, and pericardiotomy. Most authors recommend aggressive surgical management in treating mediastinal complications resulting from head and neck infections.20, 20, 52, 54 Jugular Vein Thrombosis Internal jugular vein thrombosis is a rare, but potentially life-threatening, condition which may occur in the setting of cervical infection. The classic triad predisposing to intravascular thrombosis was described by Virchow and includes endothelial damage, alteration in blood flow, and a hypercoagulable state which are present in the state of infection. Etiologies including oropharyngeal infection(Lemierre syndrome), deep neck infections, IVDA, central venous catheterization and mastoiditis have been reported in the literature.13, 20, 37, 54 Clinical findings may be subtle however fever, leukocytosis, cervical pain, neck mass, cord sign below the sternocleidomastoid muscle, sepsis, and pleuropulmonary complications have been reported in patients with internal jugular vein thrombosis.55 13, 20, 37, 54 The diagnosis of internal jugular vein thrombosis is usually confirmed with Doppler ultrasound or computed tomography scans with intravenous contrast. Ultrasonographic findings include a dilated and incompressible vein, intraluminal clot (a late finding), and lack of response to the Valsalva maneuver (expected change in intraluminal volume secondary to enhanced venous return). Ultrasonography is less accurate when the area under the mandible or clavicle is examined and therefore computed tomography with intravenous contrast is considered by many to be the study of choice for suspected internal jugular thrombosis. CT scan findings include low-density intraluminal thrombus, a sharply defined bright vessel wall (contrast uptake by the vasa vasorum), soft tissue swelling surrounding the internal jugular vein, and a distention of the vein proximal to the thrombus.9 The treatment of internal jugular vein thrombosis includes removal of catheters (if present) with prolonged antibiotic therapy specifically ticarcillin-clavulanate or ampicillin-sulbactam with clindamycin, metronidazole, or chloramphenicol used as alternatives. Duration of intravenous therapy is generally 4-6 weeks. In addition, many authors have recommended anti-coagulant/thrombolytic therapy, especially with the presence septic emboli, pulmonary emboli, or continued clot propagation, although the necessity of this adjunct has not been definitively evaluated in the literature.13, 20, 37, 54-57 In most cases, surgical therapy is rarely indicated when addressing internal jugular vein thrombosis however this assumes adequate surgical management of the underlying etiology. Carotid artery occlusion/aneurysm Carotid artery occlusion/aneurysm is a rare but serious complication of cervical infections. Prompt recognition and treatment of the involved carotid artery are critical to avoid potentially devastating neurologic injury. Clinical signs include pulsetile neck mass, neurological symptoms/deficits, and audible bruits within the neck.56, 58 The diagnosis of carotid artery occlusion/aneurysm is confirmed with traditional vascular imaging modalities such as Doppler ultrasound, computed tomography, MRA, and formal arteriography. Confirmed diagnosis of a carotid artery complication should prompt immediate consultation with a vascular surgeon or neurosurgeon depending on the clinical situation. Management strategies include both endovascular and open surgical techniques. Formal ligation of the carotid artery has been performed as well although with inherent risk.59-62 Reported treatment benefits of endovascular modality include shorter convalescent and less procedural-related complications, however some authors still prefer to definitively manage carotid artery complications with open surgical techniques.63, 64 <p/>
Jugular Vein Thrombosis
Internal jugular vein thrombosis is a rare, but potentially life-threatening, condition which may occur in the setting of cervical infection. The classic triad predisposing to intravascular thrombosis was described by Virchow and includes endothelial damage, alteration in blood flow, and a hypercoagulable state which are present in the state of infection. Etiologies including oropharyngeal infection(Lemierre syndrome), deep neck infections, IVDA, central venous catheterization and mastoiditis have been reported in the literature.13, 20, 37, 54 Clinical findings may be subtle however fever, leukocytosis, cervical pain, neck mass, cord sign below the sternocleidomastoid muscle, sepsis, and pleuropulmonary complications have been reported in patients with internal jugular vein thrombosis.55 13, 20, 37, 54 The diagnosis of internal jugular vein thrombosis is usually confirmed with Doppler ultrasound or computed tomography scans with intravenous contrast. Ultrasonographic findings include a dilated and incompressible vein, intraluminal clot (a late finding), and lack of response to the Valsalva maneuver (expected change in intraluminal volume secondary to enhanced venous return). Ultrasonography is less accurate when the area under the mandible or clavicle is examined and therefore computed tomography with intravenous contrast is considered by many to be the study of choice for suspected internal jugular thrombosis. CT scan findings include low-density intraluminal thrombus, a sharply defined bright vessel wall (contrast uptake by the vasa vasorum), soft tissue swelling surrounding the internal jugular vein, and a distention of the vein proximal to the thrombus.9
The treatment of internal jugular vein thrombosis includes removal of catheters (if present) with prolonged antibiotic therapy specifically ticarcillin-clavulanate or ampicillin-sulbactam with clindamycin, metronidazole, or chloramphenicol used as alternatives. Duration of intravenous therapy is generally 4-6 weeks. In addition, many authors have recommended anti-coagulant/thrombolytic therapy, especially with the presence septic emboli, pulmonary emboli, or continued clot propagation, although the necessity of this adjunct has not been definitively evaluated in the literature.13, 20, 37, 54-57 In most cases, surgical therapy is rarely indicated when addressing internal jugular vein thrombosis however this assumes adequate surgical management of the underlying etiology.
Carotid artery occlusion/aneurysm
Carotid artery occlusion/aneurysm is a rare but serious complication of cervical infections. Prompt recognition and treatment of the involved carotid artery are critical to avoid potentially devastating neurologic injury. Clinical signs include pulsetile neck mass, neurological symptoms/deficits, and audible bruits within the neck.56, 58 The diagnosis of carotid artery occlusion/aneurysm is confirmed with traditional vascular imaging modalities such as Doppler ultrasound, computed tomography, MRA, and formal arteriography. Confirmed diagnosis of a carotid artery complication should prompt immediate consultation with a vascular surgeon or neurosurgeon depending on the clinical situation. Management strategies include both endovascular and open surgical techniques. Formal ligation of the carotid artery has been performed as well although with inherent risk.59-62 Reported treatment benefits of endovascular modality include shorter convalescent and less procedural-related complications, however some authors still prefer to definitively manage carotid artery complications with open surgical techniques.63, 64
CONCLUSION
The management of infections within the cervical space continues to be a challenge. Clinical examination, correct empiric antibiotic selection, and appropriate surgical intervention are the cornerstones of proper management of deep cervical infections. Proper radiologic evaluation is paramount to properly diagnose the extent of infection and improves surgical treatment planning. Airway management techniques are an important part of the management of infection within the neck. Necrotizing fasciitis represents a special situation which may require aggressive, staged surgical resections of involved tissue to avoid devastating outcomes. Early recognition of complications resulting from deep cervical infections along with appropriate consultation is critical in the management of patients with cervical space infections.
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