10.14639/0392-100X-suppl.1-41-2021-14
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.
text/xml
1827-675X
1695
en
Marco de Vincentiis
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
abscesses
Surgical multidisciplinary approach in the management of odontogenic or non-odontogenic neck infections
Text.Serial.Journal
https://www.actaitalica.it/
41
Annual congress report
2021-05-14
2021-05-10
2021-05-14
2021-05-14
138-144
1
Marco de Vincentiis
2021/05/14
10.14639/0392-100X-suppl.1-41-2021-14
138
Department of Oral and Maxillo-Facial Surgery, University Sapienza of Rome, Italy
1827-675X
abscesses
144
Surgical multidisciplinary approach in the management of odontogenic or non-odontogenic neck infections
https://www.actaitalica.it/article/download/1695/568
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41(SUPPL.1):S138-S144; doi: 10.14639/0392-100X-suppl.1-41-2021-14




Surgical multidisciplinary approach in the
management of odontogenic or non-odontogenic
neck infections
Gestione chirurgica multidisciplinare delle complicanze cervicali nelle patologie
odontogene o non odontogene
Francesca Cambria1, Massimo Fusconi1, Francesca Candelori1, Massimo Galli2,
Francesca Romana Federici Stanganelli2, Federico Venuta3, Valentino Valentini1, Marco de Vincentiis2
1
 Department of Sense Organs, University Sapienza of Rome, Italy; 2 Department of Oral and Maxillo-Facial Surgery, University
Sapienza of Rome, Italy; 3 Department of Thoracic Surgery, University Sapienza of Rome, Rome, Italy


SUMMARY
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.
                                                                                                  Received: November 10, 2020
KEY WORDS: multidisciplinary team, head-neck, dental disease, abscesses                           Accepted: February 25, 2021


RIASSUNTO                                                                                         Correspondence
                                                                                                  Massimo Fusconi
Negli ultimi anni, nel nostro ospedale universitario, il numero di ascessi cervicali, odon-
                                                                                                  Department of Sense Organs, Sapienza University,
togeni e non odontogeni, si è mostrato in rapido aumento. Dal 4 gennaio 2018 fino al 19           Umberto I Hospital
febbraio 2020 abbiamo valutato 70 pazienti affetti da ascessi di natura odontogena. Le            viale del Policlinico 155, 00161 Rome, Italy
infezioni degli spazi profondi del collo possono portarsi fino al torace ed hanno un alto         E-mail: massimo.fusconi@uniroma1.it
tasso di morbilità e mortalità. Lo scopo di questo studio è di dimostrare che, in caso di com-
plicanze, è richiesto un approccio multidisciplinare per trattare queste patologie. Quindi        Funding
tutti gli specialisti coinvolti dovrebbero collaborare per ottenere una rapida ripresa delle      None.
condizioni del paziente.
                                                                                                  Conflict of interest
PAROLE CHIAVE: team multidisciplinare, testa-collo, patologie odontogene, ascessi                 The Authors declare no conflict of interest.


                                                                                                    How to cite this article: Cambria F, Fusconi
Introduction                                                                                        M, Candelori F, et al. Surgical multidisciplinary
                                                                                                    approach in the management of odontogenic or
Dental infections are very common and are mainly due to dental caries. They                         non-odontogenic neck infections. Acta Otorhi-
                                                                                                    nolaryngol Ital 2021;41(SUPPL.1):S138-S144.
affect mostly men, between the third and fifth decades, with underlying sys-                        https://doi.org/10.14639/0392-100X-sup-
temic disease (as diabetes), from a rural background, with poor oral hygiene                        pl.1-41-2021-14
and lack of dental care 1-3. The clinical progression of these infections can lead
                                                                                                  © Società Italiana di Otorinolaringoiatria
to the appearance of an abscess. Deep neck abscesses of non-dental origin can                     e Chirurgia Cervico-Facciale
be caused by peritonsillar or retropharyngeal abscess, sialoadenitis, epiglot-
titis, cervical lymphadenitis, jugular intravenous drug use and trauma, as well                                  OPEN ACCESS
as iatrogenic causes including infection of surgical wounds 4. The abscesses                      This is an open access article distributed in accordance with
                                                                                                  the CC-BY-NC-ND (Creative Commons Attribution-Non-
have many complications that affect the head-neck district. They are poten-                       Commercial-NoDerivatives 4.0 International) license. The
tially lethal, and consist of upper airway obstruction, mediastinitis, necrotizing                article can be used by giving appropriate credit and mentio-
                                                                                                  ning the license, but only for non-commercial purposes and
fascitis, thoracic empyema, jugular vein thrombosis, sepsis, orbital abscess                      only in the original version. For further information: https://
and osteomyelitis 5-8.                                                                            creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                         Treatment of dental abscess: a management model




With the advent of modern antibiotics, the mortality rate as-
sociated with complications has significantly decreased 8.
The treatment of complications often requires a multidisci-
plinary surgical approach that can involve the otolaryngol-
ogist, 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 indus-
trialized countries as it affects 60-90% of school-aged chil-
dren 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 lo-
calized 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 antibi-
otic therapy, if necessary 11.
Pulp necrosis, caused by dental caries, represents the most
common way of diffusion. The bacteria responsible for the        Figure 1. Ludwig angina, bilateral submandibular phlegmon caused by low-
                                                                 er molars caries.
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         cal diagnosis with contrast-enhanced CT imaging and ul-
periapical region’s contamination happens after the propa-       trasound.
gation 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       Non-odontogenic neck infections
anatomical structures (for example a maxillary sinusitis or      Deep neck infections of non-dental origin are mainly due to
a cystic infected lesion), can extend to the periapical region   peritonsillar abscesses, adenoiditis, epiglottitis, sialadenitis
of the adjacent tooth, causing its necrosis. Therefore, it is    and otomastoiditis. Peritonsillar abscess is the most com-
necessary to check the vitality of the teeth that could have     mon deep infection of the head and neck. Most cases are
been infected.                                                   consequences of recurrent or chronic bacterial tonsillitis,
Regarding pericoronitis, the incomplete eruption of a tooth      leading to abscesses in the parapharyngeal space. It is most
can promote the bacterial proliferation in the region be-        common in patients 20-40 years of age, with no gender pre-
tween the crown of the tooth and the surrounding soft tis-       dilection. Although rare in childhood, peritonsillar abscess
sues. In case of more aggressive forms, it can extend to the     has a greater risk of airway obstruction in paediatric popu-
outlying tissues 14.                                             lation than in adults. Patients may present with changes in
Typical signs and symptoms of cervical complications             voice, odynophagia, drooling, dysphagia, trismus, and sys-
from dental origin are fever, neck mass, lymphadenopathy,        temic symptoms such as malaise and fever. The most com-
trismus and odynophagia. It is important to support clini-       mon pathogens are β-Haemolytic Streptococcus, Pneumo-



                                                                                                                                  S139
F. Cambria et al.




                                                                         pears as a collection of low attenuating fluids that dilates
                                                                         the retropharyngeal space with enhancement of the periph-
                                                                         eral 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 sialolithi-
                                                                         asis. 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 demon-
                                                                         strate an enlarged salivary gland with increased attenua-
                                                                         tion, increased enhancement poorly defined borders, sur-
                                                                         rounding 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 re-
                                                                         mains 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 vari-
                                                                         ant) or on the sheath of the digastric muscle (Truffert ana-
                                                                         tomical variant), does not reach the medial aspect of the
Figure 2. Left parapharyngeal and cheek phlegmon caused by upper third
molar dysodontiasis.
                                                                         mandible resulting in a communication between the sub-
                                                                         maxillary lodge and the perivisceral space.
                                                                         Due to a similar etiopathogenesis, a phlegmon or perivis-
coccus, Staphylococcus aureus and Haemophilus inﬂuenzae.                 ceral abscess can originate from the parotid gland; the inva-
Infection, that penetrates the fibrous tonsillar capsule and the         sion of the perivisceral space is caused by the lack of a true
peritonsillar space, may continue to extend into the mastica-            capsule on the deep edge of the gland.
tor, parapharyngeal, or submandibular space. Imaging is not              Bezold’s abscess is a rare complication of acute otomastoidi-
performed routinely as the diagnosis is clinical. However, CT            tis in which the infection erodes, through the medial cortex,
with contrast agent is used if the diagnosis is uncertain, and           the tip or internal surface of the mastoid and causes abscess
typically shows fluid density with peripheral enhancement                formation in the sternocleidomastoid muscle that extends into
                                                                         the infratemporal fossa. Due to the depth of the cervical fascia
adjacent to an inflamed tonsil.
                                                                         that surrounds the sternocleidomastoid and trapezius muscles,
Infections of the retropharyngeal space generally result
                                                                         the abscess is impalpable. As the mastoid sinus pneumatises
from the spread of infection from one site with a primary
                                                                         late in childhood, Bezold’s abscess occurs more frequently in
drainage route to the lymph nodes of the retropharyngeal
                                                                         adults. Due to its proximity to the internal jugular vein, the
space. In these cases, the causes can be otitis, pharyngitis,
                                                                         thrombosis is a possible complication 16.
tonsillitis and infections of the oral cavity 5.
An abscess occupying the retropharyngeal space can also
derive from adenoiditis. The retropharyngeal lymph nodes                 Antibiotics
affected by the infection become enlarged and suppurate.                 Antibiotic therapy for deep neck space infections is based
On contrast-enhanced CT, a retropharyngeal abscess ap-                   on broad-spectrum antibiotics such as penicillin based,



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                                                                                                     Treatment of dental abscess: a management model




                                                                                clindamycin, and metronidazole 17. The literature supports
 A
                                                                                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 unavoid-
                                                                                able.

                                                                                Multidisciplinary management of deep neck
                                                                                infections
                                                                                Without treatments, the infection can spread into surround-
                                                                                ing tissues. When there is airway impairment, sepsis, de-
                                                                                scending 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 laryn-
 B
                                                                                goscopy to evaluate the obstruction generated at the level of
                                                                                the oropharynx (glossoptosis) or the laryngo-pharynx (pe-
                                                                                ripharyngeal oedema). Compared with elective intubation,
                                                                                emergency intubation is therefore associated with an ele-
                                                                                vated 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 al-
                                                                                low intubation of more challenging patients. They are per-
                                                                                formed 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 tra-
                                                                                cheostomy 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
 C
                                                                                related complications. Moreover, in severe cases of airway
                                                                                oedema, a prolonged intubation is required, and early tra-
                                                                                cheostomy can offer several benefits in ICU care compared
                                                                                to intubation such as for example avoiding laryngeal in-
                                                                                jury 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 sci-
                                                                                entific 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
Figure 3. Odontogenic abscess of the upper right arch, partial obstruction of
the upper airway. The head, neck and chest CT scan, with contrast medium,
                                                                                tracheostomy was superior regarding reduced duration of
documented a phlegmon that reached the mediastinum, through the perivis-        mechanical ventilation, with less mortality rates and less
ceral space. (A) coronal plane; (B) sagittal plane; (C) axial plane.            duration of stay in ICU 23.



                                                                                                                                             S141
F. Cambria et al.




In the case of abscesses of odontogenic origin, to treat the       sive drains should be covered with a sterile bandage that is
infections of cervical space a surgical approach in team           placed and aseptically exchanged. if it does not, fluid can
with the dentist is almost mandatory, since in most cases it       lead to severe skin irritation and excoriation in addition to
is necessary to perform the extraction of one or more dental       increasing the risk for ascending infection 34.
elements. As Heim and Warwas proved quite recently, this           Active drains, like Jackson-Pratt ones, are closed systems
better happens during the execution of an exploratory cervi-       that collect fluid into a reservoir. This decreases the risk
cotomy 24. Odontogenic infections spread from mandible or          for ascending infection and can reduce exposure of hospital
maxilla into the sublingual, submandibular, or masticatory         staff or other patients to contaminated fluid. Active drains
spaces and then into the parapharyngeal space. For this rea-       apply an artificial pressure gradient to pull fluid or gas from
son, the site of neck incision depends on the affected area.       a wound or body cavity 35.
In any case the surgical incision should be placed in healthy      Through the perivisceral space or the vascular space the
skin, when possible, not at the site of maximum fluctuance,        infectious process can reach the anterior mediastinum,
because these wounds tend to heal with an unsightly scar. It       differently when the abscess involves the third or fourth
should be into a natural skin fold, in a dependent position.       cervical lodge, respectively the perivisceral space and the
Drainage of the submandibular space can be required a              prevertebral space, it can reach the chest, causing posterior
subperiosteal intraoral and an extraoral incision. For the ex-     mediastinitis. In fact, Endo et al. classified descending me-
ternal approach the incision should be done approximately          diastinitis according to the degree of diffusion of infection
3 to 4 cm below the angle of the mandible. The incision is         diagnosed by computed tomography. Localized descending
performed on skin and subcutaneous tissues, to the platy-          mediastinitis, type I, is localized in the upper mediastinal
sma. The platysma is divided with electrocautery or sharp          space above the carina. Diffuse descending mediastinitis,
dissection. Superficial and middle cervical fascia are cut in      type IIA, is extended to the lower anterior mediastinum and
parallel to the inferior border of the mandible. The dissec-       type IIB reach both anterior and posterior lower mediasti-
tion continues in a superior-medial direction to enter the         num 36.
submandibular space.                                               Surgery is a complex procedure; thoracotomy and extended
Drainage of the lateral pharyngeal space is approached             cervicotomy is the gold standard approach, as Corsten and
mainly through an external approach. In this case, neck            Taylor assert in their papers 4,37. The goal is to drain all the
dissection can be performed according to Paul André’s ap-          suppurated fluids, to save the organs from the close pus and
proach 25. Once reached the SCM muscle, the incision is            fibrin collections. These operations give the chance to na-
carried down to the superficial and middle cervical fascia,        tive tissues to regenerate consequently. Drainages and tis-
and the carotid sheath is identified and opened. Dissection        sue stimulating dressings can be left in each corner of the
is carried superiorly along the vessels.                           affected areas after debridement. More recently, the arma-
In order to reach abscesses affecting the perivisceral space       mentarium has been improved with a new technology that
up to the base of the neck, it is possible to extend the Paul      has shown promising results; the VAC-therapy seems to be
André’s incision or perform a horizontal or median arch-           associated to a faster resolution of the local tissue damage
shaped incision about 3 cm above the sternum dimple. In            and some studies has encouraged to use this device more
this case, the perivisceral space surrounding the thyroid and      extensively 38.
larynx is reached after incision of the superficial and mid-
dle cervical fascia.
In people who have large retropharyngeal space abscesses,
                                                                   Conclusions
an external approach is needed. The carotid sleeve is mo-          The number of cervical deep infections has been rapidly
bilized medially, so it is possible to reach the deep cervical     increasing in the last years. Abscesses of odontogenic and
fascia and if necessary, the prevertebral fascia. In selected      non-odontogenic origin have a strong tendency to spread
cases, with single-chamber and circumscribed abscess cav-          between the tissues and to invade the deep spaces of the
ities, endopharyngeal access to the abscess is possible 26-31.     neck down to the chest. The main reason for ENT consul-
After the abscess has been drained, the drains are placed 32,33.   tation is the evaluation of the airway but in many cases,
To date, it is not clear if it is better use passive drains than   thoracotomy and extended lateral/anterior cervicotomy is
open ones. Passive drains are made of latex, polypropyl-           required in order to drain all the suppurated fluids. In this
ene, or silastic rubber. These include Penrose drains and          scenario, a multidisciplinary approach involving the ENT
glove finger. They work by capillary action, gravity, over-        surgeon, the dentist, the thoracic surgeon and the infectivo-
flow, or fluctuations of pressure gradients caused by body         logist, is the best option to treat such a challenging compli-
movement. To reduce the risk for ascending infection, pas-         cation of several head and neck pathologies.



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                                                                                                         Treatment of dental abscess: a management model




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