|Year : 2015 | Volume
| Issue : 1 | Page : 61-65
Bilateral deep neck space infection in pediatric patients: Review of literature and report of a case
Manish J Raghani1, Nisha Raghani2
1 Department of Dentistry, Maxillofacial Surgery Services, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2 Dental Surgeon, Raipur, Chhattisgarh, India
|Date of Web Publication||9-Jan-2015|
Dr. Manish J Raghani
Department of Dentistry, Maxillofacial Surgery Services, All India Institute of Medical Sciences, G. E. Road, Tatibandh, Raipur - 492 099, Chhattisgarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The diagnosis and treatment of deep neck infections is still an enigma for surgeons and physicians. Because of the complexity and the deep location of this region, the diagnosis and treatment in this area is difficult. The anatomy of deep neck spaces is highly complex and therefore precise localization of infections in this region is very difficult. The diagnoses of deep neck space infection (DNSI) are difficult because of the deep location of these spaces and are usually covered by substantial amount of normal superficial soft tissue. Access: To gain surgical access to the deep neck spaces, the superficial tissues must be crossed with the risk of injury to the neurovascular structures in the neck. Neural dysfunction, vascular erosion or thrombosis, and osteomyelitis are some of the complications of DNSI because of the proximity of nerves, vessels, bones, and other soft tissues. Deep neck spaces are communicated with each other and infections from one space can spread to adjacent space. DNSI, if not diagnosed early and promptly, may result in serious consequences even mortality. The treatment of DNSI with antibiotic therapy and drainage is most often definitive and recurrence of these cases is rare.
Keywords: Deep neck space infections, incision and drainage, submandibular space abscess
|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
|How to cite this URL:|
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 [serial online] 2015 [cited 2019 Jul 16];33:61-5. Available from: http://www.jisppd.com/text.asp?2015/33/1/61/149009
| Introduction|| |
Deep neck space infections (DNSIs) can occur at any age but the pediatric deep neck infections require more intimate management because of their rapidly progressive nature.  Delay in diagnosis and treatment may lead to life-threatening complications. The incidence and morbidity of DNSIs has been significantly reduced with the introduction of antibiotic therapy. Concurrent abscess in distinct neck spaces has rarely been reported in healthy children. Here, a rare case of bilateral neck abscess in a 9-month-old male child is reported and the clinical presentation along with the management is discussed with a review of literature.
| Case Report|| |
A 9-month-old male child presented with a 3-4 days history of fever, progressive swellings in both right and left submandibular spaces and right buccal space. Clinical examination showed a non-toxic appearance with a low-grade fever. The swelling was diffuse, soft to firm 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 corner of mouth. Mouth opening was adequate but no teeth were present (erupted) and no significant finding which could relate to the swelling was found intraorally. Chest radiography revealed no abnormality, but the laboratory studies showed a leukocyte count of 18,160/μl with neutrophil dominance and hemoglobin level of 10 g/dl. Neck ultrasound identified bilateral abscess formation. Medicinal treatment started immediately in the form of intravenous Ceftriaxone and Metronidazole and hydration was maintained adequately. But there was no significant clinical improvement with medical management alone within first 48 hours. Subsequently, incision and drainage of the bilateral submandibular abscesses was done extraorally. Fever and swelling subsided after surgical drainage and intravenous antibiotics. Due to uncommon occurrence of such severe infection in infants, we tried to search for underlying etiology. According to the parents of the 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. Serologic studies for TOxoplasmosis, Rubella, Cytomegalovirus and Herpes (TORCH) simplex virus, Epstein-Barr virus (EBV), hepatitis, and human immunodeficiency virus (HIV) were negative. Evaluation for tuberculosis did not show any abnormality. No clinical evidence of an underlying immunocompromisation was detected and the patient was discharged from the hospital with complete recovery after 2 weeks. Most likely, cause of the bilateral DNSI in this particular case could be the upper respiratory tract infection (Tonsillitis) because it is the most common etiology for DNSI in children. ,,,
| 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. , Before the advent of widespread use of antibiotics, 70% of DNSIs were caused by spread from tonsillar and pharyngeal infections. Today, tonsillitis remains the most common etiology of DNSIs in children, whereas odontogenic origin is the most common etiology in adults. ,,,
Causes 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 by falls onto pencils or popsicle sticks, esophageal lacerations from ingestion of fish bones or other sharp objects)
- Instrumentation, particularly from esophagoscopy or bronchoscopy
- Foreign body aspiration
- Cervical lymphadenitis
- Branchial cleft anomalies
- Thyroglossal duct cysts
- Mastoiditis with petrous apicitis and Bezold abscess
- Intravenous (IV) drug use 
- Necrosis and suppuration of a malignant cervical lymph node or mass
As many as 20-50% of deep neck infections have no identifiable source. Other important considerations include patients who are immunosuppressed because of HIV infection, chemotherapy, or immunosuppressant drugs for transplantation. These patients may have increased frequency of deep neck infections and atypical organisms, and they may have more frequent complications.
| Pathophysiology|| |
DNSIs can arise from a multitude of causes. Whatever the initiating event, development of a DNSI precedes by one of several paths, as follows:
- Spread of infection can be from the oral cavity, face, or superficial neck to the deep neck space via the lymphatic system.
- Lymphadenopathy may lead to suppuration and finally focal abscess formation.
- Infection can spread among the deep neck spaces by the paths of communication between spaces.
- Direct infection may occur by penetrating trauma.
Once initiated, a deep neck infection can progress to inflammation and phlegmon or to fulminant abscess with a purulent fluid collection.
The presenting symptoms and signs of the patient with a DNSI, as well as the source of infection, will vary somewhat depending upon which of the spaces is involved. In a study reported by Coticchia et al., the most commonly encountered sites of abscesses in the head and neck region of pediatric patients were retropharyngeal or parapharyngeal spaces, followed by anterior or posterior triangle and submandibular or submental regions, respectively. Retropharyngeal or parapharyngeal involvement was more common in 1-year-old children, or older, whereas submandibular or submental involvement was more common in children younger than 1 year. However, there are different results, in different studies, in the literature regarding the distribution of abscesses among the spaces of the neck. 
Ungkanont et al., reviewed 117 children treated for deep neck infections during a 6-year period. 
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 spaces simultaneously through the potential pathways of extension as illustrated [Figure 1].
|Figure 1: Network of patterns of infectious extension within the potential spaces of the neck (from Gadre et al., 2006 15)|
Click here to view
The microbiology of deep neck infections usually reveals mixed aerobic and anerobic organisms, often with a predominance of oral flora. Both gram-positive and gram-negative organisms may be cultured. Contemporary reports from different countries or areas may reveal different common pathogens.  Most studies have determined the predominance of streptococcus and Staphylococcusaureus as a causative organism although often infections are polymicrobial. On the other hand, the presence of anerobes may be underestimated because of the difficulty in culturing them.  Streptococcus and normal oropharyngeal flora were more common in retropharyngeal and parapharyngeal abscesses because these organisms are found in the oropharynx. Likewise, one would expect Staphylococcus aureus to be more common in anterior and posterior triangle and submandibular and submental abscesses because this organism is a common skin contaminant and these regions are more distant from the oropharynx. 
A detailed history should be obtained from a patient of deep neck infection. Physical examination should focus on determining the location of the infection, the deep neck spaces involved, and any potential functional compromise or complications that may be developing. A comprehensive head and neck examination should be performed, including examination of the dentition and tonsils. The most consistent signs of a DNSI are fever, elevated white blood cell (WBC) count, and tenderness. Other signs and symptoms largely depend on the particular spaces involved and include the following:
- Asymmetry of the neck and associated neck masses or lymphadenopathy, which is present in almost 70% of pediatric retropharyngeal abscesses according to a study by Thompson and colleagues
- Medial displacement of the lateral pharyngeal wall and tonsil caused by parapharyngeal space involvement
- Trismus caused by inflammation of the pterygoid muscles
- Torticollis and decreased range of motion of the neck caused by inflammation of the paraspinal muscles
- Fluctuance that may not be palpable because of the deep location and the extensive overlying soft tissueand muscles (e. g., sternocleidomastoid muscle)
- Possible neural deficits, particularly of the cranial nerves (e. g., hoarseness from true vocal cord paralysis with carotid sheath and vagal involvement), and Horner syndrome from involvement of the cervical sympathetic chain
- Regularly spiking fevers (may suggest internal jugular vein thrombophlebitis and septic embolization)
- Tachypnea and shortness of breath (may suggest pulmonary complications and warn of impending airway obstruction)
Children with DNSI's have minimal signs and symptoms and also they do not verbalize their symptoms or cooperate with the physical examination.  The most common signs and symptoms are a neck mass or swelling, fever, poor oral intake, and prior symptoms of an upper respiratory infection such as rhinorrhea or cough. Other symptoms include: Neck pain, irritability, decreased neck mobility, sore throat, upper airway obstructive symptoms, and febrile seizures. In our case, the patient presented with bilateral submandibular soft swelling and low grade fever [Figure 2], [Figure 3], [Figure 4].
|Figure 2: Bilateral submandibular swellings (abscess) also a small swelling over right buccal region|
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|Figure 3: The swelling was soft and tender with inflammed, red, tense, shiny skin showing all signs of acute abscess|
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Computerized tomography (CT) scanning is the most widely used modality for diagnosing deep space neck infections because it is less expensive and readily available.  Although CT is helpful both in determining the presence and location of neck infections in children, it is less helpful in differentiating abscess from lymphadenitis and cellulitis. On the other hand, use of magnetic resonance imaging (MRI) gives improved soft tissue definition without the use of radiation but its use is limited due to the lack of availability and cost. , Ultrasonography is also effective in identifying abscess versus cellulitis. The lateral neck plain X-ray film has been used in the past as a screening X-ray to look primarily at the retropharyngeal and prevertebral spaces.
The mainstays for successful management of deep neck infections are securing airway, antibiotics, and surgical drainage. Antibiotics are not substitute for surgery and incision and drainage are considered the gold standard for the majority of pediatric deep neck abscesses.  Because of the different causative organisms, broad-spectrum antibiotics are advocated in treating deep neck infections.  Empirical parenteral antibiotics should be started before the culture results become available and then tailored to the culture results when available. Fortunately, most pediatric DNSIs are located either in the anterior or posterior triangle of the neck or in the retropharyngeal area. Surgical drainage of these abscesses is usually direct and effective.  Needle aspiration of abscess can be used in some cases but it is not much effective and may require recurrent aspirations. In my case, we there was no clinical improvement after antibiotics so I performed external incision and drainage in which pus was evacuated and diagnosis of abscess was confirmed. The postoperative recovery was uneventful.
| Conclusion|| |
The treatment of DNSIs with antibiotic therapy and drainage is most often definitive and recurrence of these cases is rare. The exception to this rule is the deep neck infection that occurs in association with a pre-existing congenital abnormality. So that, in the patient that presents with a prior history of a similar deep neck infection or abscess, the level of suspicion should be raised for an underlying lesion. Imaging, particularly CT scan, can be extremely helpful in making the diagnosis in these cases. In a review of 12 cases of recurrent deep neck infection, Nusbaum et al., found the most common underlying congenital anomaly to be a second branchial cleft cyst. Other causes included first, third, and fourth branchial cleft cysts, lymphangiomas, thyroglossal duct cysts, and a cervical thymic cyst.
Why this paper is important to pediatric dentists?
This paper (article) describes the details of the deep neck infections in pediatric patients including various etiologies, pathophysiology, clinical manifestations, and treatment of these patients. The etiology is frequently from oral cavity (carious tooth) and the submandibular space is involved in most of the cases, so the pediatric dentist is usually the first person to see these patients. The purpose of writing this article in this journal is that the pediatric dentist should be able to diagnose the deep neck infections cases early and promptly, so that proper treatment should be started as early as possible to avoid dangerous consequences and even mortality.
The case described here is a very small child (9 months old) for which a pediatric dentist or a maxillofacial surgeon can be called upon in a hospital to attend and manage the case. In dentistry, we rarely see such patients, so I thought of worth mentioning it here. I think this would be of some help to our pediatric dentist friends.
| References|| |
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.
Conrad DE, Parikh SR. Deep neck infections. Infect Disord Drug Targets 2012;12:286-90.
Chang L, Chi H, Chiu NC, Huang FY, Lee KS. Deep neck infections in different age groups of children. J Microbiol Immunol Infect 2010;43:47-52.
Wang LF, Tai CF, Kuo WR, Chien CY. Predisposing factors of complicated deep neck infections: 12-year experience at a single institution. J Otolaryngol Head Neck Surg 2010;39:335-41.
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 on severe deep space head and neck infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:151-6.
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.
Daramola OO, Flanagan CE, Maisel RH, Odland RM. Diagnosis and treatment of deep neck space abscesses. Otolaryngol Head Neck Surg 2009;141:123-30.
Coticchia JM, Getnick GS, Yun RD, Arnold JE. Age-, site-, and time-specific differences in pediatric deep neck abscesses. Arch Otolaryngol Head Neck Surg 2004;130:201-7.
Osborn TM, Assael LA, Bell RB. Deep space neck infection: Principles of surgical management. Oral Maxillofac Surg Clin North Am 2008;20:353-65.
Caccamese JF Jr, Coletti DP. Deep neck infections: Clinical considerations in aggressive disease. Oral Maxillofac Surg Clin North Am 2008;20:367-80.
Meyer AC, Kimbrough TG, Finkelstein M, Sidman JD. Symptom duration and CT findings in pediatric deep neck infection. Otolaryngol Head Neck Surg 2009;140:183-6.
Naidu SI, Donepudi SK, Stocks RM, Buckingham SC, Thompson JW. Methicillin-resistant Staphylococcus aureus as a pathogen in deep neck abscesses: A pediatric case series. Int J Pediatr Otorhinolaryngol 2005;69:1367-71.
Gadre AK, Gadre KC. Infections of the deep spaces of the neck. In: Bailey BJ, Johnson JT, Newlands SD, editors. Head and Neck Surgery: Otolaryngology. 4 th
ed. Philadelphia: Lippincott, Williams and Wilkins; 2006. p. 668-82.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]