GUEST EDITORIAL

Deep cervical infections – an uncommon but significantproblem

M Schiodt

Department of Oral and Maxillofacial Surgery, Copenhagen County University Hospital, Copenhagen, Denmark

Many dentists, physicians, and certainly all oral andmaxillofacial surgeons, ENT surgeons, and head andneck surgeons once in a while encounter patients withsevere deep cervical infections (DCI). In that situation anumber of questions arise which must be dealt withimmediately: What is the diagnosis? Which diagnosticprocedures should be pursued? What will the correcttreatment be? Is airway obstruction a risk? How shouldyou monitor the patient? What is the risk of complica-tions?

Inspired by the case report of a Clostridium infectionof the neck in this issue of the journal by Nakamuraet al (2002), this editorial will deal briefly with someaspects of infections with an odontogenic origin.

The most common infections of odontogenic origininclude localized phlegmones and abscesses. The diag-nosis and treatment of localized infections of this type isusually straightforward and outside the scope of thiseditorial.

Important terms related to the severe and/or morewidespread infections include: DCI; gas gangrene (GG)of the head and neck; and necrotizing fasciitis (NF) ofthe head and neck. These terms sometimes coversimilar or overlapping conditions. Whereas DCI onlyrelates to the location of the infection, GG indicatesinvolvement of gas producing bacteria, which give riseto crepitation of the tissue. Nakamura et al state thatthe majority of gas productive infections in the headand neck region are non-clostridial and proceeds alongfascia, whereas clostridial infections progress in mus-cular layers. NF is used to describe an inflammatoryprocess dominated by necrosis of tissue, spreadingrapidly along fascia and is in its classical form causedby Group A beta hemolytic streptococci, but can becaused by a number of anaerobic bacteria, includingbacteroides, fusobacteria, peptostreptococci and veryrarely Clostridium (Jackson and Sproat, 1995; Jovic

et al, 1999). NF may be associated with GG, this iswhy the various terms seem to describe a predominantclinical type of manifestation.

The incidence of such lesions is not well described.Bloching et al (2000) estimated an incidence of 40 peryear of NF of the head and neck in Germany. Tung-Yiu et al (2000) reported 11 cases of NF of odonto-genic origin occurring over a period of 11 years inTaiwan. These 11 cases constituted 2.6% of 422infections seen during the same period. Several reportsof NF and/or DCI include series of 3–21 casescollected over 6–12 years with an average of 1.5 casesper year (Fernandez et al, 1999; Jovic et al, 1999;Mohammedi et al, 1999; Tung-Yiu et al, 2000; White-sides, Cotto-Cumba and Myers, 2000; Bahu et al, 2001;Fujiyoshi et al, 2001; Lin et al, 2001). NF and GG arethus rare events, and a literature search on ‘Clostridiumand DCI’ revealed 0 (zero) references, underliningthe rarity of the case of Clostridium reported byNumakura et al.Clostridium may rarely occur in the oral cavity,

and a novel strain of Clostridium has been describedin association with HIV infection (Lamster et al,1997).

In a case similar to that of Numakura et al a numberof deep neck infections are triggered by a surgicalprocedure such as tooth extraction whereas others occurspontaneously from apical or periodontal infections oflower molar teeth or pericononitis around lower wisdomteeth (Simon and Matee, 1999; Obiechina, Arotiba andFasola, 2001). Non-odontogenic origins include seque-lae from tonsillectomy, peritonsillar abscess, pharyngitisand suppuration of lymph nodes from rhinological- orpharyngeal-infectious sources (Virolainen et al, 1979;Jackson and Sproat, 1995).

The anatomy is of utmost importance for the spreadof the infection. Many of these infections primarilyinvolve the submandibular or retromandibular region.Progression from here may involve spreading to theparapharyngeal or retropharyngeal spaces from whichthere is a potential for spreading downwards into themediastinum, possibly leading to mediastinitis, pericar-ditis, lung infection and sepsis (Bloching et al, 2000;

Correspondence: Morten Schiodt, Department of Oral and Maxillo-facial Surgery, Copenhagen County University Hospital, Copenhagen,Denmark. E-mail: mosc@glostruphosp.kbhamt.dkReceived 1 March 2001; accepted 20 November 2001

Oral Diseases (2002) 8, 180–182� 2002 Blackwell Munksgaard All rights reserved 1354-523X/01

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Bahu et al. 2001). The infection may spread upwards tothe skull base and to the meninges. Another scenario isthe spreading of the infection via the blood vesselsgiving rise to suppurative thrombophlebitis (Wills andVernon, 1981), development of toxic shock syndrome(Bloching et al, 2000), sepsis or disseminated intravas-cular coagulation (DIC) (Fujiyoshi et al, 2001). Obvi-ously, a spreading to the thorax and/or dissemination ofthe infection carries a grave prognosis. Thus, themortality rate of these severe infections is in the rangeof 20–50% or higher (Bloching et al, 2000). This is incontrast to the low mortality of oral and maxillofacialinfections in general. Thus, a national survey study inTaiwan revealed only 18 deaths among 2790 cases oforal and maxillofacial infections admitted to inpatientservices over a 3-year period (mortality rate 0.6%,Wong, 1999). Another measure of the severity of NFand GG of the head and neck region can be inferredfrom the length of hospital stays of the patients rangingfrom 24 to 31 days (Whitesides et al, 2000; Bahu et al,2001).

Because of the rarity of these infections the scientificevidence for management is mostly based on experienceand deduction from case reports and small series ofcases rather than controlled studies.

Diagnostic procedures should include radiographs(where gas can be seen), CT or MR scans in order to getan exact picture of abscess or gas formation and thelocation and possible spread to distant regions (Beckeret al, 1997; Nielsen and Rasmussen, 2000; Seal, 2001).Becker et al (1997) advocated repeated CT scans tomonitor spreading in selected cases. Hospitalization atan intensive care unit including airway monitoring maysometimes be required.

Most authors stress the importance of antibiotictreatment with a broad spectrum antibiotic initially,and resolute and prompt surgical exploration anddrainage, as also stated by Nakamura et al (2002). Thesurgical drainage should be instituted as quickly aspossible in order to limit the spread of this primarilyanaerobic process (Peterson, 1993).

Often, repeated surgical drainage may be necessary.Bacterial culture of the obtained pus or necrotic tissue ismandatory and after culturing the antibiotic regimenshould be adjusted accordingly. Hyperbaric oxygen(HBO) is advocated as an adjunct treatment by severalauthors (Peterson, 1993; Korhonen, 2000), but mostoften has not been used, possibly for practical reasons.The rationale for using HBO is to increase the oxygentension in the tissue and thereby inhibit the spread of theanaerobic flora. This appears logical in the light of thedocumented increase of oxygen tension in the tissuefollowing HBO (Peterson, 1993). However, the effect ofHBO on mortality is yet to be proven.

Immunoglobulin infusion has been used as adjuncttherapy: its value appears not to be proven (Obiechinaet al, 2001).

What are the risk factors for a more severe course ofinfection?

The host immune response seems to be of importance.In several studies diabetes occurred in a significant

proportion of the patients (like Nakamura et al’s case,Wong, 1999; Tung-Yiu et al 2000), but HIV-infectedand other immune compromised patients are also atrisk.

At time of admission individual risk parametersinclude fever, white blood cells (WBC) and the level ofcomplement reacting protein (CRP). Wall et al (2000)reported a model to distinguish between necrotizing andnon-necrotizing infection. If WBC were >15.4 · 109 l)1

or serum sodium <135 mmol l)1 the patients were atrisk for a necrotizing infection. In a Finnish study of 100consecutive patients with odontogenic infections, Ylijokiet al (2001) found that fever and a high level of CRP wasa good indicator for the need for intensive care unittreatment and thus for the course of the infection.Frequent monitoring of CRP during the course appearslikewise to be of value.

Should the oral and maxillofacial surgeon care aboutthese rarities when the risk of encountering them is solow?

Most likely, few oral clinicians will be experts on theseinfections, but bearing in mind the high risk of a rapiddevelopment into a life-threatening condition the oralclinician must care. One day it could make the differencefor that one severely infected patient of your life.

References

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