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Case Report
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.
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.[1] 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
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DOI:
10.4103/0970-4388.149009
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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/l
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
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Raghani: Bilateral deep neck space infection in pediatric patients:Systematic review of literature and report of a case
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] 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.[2-5]
Etiology
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 literatureregarding the
distribution of abscesses among the spaces of the neck.[8]
Ungkanont et al., reviewed 117 children treated for
deep 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 spaces
simultaneously through the potential pathways of
extension as illustrated [Figure1].
Microbiology
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Raghani: Bilateral deep neck space infection in pediatric patients:Systematic review of literature and report of a case
Clinical Presentation
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Raghani: Bilateral deep neck space infection in pediatric patients:Systematic review of literature and report of a case
Figure 3: The swelling was soft and tender with inflammed, red, tense,
shiny skin showing all signs of acute abscess
Treatment
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.
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Bullet points
Why this paper is important to pediatric dentists?
References
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Raghani: Bilateral deep neck space infection in pediatric patients:Systematic review of literature and report of a case
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