Surgical multidisciplinary approach in the management of odontogenic or non-odontogenic neck infections
In recent years, in our university hospital, the number of odontogenic and non-odontogenic abscesses has been rapidly increasing. We included 70 patients from January 4th 2018 to February 19th 2020 affected by the odontogenic ones. Deep neck infection can spread to the chest and is associated with high morbidity and mortality. The purpose of this mini-review is to demonstrate that, in case of complications, a multidisciplinary approach is needed to treat these infections, so that all practitioners should work together to achieve the patient’s rapid recovery.
Dental infections are very common and are mainly due to dental caries. They affect mostly men, between the third and fifth decades, with underlying systemic disease (as diabetes), from a rural background, with poor oral hygiene and lack of dental care 1-3. The clinical progression of these infections can lead to the appearance of an abscess. Deep neck abscesses of non-dental origin can be caused by peritonsillar or retropharyngeal abscess, sialoadenitis, epiglottitis, cervical lymphadenitis, jugular intravenous drug use and trauma, as well as iatrogenic causes including infection of surgical wounds 4. The abscesses have many complications that affect the head-neck district. They are potentially lethal, and consist of upper airway obstruction, mediastinitis, necrotizing fascitis, thoracic empyema, jugular vein thrombosis, sepsis, orbital abscess and osteomyelitis 5-8.
With the advent of modern antibiotics, the mortality rate associated with complications has significantly decreased 8. The treatment of complications often requires a multidisciplinary surgical approach that can involve the otolaryngologist, the dentist, the maxillofacial and thoracic surgeons and sometimes the general surgeon.
Odontogenic neck infections
As Buckley et al., in the last few year, we have seen an increasing number of patients who went to the emergency room for neck abscesses due to dental infections 2. The bacteria responsible for dental infection are often the ones of the dental plaque. In fact, Buckley 2 and Prabhu et al. 9 proved, from the pus samples, that Streptococcus Spp and Staphylococcus Aureus were the most common bacteria found. WHO Global Oral Health Data Bank reports that dental caries is still a major health problem in most industrialized countries as it affects 60-90% of school-aged children and the vast majority of adults 10. It is one of the most frequent causes of consultation on dental issues. In most cases the origin of the infections are the inferior molars, and the periapical periodontitis is determined by caries in 90% of cases. (Figs. 1, 2) As Martins and Chagas said in their paper review, when the infections are immediately localized and diagnosed, the treatment is based on dental care such as endodontic therapy or removal of the infected part, usually one or more teeth, combined with specific antibiotic therapy, if necessary 11.
Pulp necrosis, caused by dental caries, represents the most common way of diffusion. The bacteria responsible for the caries, after causing septic pulpitis and pulp necrosis, reach the periapical region through the root canal region 12. Pulp necrosis can also be caused by periodontal diseases: the periapical region’s contamination happens after the propagation of the infective process through a deep periodontal pocket 13. It is even possible a retrograde contamination of the apex: infective processes, passing through surrounding anatomical structures (for example a maxillary sinusitis or a cystic infected lesion), can extend to the periapical region of the adjacent tooth, causing its necrosis. Therefore, it is necessary to check the vitality of the teeth that could have been infected.
Regarding pericoronitis, the incomplete eruption of a tooth can promote the bacterial proliferation in the region between the crown of the tooth and the surrounding soft tissues. In case of more aggressive forms, it can extend to the outlying tissues 14.
Typical signs and symptoms of cervical complications from dental origin are fever, neck mass, lymphadenopathy, trismus and odynophagia. It is important to support clinical diagnosis with contrast-enhanced CT imaging and ultrasound.
Non-odontogenic neck infections
Deep neck infections of non-dental origin are mainly due to peritonsillar abscesses, adenoiditis, epiglottitis, sialadenitis and otomastoiditis. Peritonsillar abscess is the most common deep infection of the head and neck. Most cases are consequences of recurrent or chronic bacterial tonsillitis, leading to abscesses in the parapharyngeal space. It is most common in patients 20-40 years of age, with no gender predilection. Although rare in childhood, peritonsillar abscess has a greater risk of airway obstruction in paediatric population than in adults. Patients may present with changes in voice, odynophagia, drooling, dysphagia, trismus, and systemic symptoms such as malaise and fever. The most common pathogens are β-Haemolytic Streptococcus, Pneumococcus, Staphylococcus aureus and Haemophilus inﬂuenzae. Infection, that penetrates the fibrous tonsillar capsule and the peritonsillar space, may continue to extend into the masticator, parapharyngeal, or submandibular space. Imaging is not performed routinely as the diagnosis is clinical. However, CT with contrast agent is used if the diagnosis is uncertain, and typically shows fluid density with peripheral enhancement adjacent to an inflamed tonsil.
Infections of the retropharyngeal space generally result from the spread of infection from one site with a primary drainage route to the lymph nodes of the retropharyngeal space. In these cases, the causes can be otitis, pharyngitis, tonsillitis and infections of the oral cavity 5.
An abscess occupying the retropharyngeal space can also derive from adenoiditis. The retropharyngeal lymph nodes affected by the infection become enlarged and suppurate. On contrast-enhanced CT, a retropharyngeal abscess appears as a collection of low attenuating fluids that dilates the retropharyngeal space with enhancement of the peripheral border (Fig. 3).
Deep neck infections may also be due to sialadenitis, that are multifactorial diseases that can be acute or chronic. The most frequent cause of purulent sialadenitis is sialolithiasis. Salivary duct stones are present in sialadenitis which involves approximately 10-20% of parotid glands and 80-90% of the submandibular glands. Since obstruction of the salivary duct plays a significant role in sialadenitis, most cases occur in the submandibular glands, which are most frequently affected by sialolithiasis. CT is one of the main modalities for evaluation for sialadenitis and can demonstrate an enlarged salivary gland with increased attenuation, increased enhancement poorly defined borders, surrounding fat stranding, lymphadenopathy, and thickening of platysma and adjacent cervical fascia. Ultrasound is a valid alternative even if it turns out to be a less accurate examination. MRI makes it possible to distinguish acute and chronic sialadenitis.
The submaxillary gland can be the origin of an infectious process that reaches the perivisceral space directly or remains confined to the submaxillary lodge itself 15. The different evolution depends on some anatomical variants. The middle cervical fascia can completely circumscribe the submaxillary lodge separating it from the perivisceral space. In other cases, the middle cervical fascia inserting itself on the hyoid bone (Charpy-Moresten anatomical variant) or on the sheath of the digastric muscle (Truffert anatomical variant), does not reach the medial aspect of the mandible resulting in a communication between the submaxillary lodge and the perivisceral space.
Due to a similar etiopathogenesis, a phlegmon or perivisceral abscess can originate from the parotid gland; the invasion of the perivisceral space is caused by the lack of a true capsule on the deep edge of the gland.
Bezold’s abscess is a rare complication of acute otomastoiditis in which the infection erodes, through the medial cortex, the tip or internal surface of the mastoid and causes abscess formation in the sternocleidomastoid muscle that extends into the infratemporal fossa. Due to the depth of the cervical fascia that surrounds the sternocleidomastoid and trapezius muscles, the abscess is impalpable. As the mastoid sinus pneumatises late in childhood, Bezold’s abscess occurs more frequently in adults. Due to its proximity to the internal jugular vein, the thrombosis is a possible complication 16.
Antibiotic therapy for deep neck space infections is based on broad-spectrum antibiotics such as penicillin based, clindamycin, and metronidazole 17. The literature supports also the use of corticosteroids 18. The antibiogram is also useful to test the material taken during the operation and to identify the bacteria and to start a target therapy. For this reason, beside surgery, supportive care is unavoidable.
Multidisciplinary management of deep neck infections
Without treatments, the infection can spread into surrounding tissues. When there is airway impairment, sepsis, descending infection, abscess larger than 3 cm, involvement of deep neck spaces or the failure of antibiotics therapy, surgical drainage is necessary. The airway management can be challenging. The main reason for ENT consultation is the evaluation of the air tract 19. The purpose of the surgery is to eliminate the triggering cause, to drain the purulent material and preserve the airway patency. We need a laryngoscopy to evaluate the obstruction generated at the level of the oropharynx (glossoptosis) or the laryngo-pharynx (peripharyngeal oedema). Compared with elective intubation, emergency intubation is therefore associated with an elevated risk of complications and severe adverse events such as aspiration, a fall in oxygen saturation, or even death. For these reasons, according with Rombey and Shieren, it is better recommended to secure patient’s airway via awake fiberoptic intubation and video laryngoscopy 20, that allow intubation of more challenging patients. They are performed under local anaesthesia and sedation and should be performed by an experienced anaesthesiologist. Fang et al. 21 and Ahuja et al. 22 showed that emergent awake tracheostomy should be considered in patients with impeding airway obstruction and is a safe and effective method to secure an airway in these patients. Some studies advocate early tracheotomy in severe deep neck infections in order to decrease the hospitalization in intensive care unit and related complications. Moreover, in severe cases of airway oedema, a prolonged intubation is required, and early tracheostomy can offer several benefits in ICU care compared to intubation such as for example avoiding laryngeal injury caused by prolonged intubation, facilitating nursing care, improving patient comfort by reducing the need for sedation, reducing the need for mechanical ventilation and making faster the discharge. Adley et al. evaluated scientific articles relating to a period of time of thirty years and said that there was a significant difference in favor of early tracheostomy in adults and pediatric group as early tracheostomy was superior regarding reduced duration of mechanical ventilation, with less mortality rates and less duration of stay in ICU 23.
In the case of abscesses of odontogenic origin, to treat the infections of cervical space a surgical approach in team with the dentist is almost mandatory, since in most cases it is necessary to perform the extraction of one or more dental elements. As Heim and Warwas proved quite recently, this better happens during the execution of an exploratory cervicotomy 24. Odontogenic infections spread from mandible or maxilla into the sublingual, submandibular, or masticatory spaces and then into the parapharyngeal space. For this reason, the site of neck incision depends on the affected area. In any case the surgical incision should be placed in healthy skin, when possible, not at the site of maximum fluctuance, because these wounds tend to heal with an unsightly scar. It should be into a natural skin fold, in a dependent position.
Drainage of the submandibular space can be required a subperiosteal intraoral and an extraoral incision. For the external approach the incision should be done approximately 3 to 4 cm below the angle of the mandible. The incision is performed on skin and subcutaneous tissues, to the platysma. The platysma is divided with electrocautery or sharp dissection. Superficial and middle cervical fascia are cut in parallel to the inferior border of the mandible. The dissection continues in a superior-medial direction to enter the submandibular space.
Drainage of the lateral pharyngeal space is approached mainly through an external approach. In this case, neck dissection can be performed according to Paul André’s approach 25. Once reached the SCM muscle, the incision is carried down to the superficial and middle cervical fascia, and the carotid sheath is identified and opened. Dissection is carried superiorly along the vessels.
In order to reach abscesses affecting the perivisceral space up to the base of the neck, it is possible to extend the Paul André’s incision or perform a horizontal or median arch-shaped incision about 3 cm above the sternum dimple. In this case, the perivisceral space surrounding the thyroid and larynx is reached after incision of the superficial and middle cervical fascia.
In people who have large retropharyngeal space abscesses, an external approach is needed. The carotid sleeve is mobilized medially, so it is possible to reach the deep cervical fascia and if necessary, the prevertebral fascia. In selected cases, with single-chamber and circumscribed abscess cavities, endopharyngeal access to the abscess is possible 26-31.
After the abscess has been drained, the drains are placed 32,33. To date, it is not clear if it is better use passive drains than open ones. Passive drains are made of latex, polypropylene, or silastic rubber. These include Penrose drains and glove finger. They work by capillary action, gravity, overflow, or fluctuations of pressure gradients caused by body movement. To reduce the risk for ascending infection, passive drains should be covered with a sterile bandage that is placed and aseptically exchanged. if it does not, fluid can lead to severe skin irritation and excoriation in addition to increasing the risk for ascending infection 34.
Active drains, like Jackson-Pratt ones, are closed systems that collect fluid into a reservoir. This decreases the risk for ascending infection and can reduce exposure of hospital staff or other patients to contaminated fluid. Active drains apply an artificial pressure gradient to pull fluid or gas from a wound or body cavity 35.
Through the perivisceral space or the vascular space the infectious process can reach the anterior mediastinum, differently when the abscess involves the third or fourth cervical lodge, respectively the perivisceral space and the prevertebral space, it can reach the chest, causing posterior mediastinitis. In fact, Endo et al. classified descending mediastinitis according to the degree of diffusion of infection diagnosed by computed tomography. Localized descending mediastinitis, type I, is localized in the upper mediastinal space above the carina. Diffuse descending mediastinitis, type IIA, is extended to the lower anterior mediastinum and type IIB reach both anterior and posterior lower mediastinum 36.
Surgery is a complex procedure; thoracotomy and extended cervicotomy is the gold standard approach, as Corsten and Taylor assert in their papers 4,37. The goal is to drain all the suppurated fluids, to save the organs from the close pus and fibrin collections. These operations give the chance to native tissues to regenerate consequently. Drainages and tissue stimulating dressings can be left in each corner of the affected areas after debridement. More recently, the armamentarium has been improved with a new technology that has shown promising results; the VAC-therapy seems to be associated to a faster resolution of the local tissue damage and some studies has encouraged to use this device more extensively 38.
The number of cervical deep infections has been rapidly increasing in the last years. Abscesses of odontogenic and non-odontogenic origin have a strong tendency to spread between the tissues and to invade the deep spaces of the neck down to the chest. The main reason for ENT consultation is the evaluation of the airway but in many cases, thoracotomy and extended lateral/anterior cervicotomy is required in order to drain all the suppurated fluids. In this scenario, a multidisciplinary approach involving the ENT surgeon, the dentist, the thoracic surgeon and the infectivologist, is the best option to treat such a challenging complication of several head and neck pathologies.
Figures and tables
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