|Year : 2019 | Volume
| Issue : 1 | Page : 48-52
Analysis of facial and deep neck space infections in patients with comorbidities
Department of Dental Surgery, Maxillofacial Unit, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
|Date of Web Publication||18-Feb-2019|
Dr. Arthur Nwashindi
Department of Dental Surgery, Maxillofacial Unit, University of Uyo Teaching Hospital, Uyo, PMB 1136, Akwa Ibom State
Source of Support: None, Conflict of Interest: None
OBJECTIVE: The objective of this study was to analyze a series of patients with facial space infection associated with comorbidities.
MATERIALS AND METHODS: Data were collated from 98 patients with facial and deep neck space infections who met the inclusion criteria over a period of 3 years. Data included demographic information, anatomic space involved, and comorbid factors.
RESULTS: A total of 98 patients who met the inclusion criteria were investigated in this study. Majority of the patients were within the age group of 46–55 (36.73%) years, whereas the least affected age group was 16–25 years (3.06%). Females were more involved while the spaces involved with Ludwig angina had the highest frequency. Diabetes mellitus (DM) was the highest comorbid factor. The patients presented mostly within 24–48 h from the onset of infection.
CONCLUSIONS: Facial and deep neck space infections occur due to spread of infection within the spaces. DM and HIV infections are the most common comorbid factors.
Keywords: Comorbid, diabetes mellitus, facial space infection, Ludwig angina
|How to cite this article:|
Nwashindi A. Analysis of facial and deep neck space infections in patients with comorbidities. Int J Health Allied Sci 2019;8:48-52
|How to cite this URL:|
Nwashindi A. Analysis of facial and deep neck space infections in patients with comorbidities. Int J Health Allied Sci [serial online] 2019 [cited 2019 May 24];8:48-52. Available from: http://www.ijhas.in/text.asp?2019/8/1/48/252451
| Introduction|| |
Facial spaces in the face and neck are potential spaces between the layers of fascia, normally filled with loose connective tissue and various anatomical structures such as veins, arteries, glands, and lymph nodes.,
The anatomy of these areas includes multiple potential spaces with connecting pathways down to the mediastinum and along the entire vertebral spine. Infection can spread easily from one potential space to another and also to connecting regions. If facial space infections are left untreated, it can spread and involve more than one spaces and sometimes develop into life-threatening infections leading to death.
Infections of facial and deep neck space are challenging due to various clinical manifestations which can present as a minimal form of inflammatory response to potentially lethal complications such as upper airway obstruction, mediastinitis, thrombosis of the internal jugular vein, septic shock, and death.,
Ludwig angina, for example, is a potentially fatal, rapidly expanding, and progressive infection of bilateral submandibular, sublingual, and submental facial spaces. Spread of infection in these spaces is facilitated by synergism between aerobic and anaerobic organisms. Life-threatening complications are associated with Ludwig angina and other space infections with eventual death usually as a result of long-standing or significant sepsis.
Predisposing factors such as alcoholism, immunosuppression, uncontrolled diabetes mellitus (DM), and multiple underlying medical conditions have been reported to increase the risk of infections. DM is well documented as a cause of compromised immunity, poor wound healing, and increased risk of both infection and prolonged hospital stay due to increased severity of infection. Furthermore, HIV infection has been reported to result in complications and long hospital stay as well as death.
Our interest in the subject arose after we observed an increase in the number of fascial space infections associated with comorbid factors in relation to the spaces involved at the Maxillofacial Unit of the University of Uyo Teaching Hospital (UUTH), Uyo. The purpose of the study, therefore, is to analyze the cases seen and to use our results, identify the common risk patients, and understand the clinical characteristics of patients, especially those with comorbidities and immunosuppression such as DM and HIV infections.
| Materials and Methods|| |
This study was a prospective study conducted between 2012 and 2015 on patients seen in the Oral and Maxillofacial Surgery Unit of UUTH with facial and deep neck space infections which included infections of the fascial spaces of the face and neck, cellulitis, lymphadenitis, and abscess. It was a study of 98 cases of fascial space infections comprising Ludwig's angina, parapharyngeal abscess, parotid abscess, and retropharyngeal abscess that presented in the department. Ninety-eight patients who fulfilled inclusion criteria were eventually analyzed. The following data were recorded: age, gender, comorbidities including DM and HIV were also noted as well as occupation of the patient and time of presentation.
Inclusion criteria were all facial and deep neck space infections resulting from infections as primary cause, whereas exclusion criteria were space infections from trauma. Each patient had one comorbid condition. Those with more than one comorbid conditions were excluded so as to be able to compare the effect of the comorbid factor. All cases underwent a detailed history, clinical examination, relevant investigations, and medical and surgical treatments.
Demographic information was elicited from patients using a structured questionnaire. An abscess was confirmed through a combination of the following clinical features: a well-circumscribed warm, tender swelling, fluctuant with a shiny overlying skin or erythematous mucous membrane, and pus aspirate. Cellulitis was confirmed as a warm, hard, tender, and diffuse swelling with serosanguinous aspirate of pus.
Ethical approval was obtained from the Ethical Committee of the hospital, and informed consent was obtained from the patients.
After taking detailed history, each patient was thoroughly examined. Pus was collected from the infection site before commencement of antibiotic therapy. The extraoral sites were prepared with alcohol and intraoral sites were prepared with chlorhexidine. Disposable syringes (5 ml) with disposable needle of 18 gauges were used to aspirate the pus from the abscess. The aspirated syringes with needle were immediately taken to the Department of Microbiology of UUTH for the analysis.
Data analysis was by simple descriptive analysis.
| Results|| |
A total of 98 patients who met the inclusion criteria were investigated in this study. Majority of the patients were within the age group of 46–55 (36.73%) years, whereas the least affected age group was 16–25 years (3.06%) as shown in [Table 1]. [Table 2] shows that males were more involved, whereas [Table 3] shows the spaces involved with the group having a full complement of Ludwig angina being the highest frequency with 26 (26.53%). Of the recorded comorbid factors, DM was the highest with 32 (32.65%) as shown in [Table 4]. The patients presented mostly within 24–48 h from the onset of infection [Table 5]. [Figure 1] shows soft tissue inflammation of the neck. [Figure 2] and [Figure 3] shows the clinical pictures of patients with buccal space and submental space infections respectively. [Table 6] indicates that combination of antibiotics and drainage was mostly adopted in the management of the patients. As shown in [Table 7], the highest frequency of first line antimicrobials used was penicillin, with gentamicin the least.
|Figure 1: Neck radiograph (anterior-posterior) bilateral soft-tissue swelling with partial effacement of fascial planes showing soft-tissue inflammation of the neck|
Click here to view
| Discussion|| |
In this study, the patients' age ranged from 16 years to 75 years with a mean of 45 years which is similar to previous reports, although some other studies recorded higher values., This age group also presents with increased rates of comorbid disease, either newly diagnosed or advanced disease. The reason for this may be due to poor checkup history due to time constraints. In the present study, male-to-female ratio was 1:2, which is in contrast to those of previous studies where more males were found to be more affected with a ratio of 2:1. A possible explanation for this is that males present less for medical attention because of time constraints.
Isolated submandibular space infection was the most common space affected, in agreement with a previous study. This is in contrast to a study which reported that the medial masticator space was the most commonly involved facial space. Ludwig angina which is a combination of submandibular, submental, and sublingual spaces and reported to have 7.8% of all facial space infections in other parts of Nigeria was lower than what was recorded in this study. The three most involved spaces in descending order of frequency were submandibular, parotid, and sublingual in sharp contrast to other studies where submandibular,, buccal, and submasseteric spaces were reported to be the most frequently affected. The predominance of submandibular space infections is attributed to the higher incidence of carious mandibular molars.
HIV serostatus influenced specific fascial space involvement. Isolated submandibular, submental spaces were specific for DM, whereas Ludwig and parotid spaces were specific for HIV and DM. This is in agreement with a previous study by Srivanitchapoom et al. who reported that the submandibular space was the most frequently involved in non-HIV-infected patients, whereas the superficial masticator space was the most frequently affected in HIV-infected counterparts.
Multiple fascial space involvement has been noted to be significantly associated with life-threatening comorbid factors in agreement with a previous study. The role of comorbidity in the etiology and prognosis of facial infection is well documented., DM, HIV, and anemia were the most common comorbid factors recorded. On the contrary, Fomete et al. reported that anemia (nutritional) was the single most common comorbidity recorded, followed by DM in a study in Northern Nigeria.
DM leads to compromised immunity, poor wound healing, and increased risk of both infection and prolonged hospital stay due to increased severity of infection. The study by Miller and Dodson stated that diabetic patients were more at risk of developing bacteremias, pneumonia, and necrotizing fasciitis., There is a need for close monitoring of these patients with strict control of their blood glucose levels and early aggressive management of the initial infection or subsequent complications as stated by Chen et al.
None of the 26 (26.53%) patients with HIV died of complications. This is in contrast to a previous study where 4 of the 7 seen (57.14%) died due to complications. This may be due to prompt commencement of antibiotics and antiretroviral drugs. These findings are in contrast with the findings by Carey and Dodson, where HIV patients had complicated and longer hospital stay and had a greater percentage of complications and death associated with the infection.
The patients presented mainly within 24–48 h in agreement with a previous study. However, this is in contrast with another study with a mean period of presentation being 11.0 ± 9.4 days which was much higher than the result from this study. Due to early presentation, the majority of the patients did not have airway complications. The reason for early presentation could be due to educational level and awareness of the patients. This is a report in contrast with that of Botha et al. who reported compromised airway at presentation in majority of the patients due to late presentation.
Most patients in this study had a secondary primary level of education which agrees with previous studies in Turkey and India. Patients of low educational status may not be exposed to knowledge of how and when to present themselves to the hospital for early intervention.
Combination of surgical drainage and use of antibiotic was the major treatment option carried out in the management of these space infections. This is also the most common line of management by other authors.
In our findings, penicillin was the drug of choice for the first line of treatment cloxacillin, which is the most effective second line of antibiotics for these bacteria. This is similar to other reports in the literature.
The limitation of the study was getting the patients to consent for the study, especially HIV-positive patients.
| Conclusions|| |
Facial and deep neck space infections occur due to spread of infection within the spaces. DM and HIV infections are the most common comorbid factors in facial space infections.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thomson J. Hospital gangrene or malignant ulcers. In: Lectures on Inflammation. Edinburgh: James Ballantyne and Co.; 1813. p. 456-500.
Blackadder HH. Observations on Phagedena Gangraenosa. Edinburgh: David Brown; 1818.
Daramola OO, Flanagan CE, Maisel RH, Odland RM. Diagnosis and treatment of deep neck space abscesses. Otolaryngol Head Neck Surg 2009;141:123-30.
Chen MK, Wen YS, Chang CC, Lee HS, Huang MT, Hsiao HC, et al.
Deep neck infections in diabetic patients. Am J Otolaryngol 2000;21:169-73.
Eftekharian A, Roozbahany NA, Vaezeafshar R, Narimani N. Deep neck infections: A retrospective review of 112 cases. Eur Arch Otorhinolaryngol 2009;266:273-7.
Wang LF, Kuo WR, Tsai SM, Huang KJ. Characterizations of life-threatening deep cervical space infections: A review of one hundred ninety-six cases. Am J Otolaryngol 2003;24:111-7.
Boscolo-Rizzo P, Marchiori C, Montolli F, Vaglia A, Da Mosto MC. Deep neck infections: A constant challenge. ORL J Otorhinolaryngol Relat Spec 2006;68:259-65.
Scully C, Langdon J, Evans J. Marathon of eponyms: 12 Ludwig Angina. Oral Dis 2010;16:496-7.
Opitz D, Camerer C, Camerer DM, Raguse JD, Menneking H, Hoffmeister B, et al.
Incidence and management of severe odontogenic infections-a retrospective analysis from 2004 to 2011. J Craniomaxillofac Surg 2015;43:285-9.
Yadav S, Verma A, Sachdeva A. Facial necrotizing fasciitis from an odontogenic infection. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:e1-4.
Adekeye EO, Adekeye JO. The pathogenesis and microbiology of idiopathic cervicofacial abscesses. J Oral Maxillofac Surg 1982;40:100-6.
Miller EJ Jr., Dodson TB. The risk of serious odontogenic infections in HIV-positive patients: A pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:406-9.
Melaney F. Hemolytic Streptococcus
gangrene. Arch Surg 1924;9:317-64.
Flynn Thomas R. Principles of management of odontogenic infections. In: Miloro M, Ghali GE, Larsen P, Waite P, editors. Peterson's Principle of Oral and Maxillofacial Surgery. 2nd
ed. London, Hamilton: BC Decker Inc.; 2004. p. 277-93.
Cunningham LL Jr., Madsen MJ, Van Sickels JE. Using prealbumin as an inflammatory marker for patients with deep space infections of odontogenic origin. J Oral Maxillofac Surg 2006;64:375-8.
Osunde OD, Akhiwu BI, Efunkoya AA, Adebola AR, Iyogun CA, Arotiba JT, et al.
Management of fascial space infections in a Nigerian teaching hospital: A 4-year review. Niger Med J 2012;53:12-5.
] [Full text]
Allareddy V, Rampa S, Nalliah RP, Allareddy V. Longitudinal discharge trends and outcomes after hospitalization for mouth cellulitis and Ludwig Angina. Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:524-31.
Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig's Angina. Ann Maxillofac Surg 2015;5:168-73.
] [Full text]
Flynn TR, Shanti RM, Hayes C. Severe odontogenic infections, part 2: Prospective outcomes study. J Oral Maxillofac Surg 2006;64:1104-13.
Rao DD, Desai A, Kulkarni RD, Gopalkrishnan K, Rao CB. Comparison of maxillofacial space infection in diabetic and nondiabetic patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:e7-12.
Mathew GC, Ranganathan LK, Gandhi S, Jacob ME, Singh I, Solanki M, et al.
Odontogenic maxillofacial space infections at a tertiary care center in North India: A five-year retrospective study. Int J Infect Dis 2012;16:e296-302.
Srivanitchapoom C, Sittitrai P, Pattarasakulchai T, Tananuvat R. Deep neck infection in Northern Thailand. Eur Arch Otorhinolaryngol 2012;269:241-6.
Fomete B, Ononiwu CN, Agbara R, Idehen OK, Okeke UA. Cervicofacial necrotizing fasciitis: Case series and review of literature. Case Study Case Rep 2013;3:26-33.
Fomete B, Agbara R, Osunde DO, Ononiwu CN. Cervicofacial infection in a Nigerian tertiary health institution: A retrospective analysis of 77 cases. J Korean Assoc Oral Maxillofac Surg 2015;41:293-8.
Ryan P, McMahon G. Severe dental infections in the emergency department. Eur J Emerg Med 2012;19:208-13.
Carey JW, Dodson TB. Hospital course of HIV-positive patients with odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:23-7.
Tozoglu S, Ertas U, Buyukkurt MC, Yavuz MS, Usulu H, Kaya O. Role of socioeconomic factors in maxillofacial abscess of odontogenic origin. Ataturk Univ Dent Fac J 2009;19:26-30.
Agarwal AK, Sethi A, Sethi D, Mrig S, Chopra S. Role of socioeconomic factors in deep neck abscess: A prospective study of 120 patients. Br J Oral Maxillofac Surg 2007;45:553-5.
Uluibau IC, Jaunay T, Goss AN. Severe odontogenic infections. Aust Dent J 2005;50 Suppl 2:74-81.
Walia IS, Borle RM, Mehendiratta D, Yadav AO. Microbiology and antibiotic sensitivity of head and neck space infections of odontogenic origin. J Maxillofac Oral Surg 2014;13:16-21.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]