Sage Journals: Discover world-class research

Abstract

Background: Deep neck infection (DNI) involves the deep neck spaces and may lead to airway compromise. An intensive care unit (ICU) is a specialized unit of the hospital that provides intensive care. ICU care is required for patients with severe DNI, although the risk factors for need of ICU care in patients with DNI have not been investigated. Methods: The clinical and laboratory parameters of 350 patients aged >18 years who were diagnosed with DNI between October 2018 and October 2023 were evaluated. Of these patients, 62 were transferred to the ICU. Univariate and multivariate analyses were applied to assess the risk factors for need of ICU care. Results: Univariate analysis revealed that older age [odds ratio (OR) = 1.0324, 95% confidence interval (CI): 1.0155-1.0496, P = .0001], a higher C-reactive protein (CRP) level (OR = 1.0076, 95% CI: 1.0049-1.0103, P < .0001), and blood glucose level (OR = 1.0057, 95% CI: 1.0023-1.0091, P = .0011), involvement ≥3 spaces (OR = 2.2366, 95% CI: 1.2827-3.8998, P = .0046), and mediastinitis (OR = 4.7134, 95% CI: 2.3537-9.4391, P < .0001) were significant risk factors for ICU transfer in patients with DNI. In multivariate analysis, older age (OR = 1.0216, 95% CI: 1.0032-1.0403, P = .0210), higher CRP level (OR = 1.0063, 95% CI: 1.0033-1.0092, P < .0001), and mediastinitis (OR = 2.6103, 95% CI: 1.1974-5.6905, P = .0158) were independent risk factors of ICU transfer in patients with DNI. The ICU group had a longer hospital stay (23.98 ± 8.53 vs 7.44 ± 4.24, P < .0001) and higher rate of tracheostomy (P < .0001) than the non-ICU group. However, there were no significant differences in the rate of incision and drainage open surgery or pathogens between the groups (all P > .05). Conclusions: Elder patients and those with advanced CRP levels and mediastinitis are more likely to be transferred to the ICU, leading to prolonged hospital stays and a higher risk of tracheostomy. Clinicians should assess the patient’s need for ICU transfer and timely manage the airway according to the aforementioned laboratory parameters and complications carefully.

Keywords

C-reactive protein deep neck infection elder age intensive care unit mediastinitis

Introduction

Deep neck infection (DNI) encompasses several infections affecting spaces surrounding the neck^1,2 and deep tissues, typically involving internal structures such as the pharynx, larynx, and trachea. It can lead to severe complications.^3-11 The etiology of DNI commonly includes dental infections, tonsillar gland infections, and lymphadenitis.¹²

Currently, contrast-enhanced computed tomography (CT) scan (Figures 1 and 2) is the main method for DNI. CT scan can accurately identify the edge of the abscess and adjacent tissues, which is helpful for abscess drainage. Basically, surgical drainage depends on the size and location of the abscess. Surgical drainage is required in patients with neurovascular complications, airway compromise, or failure to improve after at least 48 hours of intravenous antibiotics. Based on previous reports, use empiric antibiotics to cover aerobic and anaerobic bacteria until pathogen culture results are obtained, including ceftriaxone 1 g every 12 hours and metronidazole 500 mg every 8 hours.^13-16

Figure 1.

An axial computed tomography scan of the head and neck of a patient with DNI. The arrowhead points to the endotracheal tube. The area shown by the double-dot arrow represents the range of DNI. P, parapharyngeal space; R, retropharyngeal space.

Figure 2.

The coronal (A) and sagittal (B) computed tomography images of the head and neck of a patient with deep neck infection. Coronal view shows that the patient has obvious inflammation and abscess lesions in the parapharyngeal space, and the double dotted arrows indicate their expansion. For the sagittal view, the curved arrow represents the trajectory of the nasotracheal intubation. Because inflammation and swelling in the retropharyngeal and parapharyngeal spaces are too severe to open the patient’s mouth, the endotracheal tube is inserted through the nose rather than through the mouth. P, parapharyngeal space; R, retropharyngeal space.

Intensive care units (ICUs) of hospitals are designed for critically ill patients who require highly intensive medical care. To prevent interference and infection transmission, ICUs adopt a closed design and strictly limit visitor entry and meeting time. They are equipped with various equipment and instruments to continuously monitor vital signs and physiological changes in patients. Medical staff work in shifts to provide comprehensive care.¹⁷ For patients with DNI, particularly those who are critically ill, admission to the ICU is necessary. In the ICU, continuous monitoring by medical staff working in 24 hours shifts facilitates the prompt detection and management of worsening DNI. Emergency tracheostomy and intubation is necessary to save the lives of patients with airway compromise.¹⁸ In cases of rapid development of DNI, the opportunity to transfer these critically ill patients to the ICU may be missed. However, the factors associated with need for ICU admission in patients with DNI have not been investigated. Therefore, this study explored the predictors of ICU admission in this population.

Materials and Methods

A total of 350 patients aged >18 years who were diagnosed with DNI at Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, between October 2018 and October 2023 were enrolled retrospectively. Clinical manifestations and diagnosis were recorded. The diagnosis of DNI was confirmed based on radiological imaging and laboratory and microbial testing.¹⁹ A total of 62 patients with DNI were admitted to the ICU.

Patient data were collected to investigate risk factors for ICU transfer in patients with DNI (Table 1) including laboratory data such as C-reactive protein (CRP) level (at initial emergency admission; normal range <5 mg/L) and blood glucose level (at initial emergency admission; normal range: 70-100 mg/dL).

Table 1.

Clinical Characteristics of the 350 Patients With DNI.

Characteristics	N (%)
Gender	350 (100.00)
Male	232 (66.28)
Female	118 (33.72)
Age, y (median; IQR)	54; 26.25
CRP, mg/L (median; IQR)	139.5; 173.25
Blood glucose, mg/dL (median; IQR)	121; 79.25
Multiple spaces, ≥3	125 (35.71)
Parapharyngeal space	218 (62.28)
Submandibular space	173 (49.42)
Retropharyngeal space	113 (32.28)
Masticator space	73 (20.85)
Parotid space	49 (14.00)
Anterior cervical space	29 (8.28)
Carotid space	24 (6.85)
Visceral space	23 (6.57)
Perivertebral space	14 (4.00)
Posterior cervical space	10 (2.85)
Mediastinitis	41 (11.71)
Mortality	22 (6.28)

Abbreviations: Blood sugar (normal range: 70-100 mg/dL); CRP, C-reactive protein (normal range <5 mg/L); DNI, deep neck infection; IQR, interquartile range; N, numbers.

The attending physician decided whether to transfer the patient to the ICU based on clinical condition. Patients admitted to the ICU often had unstable vital signs or respiratory obstruction. The vital signs of patients were continuously monitored in the ICU, and emergency airway management was promptly initiated when indicated.

Patients are usually transferred to the ICU for treatment under 2 circumstances after initial treatment in the emergency room. One is that if symptoms worsen or airway obstruction occurs, the patient will be transferred to the ICU. Second, after the abscess is incised and drained, the patient still needs ICU care.

Exclusion Criteria

Patients who had previously undergone head and neck tumor surgery, head and neck radiotherapy, or swallowed foreign bodies were excluded.

Ethics Statement

Institutional Review Board (IRB) of the Chang Gung Memorial Medical Foundation approved this study (IRB number: 202301870B0) and waived the need for informed consent due to retrospective analysis.

Statistical Analysis

We used MedCalc software (version 18.6; MedCalc) to analyze all data. The chi-square test was used to analyze categorical variables, the Mann-Whitney U test was used to compare continuous variables, and logistic regression was used for univariate and multivariate analyses. The continuous variables were presented with median and IQR (interquartile range). P < .05 indicated statistical significance.

Results

This study included 350 patients with DNI, including 232 males (66.28%) and 118 females (33.72%) with a median age of 54 (IQR = 26.25) years old. Table 1 presents the clinical features of the study participants. The median CRP level was 139.5 (IQR = 173.25) mg/L, and the median blood glucose level was 121 (IQR = 79.25) mg/dL. Multiple spaces were involved in 125 (35.71%) patients. The most commonly involved spaces were the parapharyngeal space (n = 218, 62.28%), submandibular space (n = 173, 49.42%), and retropharyngeal space (n = 113, 32.28%). Mediastinitis developed in 41 (11.71%) patients. A total of 22 people died, and the mortality rate was around 6.28% (22/350).

Univariate analysis revealed that, compared to the non-ICU group, the ICU group had a significantly older age [62; 32.5 vs 52; 25 years; odds ratio (OR) = 1.0324, 95% confidence interval (CI): 1.0155-1.0496, P = .0001], higher CRP level (243.5; 149 vs 123; 145 mg/L; OR = 1.0076, 95% CI: 1.0049-1.0103, P < .0001), and blood glucose level (156; 127.25 vs 119; 57 mg/dL; OR = 1.0057, 95% CI: 1.0023-1.0091, P = .0011), and more frequent involvement of multiple spaces (OR = 2.2366, 95% CI: 1.2827-3.8998, P = .0046) and mediastinitis (OR = 4.7134, 95% CI: 2.3537-9.4391, P < .0001; Table 2).

Table 2.

Univariate and Multivariate Analyses of Patients Admitting to ICU.

Variable	ICU		Univariate analysis			Multivariate analysis
Variable	Yes	No	OR	95% CI	P value	OR	95% CI	P value
Gender	62	288	1.3035	0.7391-2.2987	.3598			<
Male	38	194
Female	24	94
Age, y (IQR)	62; 32.5	52; 25	1.0324	1.0155-1.0496	.0001	1.0216	1.0032-1.0403	.0210
CRP, mg/L (IQR)	243.5; 149	123; 145	1.0076	1.0049-1.0103	<.0001	1.0063	1.0033-1.0092	<.0001
Blood glucose, mg/dL (IQR)	156; 127.25	119; 57	1.0057	1.0023-1.0091	.0011	—	—	—
Multiple spaces, ≥3	32	93	2.2366	1.2827-3.8998	.0046	—	—	—
Parapharyngeal space	45	173	0.5683	0.3101-1.0415	.0675
Submandibular space	24	149	0.5892	0.3363-1.0324	.0617
Retropharyngeal space	18	95	0.8311	0.4557-1.5157	.5429
Masticator space	12	61	0.8931	0.4477-1.7816	.7465
Parotid space	12	37	1.6281	0.7938-3.3395	.1963
Anterior cervical space	9	20	2.2755	0.9823-5.2713	.0670
Carotid space	6	18	1.6071	0.6106-4.2300	.3534
Visceral space	5	18	1.3158	0.4692-3.6900	.6101
Perivertebral space	4	10	1.9172	0.5812-6.3247	.3074
Posterior cervical space	4	6	3.2414	0.8866-11.850	.0927
Mediastinitis	18	23	4.7134	2.3537-9.4391	<.0001	2.6103	1.1974-5.6905	.0158

P < .05. Significant differences are shown in bold.

Abbreviations: CI, confidence intervals; CRP, C-reactive protein; DNI, deep neck infection; ICU, intensive care unit; IQR, interquartile range; OR, odds ratio.

Multivariate analysis revealed that patients with an older age (OR = 1.0216, 95% CI: 1.0032-1.0403, P = .0210), higher CRP level (OR = 1.0063, 95% CI: 1.0033-1.0092, P < .0001), and mediastinitis (OR = 2.6103, 95% CI: 1.1974-5.6905, P = .0158) were more likely to be admitted to the ICU.

Table 3 presents a comparison of the duration of hospital stay and management between patients with and without ICU admission. The median duration of hospital stay was significantly longer in the ICU group than in the non-ICU group (22; 12 vs 7; 6.75 days, P < .0001). The median length of ICU stay was 4 (IQR = 4) days. In addition, the proportion of patients requiring tracheostomy was significantly higher in the ICU group than in the non-ICU group (43.54% vs 9.72%, P < .0001). However, there were no significant differences in the proportion of patients undergoing open incision and drainage between the ICU and non-ICU groups (P = .2812). The mortality rate was also significantly higher in the ICU group than in the non-ICU group (12/62; 19.35% vs 10/288; 3.47%, P = .0001).

Table 3.

Comparison of Length of Hospital Stay and Management Between Patients With and Without Admitting to ICU.

Characteristics	ICU, N = 62, n (%)	Non-ICU, N = 288, n (%)	P value
Length of hospital stay, d (IQR)	22; 12	7; 6.75	<.0001
Length of ICU stay, d (IQR)	4; 4
Tracheostomy	27 (43.54)	28 (9.72)	<.0001
I&D open surgery	38 (61.29)	155 (53.81)	.2812
Mortality	12 (19.35)	10 (3.47)	.0001

P < .05. Significant differences are shown in bold.

Abbreviations: DNI, deep neck infection; I&D, incision and drainage; ICU, intensive care unit; IQR, interquartile range; N, number.

Table 4 presents a comparison of pathogens between patients with and without ICU admission. For the patients admitted to the ICU, the most common pathogens were Streptococcus constellatus (24.19%), followed by Streptococcus anginosus (17.74%) and Klebsiella pneumonia (16.12%). In non-ICU patients, the most common pathogens were Parvimonas micra (15.97%), followed by S. constellatus (15.27%) and Prevotella intermedia (14.58%). However, there were no statistically different results between groups (P < .05).

Table 4.

Comparison of Pathogens Between Patients With and Without Admitting to ICU.

Pathogens	All, N = 350, n (%)	ICU, N = 62, n (%)	Non-ICU, N = 288, n (%)	P value
Streptococcus constellatus	59 (16.85)	15 (24.19)	44 (15.27)	.1015
Parvimonas micra	52 (14.85)	6 (9.67)	46 (15.97)	.1862
Prevotella intermedia	47 (13.42)	5 (8.06)	42 (14.58)	.1469
Klebsiella pneumonia	43 (12.28)	10 (16.12)	33 (11.45)	.3245
Streptococcus anginosus	38 (10.85)	11 (17.74)	27 (9.37)	.0698
Prevotella buccae	35 (10.00)	7 (11.29)	28 (9.72)	.7191
Staphylococcus aureus	21 (6.00)	6 (9.67)	15 (5.21)	.2058
Staphylococcus epidemidis	8 (2.28)	3 (4.83)	5 (1.73)	.1797
Salmonella enterica	8 (2.28)	2 (3.22)	6 (2.08)	.6018
Streptococcus salivarius	7 (2.00)	0 (0.00)	7 (2.43)	.0966
Eikenella corrodens	6 (1.71)	1 (1.61)	5 (1.73)	.9455
Slackia exigua	5 (1.42)	1 (1.61)	4 (1.38)	.8944
Pseudomonas aeruginosa	3 (0.85)	1 (1.61)	2 (0.69)	.5136
Gemella morbillorum	2 (0.57)	0 (0.00)	2 (0.69)	.3764
Streptococcus oralis	1 (0.28)	0 (0.00)	1 (0.34)	.5320

Abbreviations: ICU, intensive care unit; N, number.

Discussion

An ICU is a specialized medical facility designed for the treatment of critically ill patients, usually located within a highly specialized department of a hospital. In DNI, airway protection is essential for saving lives, particularly for individuals with severe respiratory or purulent infections.²⁰ Both endotracheal intubation and tracheostomy should be considered emergent procedures to stabilize the airway structure of patients.

Although patients are typically transferred to the ICU when symptoms worsen or airway obstruction develops, surgeons may make subjective decisions about whether patients require ICU transfer. In addition, the patient capacity of each ICU in each hospital also varies. These are the reasons why there are still no standards for patients to be transferred to ICU for treatment. This study attempts to identify risk factors for ICU transfer in patients with DNI. In this research, older age, a higher CRP level, and mediastinitis were independent risk factors for need of ICU transfer in patients with DNI. Patients requiring ICU admission had a longer hospital stay and a higher rate of tracheostomy than patients who did not require ICU admission. There were no differences in DNI pathogens between patients with and without ICU admission.

Univariate analysis revealed that a higher blood glucose level and involvement ≥3 spaces were risk factors for need of ICU transfer in DNI patients. A higher blood glucose level may be associated with a higher incidence rate and more severe complications of DNI.

Lin et al²¹ revealed that patients with diabetes mellitus had a significantly higher complication rate, longer length of hospital stay, and more frequent need for tracheotomy than those without diabetes.

Similarly, Zheng et al²² demonstrated that the blood glucose level was significantly higher in patients with complications than those without complications. A high blood glucose level is an independent risk factor of simultaneous DNI and cervical necrotizing fasciitis.²³

Thus, it should be monitored closely during hospitalization. Involvement of ≥3 deep neck spaces is associated with a longer length of hospital stay and higher rates of reoperation and mortality.^24,25 However, involvement of multiple spaces is not an independent risk factor for ICU admission. Infection can spread rapidly between cervical spaces, which can worsen the clinical status of patients, which makes treatment challenging and predisposing to complications. Patients with a large abscess that is not located at a critical site and does not cause swallowing dysfunction are less likely to need ICU care.

Univariate and multivariate analyses revealed that older age, a higher CRP level, and mediastinitis are independent risk factors for ICU transfer in patients with DNI. Older patients are vulnerable and have more comorbidities, resulting in more complicated and unpredictable disease course. Previous studies have found that older patients had a longer length of hospital stay and higher risk of mortality.^26,27 DNI typically involves a higher number of spaces in older patients than in those aged <18 years.²⁸ In addition, older age is a risk factor for the need of tracheostomy.²⁹ Older patients are more likely to have systemic diseases, such as hypertension and diabetes mellitus, and diabetes increases the risk of mortality in patients with DNI.^21,30 Furthermore, patients aged >65 years had a longer hospital stay and poor response to antibiotics for DNI.³¹ These patients are also predisposed to pneumonia because of the impaired gag reflex, decreased mucociliary function, waning immunity, impaired febrile response, and cardiopulmonary dysfunction.³² Considering that the care of older patients is more complicated, older age is a risk factor for the need of ICU care in patients with DNI.

A higher CRP level is associated with more severe infection. In our study, the CRP level was significantly higher in the ICU group than in the non-ICU group, indicating that the former had more severe infection and inflammation and a higher risk of fatal complications. A previous study demonstrated that DNI patients with CRP level ˃100 mg/L had longer hospital stays.³³

Previous studies have demonstrated that the CRP level is highly correlated with the mortality rate and risk of cervical necrotizing fasciitis.²⁶ Ohata et al³⁴ found that the CRP level was significantly higher in older patients and those with diabetes mellitus or prolonged infections. Thus, it could be used to determine the need for ICU care in patients.

The diagnosis of mediastinitis is mainly based on characteristic radiographic features of mediastinitis.¹¹ Mediastinitis is a common potentially fatal complication of DNI. It can cause persistent infection, leading to the development of other diseases such as empyema, pericarditis, and vascular erosion. The mortality rate was significantly higher in patients with mediastinitis than in those without mediastinitis.³⁵ Gehrke et al³⁶ found that patients with mediastinitis exhibited significantly higher rates of surgical interventions and tracheotomy, elevated levels of inflammatory markers, a greater requirement for CT scans, prolonged hospitalization, and a higher likelihood of requiring changes in antibiotic therapy. Considering the intensive care required for patients with mediastinitis, clinicians should monitor the clinical condition carefully to determine the need for ICU transfer.

Airway management is essential in patients with DNI due to the potential airway compromise. Our study demonstrated that patients transferred to the ICU had a higher rate of tracheostomy. A previous study found that patients undergoing tracheotomy have a prolonged extended hospital stay, potentially attributable to the illness severity rather than the selected method of airway management. Similarly, we found that the ICU group had a longer length of hospital stay. Furthermore, Barber et al³⁷ demonstrated that airway compromise contributes to prolonged hospitalization. However, patients primarily treated with tracheotomy had a shorter ICU stay compared to those who were intubated without immediate extubation, although this difference was not statistically significant. Furthermore, performing tracheotomy within 7 days after intubation reduces the duration of artificial ventilation and length of ICU stay.³⁸ Mahafza et al³⁹ compared revealed that, compared to late tracheostomy, tracheotomy performed <3 weeks after intubation was associated with lower complication and mortality rates in the ICU (Table 5).

Table 5.

Findings and Descriptions Related With ICU Care of this Study in Literature.

Year	Authors	Findings and Descriptions
2005	Griffiths et al	Performing tracheotomy within 7 d after intubation reduces duration of artificial ventilation and length of ICU stay.
2012	Mahafza et al	Tracheotomy performed <3 wk after intubation was associated with lower complication and mortality rates in ICU.
2014	Barber et al	Patients primarily treated with tracheotomy had a shorter ICU stay compared to those who were intubated without immediate extubation, although this difference was not statistically significant.

Abbreviation: DNI, deep neck infection.

Recently, artificial intelligence models have also been used to evaluate patients with DNI. One study retrospectively analyzed patients with DNI who underwent drainage surgery. Multivariable logistic regression analysis and the eXtrem Gradient Boosting algorithm were applied to develop a predictive model to guide clinical decisions for postoperative ICU admission in patients with DNI.⁴⁰

Our patients were initially treated with empirical, broad-spectrum, intravenous antibiotics, which were later adjusted based on culture results. There were no significant differences between patients admitted to the ICU and those who were not. In our cohort, S. constellatus was the most frequently isolated pathogen, followed by P. micra and P. intermedia. This contrasts with findings from previous studies, in which Streptococcus viridans, S. anginosus, K. pneumoniae, and Staphylococcus aureus were commonly isolated pathogens.^13,41-43 Despite these differences, third-generation cephalosporin such as ceftriaxone plus metronidazole could effectively treat these pathogens. Empirical antibiotics were initiated and subsequently adjusted based on culture results. Considering the diverse pathogens associated with DNI, possibility of polymicrobial infections, and presence of aerobic and anaerobic organisms in the oropharyngeal microbial community, the selected antibiotics should cover both aerobic and anaerobic organisms.⁴⁴ When antibiotics have been administered previously, blood culture may not be a sensitive method for pathogen identification.^45,46

Limitations of the Article

This study had several limitations. First, airway management, surgical procedures, and ICU transfer were based on surgeon discretion. Second, each hospital may have distinct protocols for transferring patients to the ICU, which makes comparisons between studies challenging. Furthermore, blood glucose is used more frequently as the presence of diabetes mellitus as a chronic disease and offers a more objective value in the literature. As a parameter, blood glucose in this article only represents the patient’s first arrival at the emergency room. Finally, this was a retrospective study conducted in a tertiary care hospital, which may be associated with suboptimal data collection.

Conclusion

This study evaluated the clinical risk factors for ICU admission in patients with DNI. Older patients and those with a higher CRP level and mediastinitis were more likely to be transferred to the ICU, resulting in a longer hospital stay and higher risk of tracheostomy. Clinicians should carefully evaluate patients regarding potential need for ICU transfer and promptly manage the airway based on the aforementioned laboratory parameters and complications.

Footnotes

Acknowledgements

The authors thank all of the members of Department of Otorhinolaryngology and Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, for their invaluable help.

Author Contributions

Conceptualization: Y.C.H.; C.Y.H.; K.C.C; Y.C.W.; S.C.C.; S.L.C. Methodology: Y.C.H.; C.Y.H.; S.L.C. Validation: Y.C.H.; K.C.C; S.L.C. Data curation: Y.C.H.; S.L.C. Writing—original draft preparation: Y.C.H.; S.L.C. Writing—review and editing: S.L.C. Visualization: C.Y.H; S.C.C.; S.L.C. Supervision: Y.C.H.; Y.C.W.; S.L.C. Project administration: C.Y.H.; S.C.C.; S.L.C. All authors have read and agreed to the published version of the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Kai-Chieh Chan

Shih-Lung Chen

References

Velhonoja

Laaveri

Soukka

Irjala

Kinnunen

. Deep neck space infections: an upward trend and changing characteristics. Eur Arch Otorhinolaryngol. 2020;277(3):863-872.

Chen

Chin

. Deep learning artificial intelligence to predict the need for tracheostomy in patients of deep neck infection based on clinical and computed tomography findings-preliminary data and a pilot study. Diagnostics (Basel). 2022;12(8):1943.

Tapiovaara

Back

Aro

. Comparison of intubation and tracheotomy in patients with deep neck infection. Eur Arch Otorhinolaryngol. 2017;274(10):3767-3772.

Rzepakowska

Rytel

Krawczyk

, et al. The factors contributing to efficiency in surgical management of purulent infections of deep neck spaces. Ear Nose Throat J. 2021;100(5):354-359.

Boscolo-Rizzo

Marchiori

Montolli

Vaglia

Da Mosto

. Deep neck infections: a constant challenge. ORL J Otorhinolaryngol Relat Spec. 2006;68(5):259-265.

Prado-Calleros

Jimenez-Fuentes

Jimenez-Escobar

. Descending necrotizing mediastinitis: systematic review on its treatment in the last 6 years, 75 years after its description. Head Neck. 2016;38(Suppl 1):E2275-E2283.

Aizawa

Tsuchiya

Takahashi

. Two cases of deep neck infection with esophageal perforation. J-STAGE. 2013;26(2):149-154.

C-Y

Wang

Y-C

Chin

S-C

Chen

S-L

. Factors affecting patients with concurrent deep neck infection and acute epiglottitis. Diagnostics (Basel). 2022;12(1):29.

Dobele

Kragis

Salms

Apse

. Severe deep neck space infection and bilateral pneumonia of odontogenic origin: a case report. Acta Chir Latviensis. 2010;10(2):121-123.

10.

Vieira

Allen

Stocks

Thompson

. Deep neck infection. Otolaryngol Clin North Am. 2008;41(3):459-483.

11.

Chin

Chen

. Management of descending necrotizing mediastinitis, a severe complication of deep neck infection, based on multidisciplinary approaches and departmental co-ordination. Ear Nose Throat J. 2022:1455613211068575.

12.

Virolainen

Haapaniemi

Aitasalo

Suonpaa

. Deep neck infections. Int J Oral Surg. 1979;8(6):407-411.

13.

Yang

Lee

See

Huang

Chen

. Deep neck abscess: an analysis of microbial etiology and the effectiveness of antibiotics. Infect Drug Resist. 2008;1:1-8.

14.

Chen

Wen

Chang

Lee

Huang

Hsiao

. Deep neck infections in diabetic patients. Am J Otolaryngol. 2000;21(3):169-173.

15.

Lanisnik

Cizmarevic

. Necrotizing fasciitis of the head and neck: 34 cases of a single institution experience. Eur Arch Otorhinolaryngol. 2010;267(3):415-421.

16.

Hasegawa

Sada

Yaegashi

Morimoto

Mori

, Adult Pneumonia Study G-J. 1g versus 2 g daily intravenous ceftriaxone in the treatment of community onset pneumonia—A propensity score analysis of data from a Japanese multicenter registry. BMC Infect Dis. 2019;19(1):1079.

17.

Goni-Viguria

Yoldi-Arzoz

Casajus-Sola

, et al. Respiratory physiotherapy in intensive care unit: bibliographic review. Enferm Intensiva (Engl Ed). 2018;29(4):168-181.

18.

Karkos

Leong

Beer

Apostolidou

Panarese

. Challenging airways in deep neck space infections. Am J Otolaryngol. 2007;28(6):415-418.

19.

Becker

Zbaren

Hermans

, et al. Necrotizing fasciitis of the head and neck: role of CT in diagnosis and management. Radiology. 1997;202(2):471-476.

20.

Chin

Wang

Chen

. Factors affecting patients with concurrent deep neck infection and aspiration pneumonia. Am J Otolaryngol. 2022;43(3):103463.

21.

Lin

Tsai

Chen

Liang

. Influence of diabetes mellitus on deep neck infection. J Laryngol Otol. 2006;120(8):650-654.

22.

Zheng

Yang

Zhang

, et al. Is there association between severe multispace infections of the oral maxillofacial region and diabetes mellitus? J Oral Maxillofac Surg. 2012;70(7):1565-1572.

23.

Chen

S-L

Chin

S-C

Wang

Y-C

C-Y

. Factors affecting patients with concurrent deep neck infection and cervical necrotizing fasciitis. Diagnostics (Basel). 2022;12(2):443.

24.

Obregon-Guerrero

Martinez-Ordaz

Moreno-Aguilera

Ramirez-Martinez

Pena-Garcia

Perez-Alvarez

. [Deep neck abscess. Factors related to reoperation and mortality]. Cir Cir. 2013;81(4):299-306.

25.

Chan

Wang

Chin

Chen

. Assessment of factors associated with long-term hospitalization in patients with a deep neck infection. Ear Nose Throat J. 2023:1455613231168478.

26.

O’Brien

Snapp

Dugan

Westgate

Gupta

. Risk factors affecting length of stay in patients with deep neck space infection. Laryngoscope. 2020;130(9):2133-2137.

27.

Chang

Tsai

Liu

, et al. End-stage renal disease: a risk factor of deep neck infection—A nationwide follow-up study in Taiwan. BMC Infect Dis. 2017;17(1):424.

28.

Maharaj

Ahmed

Pillay

. Deep neck space infections: a case series and review of the literature. Clin Med Insights Ear Nose Throat. 2019;12:1179550619871274.

29.

Chen

Young

Tsai

, et al. Factors affecting the necessity of tracheostomy in patients with deep neck infection. Diagnostics (Basel). 2021;11(9):1536.

30.

Lee

Kim

Lim

. Predisposing factors of complicated deep neck infection: an analysis of 158 cases. Yonsei Med J. 2007;48(1):55-62.

31.

Yang

Lee

Huang

Chen

Fang

. Analysis of life-threatening complications of deep neck abscess and the impact of empiric antibiotics. ORL J Otorhinolaryngol Relat Spec. 2008;70(4):249-256.

32.

Cunha

. Pneumonia in the elderly. Clin Microbiol Infect. 2001;7(11):581-588.

33.

Wang

Kuo

Tsai

Huang

. Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases. Am J Otolaryngol. 2003;24(2):111-117.

34.

Ohata

Kikuchi

Yoshinami

, et al. [Clinical study on deep neck infection]. Nihon Jibiinkoka Gakkai Kaiho. 2006;109(7):587-593.

35.

Trevino-Gonzalez

Maldonado-Chapa

Gonzalez-Larios

Morales-Del Angel

Soto-Galindo

Zafiro Garcia-Villanueva

. Deep neck infections: demographic and clinical factors associated with poor outcomes. ORL J Otorhinolaryngol Relat Spec. 2022;84(2):130-138.

36.

Gehrke

Scherzad

Hagen

Hackenberg

. Deep neck infections with and without mediastinal involvement: treatment and outcome in 218 patients. Eur Arch Otorhinolaryngol. 2022;279(3):1585-1592.

37.

Barber

Dziegielewski

Biron

Seikaly

. Factors associated with severe deep neck space infections: targeting multiple fronts. J Otolaryngol Head Neck Surg. 2014;43(1):35.

38.

Griffiths

Barber

Morgan

Young

. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. 2005;330(7502):1243.

39.

Mahafza

Batarseh

Bsoul

Massad

Qudaisat

Al-Layla

AE.

Early

. late tracheostomy for the ICU patients: experience in a referral hospital. Saudi J Anaesth. 2012;6(2):152-154.

40.

Lei

Lin

Chen

, et al. Intelligent method to predict intensive care unit admission after drainage operation in patients with deep neck space abscess: a multicenter retrospective study. Head Neck. Published online March 15, 2024. doi:10.1002/hed.27738.

41.

Cordesmeyer

Kauffmann

Markus

, et al. Bacterial and histopathological findings in deep head and neck infections: a retrospective analysis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017;124(1):11-15.

42.

Rega

Aziz

Ziccardi

. Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin. J Oral Maxillofac Surg. 2006;64(9):1377-1380.

43.

Suehara

Goncalves

Alcadipani

Kavabata

Menezes

. Deep neck infection: analysis of 80 cases. Braz J Otorhinolaryngol. 2008;74(2):253-259.

44.

Karkas

Chahine

Schmerber

Brichon

Righini

. Optimal treatment of cervical necrotizing fasciitis associated with descending necrotizing mediastinitis. Br J Surg. 2010;97(4):609-615.

45.

Guardiani

Bliss

Harley

. Supraglottitis in the era following widespread immunization against Haemophilus influenzae type B: evolving principles in diagnosis and management. Laryngoscope. 2010;120(11):2183-2188.

46.

Islam

Oko

. Cervical necrotising fasciitis and descending mediastinitis secondary to unilateral tonsillitis: a case report. J Med Case Rep. 2008;2:368.

Intensive Care Unit Transfer in Patients With Deep Neck Infections

Abstract

Keywords

Introduction

Materials and Methods

Exclusion Criteria

Ethics Statement

Statistical Analysis

Results

Discussion

Limitations of the Article

Conclusion

Footnotes

Acknowledgements

Author Contributions

Declaration of Conflicting Interests

Funding

ORCID iDs

References