PATHOLOGY

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Multi-Space Infections in the Head and Neck: 60
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7 Do Underlying Systemic Diseases Have 62
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9 a Predictive Role in Life-Threatening 65
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11 Q2 Complications? 67
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13 Q7 Linjian Huang, MS,* Bin Jiang, MD,y Xieyi Cai, PhD,z Weijie Zhang, PhD,x 69
14 Wentao Qian, MD,k Yanjie Li, MS,{ Xin Guan, PhD,# Xiang Liang, PhD,** 70
15 Longnv Zhou, PhD,yy Jian Zhu, PhD,zz and Zhiyuan Zhang, PhDxx 71
16 72
17 Purpose: To assess the incidence, risk factors, treatment, and outcomes of life-threatening complica- 73
18 tions of multi-space infections (LCMIs) in the head and neck. 74
19 Patients and Methods: This was a retrospective cohort study that enrolled a sample of patients with 75
20 multi-space infections who were referred from February 2006 through July 2014. The patients were 76
21 classified into LCMI and non-LCMI groups. The primary predictor in this study was underlying systemic 77
22 disease. The primary outcome variable was LCMI. Univariate analyses were used for data statistics. 78
23 Results: A total of 549 patients were included, and an LCMI was found in 66 patients (12.20%). Descend- 79
24 ing mediastinitis was the most frequent LCMI (n = 37; 56.06%), followed by airway obstruction (n = 27; 80
25 40.91%), pneumonia (n = 12; 18.18%), pericarditis (n = 6; 9.09%), intraorbital infection (n = 2; 3.03%), 81
26 multiple organ failure (n = 2; 3.03%), intracranial infection (n = 2; 3.03%), and sudden cardiac death 82
27 (n = 1; 1.52%). Twelve patients with LCMI died during treatment. Elderly patients with an underlying 83
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28 systemic disease more commonly developed an LCMI. 84
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31 *Resident, Department of Oral Surgery, Ninth People’s Hospital, yyProfessor, Department of Internal Medicine, Ninth People’s 87
32 College of Stomatology, Shanghai Jiao Tong University School of Hospital, Shanghai Jiao Tong University School of Medicine, 88
33 Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. Shanghai, China. 89
34 yAttending Physician, Department of Oral Surgery, Ninth People’s zzProfessor, Department of Internal Medicine, Ninth People’s 90
35 Hospital, College of Stomatology, Shanghai Jiao Tong University Hospital, Shanghai Jiao Tong University School of Medicine, 91
36 School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. 92
37 Shanghai, China. xxProfessor, Department of Oral Surgery, Ninth People’s Hospital, 93
38 zProfessor, Department of Oral Surgery, Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of 94
39 College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology. Shanghai, China. 95
40 Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. Mr Huang and Dr Jiang contributed equally to this work. Q3 96
41 xProfessor, Department of Oral Surgery, Ninth People’s Hospital, This study was financially supported by the National Natural Sci- 97
42 College of Stomatology, Shanghai Jiao Tong University School of ence Foundation of China (grant 81200766), the Science and Tech- 98
43 Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. nology Commission of Shanghai (grants 13140902702 and 99
44 kAttending Physician, Department of Oral Surgery, Ninth People’s 13XD1402300), and the Shanghai Health Bureau (grant 100
45 Hospital, College of Stomatology, Shanghai Jiao Tong University 2012Y046). The funders had no role in the study design, data collec- 101
46 School of Medicine, Shanghai Key Laboratory of Stomatology, tion and analysis, or decision to publish. 102
47 Shanghai, China. Address correspondence and reprint requests to Dr Cai: Depart- 103
48 {Resident, Department of Oral Surgery, Ninth People’s Hospital, ment of Oral and Maxillofacial Surgery, Ninth People’s Hospital, 104
49 College of Stomatology, Shanghai Jiao Tong University School of Shanghai Jiao Tong University School of Medicine, No 639 Zhizaoju 105
50 Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. Road, Shanghai, People’s Republic of China; e-mail: caixieyi27@126. Q4 106
51 #Professor, Department of Thoracic Surgery, Ninth People’s com 107
52 Hospital, Shanghai Jiao Tong University School of Medicine, Received February 4 2015 108
53 Shanghai, China. Accepted April 2 2015 109
54 **Attending Physician, Department of Thoracic Surgery, Ninth Ó 2015 American Association of Oral and Maxillofacial Surgeons 110
55 People’s Hospital, Shanghai Jiao Tong University School of 0278-2391/15/00355-9 111
56 Medicine, Shanghai, China. http://dx.doi.org/10.1016/j.joms.2015.04.002 112

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 1.e2 MULTI-SPACE INFECTIONS IN THE HEAD AND NECK Q1

113 Conclusions: Multi-space infections in the head and neck can cause several life-threatening complica- 169
114 tions, and the morbidity of LCMI is considerable. Older age and underlying systemic disease can increase 170
115 Q6 the risk of an LCMI. 171
116 Ó 2015 American Association of Oral and Maxillofacial Surgeons 172
117 J Oral Maxillofac Surg -:1.e1-1.e10, 2015 173
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Multi-space infections in the head and neck are much sity School of Medicine (Shanghai, China), a 1,019-
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less common because of improved oral hygiene and bed teaching medical center in eastern China. The
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widespread use of antibiotic therapy. Nonetheless, study population was composed of all patients with
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they remain one of the most serious emergencies in multi-space infections of the head and neck who
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clinical practice. Odontogenic infections are the were referred to the authors’ clinic from February
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most common cause for head and neck infections.1 Ac- 2006 through July 2014. Patients with complete medi-
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cording to previous studies, the mortality of multi-space cal records were included, and those with a single
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infections in the head and neck ranges from 1.6 to space infection or with incomplete medical records
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2.6%,2-4 and the mainstay treatment is antibiotic were excluded. This study was approved by the inde-
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therapy combined with surgical incision and pendent ethics committee of the Ninth People’s Hospi-
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drainage.5,6 Complications of multi-space infections tal affiliated with the Shanghai Jiao Tong University
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can be severe and can develop before or during treat- School of Medicine.
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ment.3 Life-threatening complications of multi-space in-
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fections (LCMIs) of the head and neck usually imply that STUDY VARIABLES
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the infections have direct extension along the fascial The primary predictor in this study was underlying
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planes or spread along nerves and blood vessels to adja- systemic disease, and age was set as a confounding var-
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cent vital organs or result in serious systemic diseases, iable. LCMI was designated the primary outcome vari-
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which are life threatening.1 In recent years, more and able. In addition, variables that might have a relation
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more studies on LCMIs have been reported. Descend- with outcomes of multi-space infections of the head
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ing mediastinitis is one of the most frequent complica- and neck were recorded and analyzed.
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tions; others include airway obstruction, pneumonia,
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pericarditis, internal jugular vein thrombosis, intraorbi- DATA COLLECTION
141 197
tal infection, and intracranial infection.7-9 However,
142 Data collection involved demography, causes of in- 198
most reports are case reports or case series and have
143 fections, underlying systemic diseases, bacteriologic 199
focused mainly on the diagnosis and treatment of a
144 studies, imaging studies, treatment regimens, compli- 200
single complication. The exact morbidity of LCMIs in
145 cations, and outcomes. Diagnoses of LCMIs were 201
the head and neck is unknown. As severe as LCMIs
146 based on clinical, imaging, and surgical findings. Diag- 202
are, early diagnosis and appropriate treatment are
147 nostic imaging studies included contrast-enhanced 203
crucial to save patients’ lives. Therefore, it is
148 computed tomography (CT), magnetic resonance im- 204
important for clinicians to understand the incidence
149 aging (MRI), ultrasonography, and plain radiography. 205
and epidemiologic features of LCMIs.
150 206
The purpose of this study was to assess the inci-
151 STATISTICAL ANALYSIS 207
dence, risk factors, treatment, and outcomes of LCMIs.
152 To determine differences between the LCMI and 208
The authors hypothesized that patients with underly-
153 non-LCMI groups, the Student t test was performed 209
ing systemic diseases might be more susceptible to
154 210
developing LCMIs. The specific aims of the study
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were to 1) estimate the incidence of LCMIs, 2)
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compare the percentage of underlying systemic dis-
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eases between an LCMI group and a non-LCMI group,
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and 3) compare mortality between patients with and
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those without LCMIs.
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162 Patients and Methods 218
163 219
164 STUDY DESIGN AND SAMPLE 220
165 To address the research purpose, the authors de- FIGURE 1. Age distribution of multi-space infection of the head
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166 signed and implemented a retrospective cohort study, and neck. 222
167 which was conducted at the Shanghai Ninth People’s Huang et al. Multi-Space Infections in the Head and Neck. J Oral 223
168 Hospital affiliated with the Shanghai Jiao Tong Univer- Maxillofac Surg 2015. 224

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225 Table 1. TYPES AND INCIDENCE OF LCMI OF THE HEAD Results 281
226 AND NECK 282
227 During the 102-month period, 549 patients (342 283
228 LCMI (n = 66) n % male [62.30%] and 207 female [37.70%]) with multi- 284
229 spaces infections of the head and neck were included 285
230 Descending mediastinitis 37 56.06 in this study. The patients’ mean age was 49.11  286
231 Airway obstruction 27 40.91 18.53 years (range, 20 months to 89 yr; Fig 1). Four 287
232
Pneumonia 12 18.18 hundred three were outpatients (73.41%) and 146 288
Pericarditis 6 9.09 were hospitalized patients (26.59%). Odontogenic in-
233 Intraorbital infection 2 3.03
289
234 fections were the most frequent causes of multi- 290
Multiple organ failure 2 3.03 space infections (401 patients [73.04%]). Other causes
235 Intracranial infection 2 3.03 291
236 included oropharyngeal infection, adenogenous infec- 292
Sudden cardiac death 1 1.52
237 tion, postoperative infection, post-traumatic infection, 293
238
Note: Some patients had more than 1 LCMI. and secondary infection of a congenital cyst. The sub- 294
Abbreviation: LCMI, life-threatening complication of mandibular space was the most commonly involved
239 multi-space infections. 295
240 space (381 patients [69.40%]), followed by the masse- 296
Huang et al. Multi-Space Infections in the Head and Neck. J Oral teric space (178 patients [32.42%]) and the pterygo-
241 Maxillofac Surg 2015. 297
242 mandibular space (162 patients [29.51%]). Two 298
243 hundred thirty-one patients (42.08%) had underlying 299
244 systemic diseases. Diabetes mellitus was most common 300
to assess the importance of age. The c2 test was used (126 patients). Other associated systemic diseases
245 301
to analyze the importance of gender. The Fisher exact included hypertension and cardiopathy. Four hundred
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test was performed to assess the mortality rate. Statis- ninety-three patients (89.80%) underwent contrast-
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tical differences were analyzed with SPSS 19.0 (SPSS, enhanced CT scanning at the initial visit. Thirty-one pa-
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Inc, Chicago, USA). P values less than .05 were consid- tients (5.65%) underwent B ultrasound, including 26
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ered statistically significant. pregnant women. In addition, B ultrasound was used
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278 FIGURE 2. Axial contrast-enhanced computed tomogram of the chest visualizes an aerocele invading posterior mediastinal components at the 334
279 level of the heart (yellow arrows). 335
280 Huang et al. Multi-Space Infections in the Head and Neck. J Oral Maxillofac Surg 2015. 336

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337 for an evaluation of the volume of pericardial effusion Some patients had more than 1 complication. The inci- 393
338 in 3 patients with pericarditis. If life-threatening com- dence of each LCMI is presented in Table 1. The most 394
339 plications were suspected, aggressive imaging studies frequent complication was descending mediastinitis 395
340 would be applied. Two patients (0.36%) with intracra- (n = 37; Fig 2), followed by airway obstruction 396
341 nial extension underwent brain MRI. Thirty-seven (n = 27; Fig 3), pneumonia (n = 12), pericarditis 397
342 patients with mediastinitis underwent chest radiog- (n = 6; Fig 4), intraorbital infection (n = 2; Fig 5), mul- 398
343 raphy and contrast-enhanced CT. The results of bacte- tiple organ failure (n = 2), intracranial infection (n = 2; 399
344 rial cultures were available in 240 cases. Of these, 72 Fig 6), and sudden cardiac death (n = 1). 400
345 cultures grew bacteria (31.67%) and the remaining Univariate analysis showed that patients with under- 401
346 168 showed no growth of bacteria. lying systemic diseases were considerably older than 402
347 those without underlying systemic diseases 403
348 (P < .001). The difference in the incidence of underly- 404
349 INCIDENCE OF AND RISK FACTORS FOR LCMI ing systemic disease did not differ between men and 405
350 Sixty-six patients had LCMIs in the present study. women (Table 2). As presented in Table 3, there was 406
351 Thus, the morbidity of LCMI was 12.02% (66 of 549). no statistically significant difference for men and 407
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390 FIGURE 3. Axial contrast-enhanced computed tomogram of the neck shows abscess formation in the left submandibular space and around the 446
391 pharyngeal space (yellow arrows). The airway was constricted and displaced by nearby abscesses (red asterisk). 447
392 Huang et al. Multi-Space Infections in the Head and Neck. J Oral Maxillofac Surg 2015. 448

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476 FIGURE 4. Coronal contrast-enhanced computed tomogram of the chest shows pericardial effusion (yellow arrow).
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Huang et al. Multi-Space Infections in the Head and Neck. J Oral Maxillofac Surg 2015.
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480 women between the LCMI and non-LCMI groups by descending mediastinitis and intracranial infection. 536
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(P < .435). The mean age of patients with LCMIs was The details for the patients who died are listed
482 538
55.41  15.74 years compared with 48.25  in Table 4.
483 18.73 years of those without LCMIs (P = .001). A 539
484 540
strong statistical association was found between un- Discussion
485 derlying systemic diseases and LCMIs (57.58% of pa- 541
486 tients in the LCMI group had underlying systemic The purpose of this retrospective cohort study was 542
487 diseases vs 39.96% in the non-LCMI group; P = .007). to assess the incidence, risk factors, treatment, and 543
488 outcomes of LCMIs in the past 8 years. The authors hy- 544
489 pothesized that patients with underlying systemic dis- 545
490 TREATMENT AND OUTCOMES OF LCMI eases might be more susceptible to developing LCMIs. 546
491 All patients received antibiotic therapy. Moreover, The specific aims of the study were to 1) estimate the 547
492 514 patients (93.62%) underwent facial and cervical incidence of LCMIs in China, 2) compare the percent- 548
493 incision and drainage, including all LCMIs. Mediastinal age of underlying systemic diseases between the LCMI 549
494 drainage was performed in 33 patients with descend- and non-LCMI groups, and 3) compare mortality 550
495 ing mediastinitis. Additional pericardial drainage was between patients with and those without LCMIs to 551
496 applied for 4 patients with pericarditis. Seventeen provide useful information for the prevention and 552
497 patients with airway obstruction underwent tracheot- early intervention of LCMIs. In this study, the 553
498 omy immediately; the other 10 patients received morbidity of patients with LCMIs was 12.02%, and un- 554
499 tracheal intubation. Twelve patients died during derlying systemic diseases were strongly associated 555
500 treatment, and all had LCMIs. The mortality rate of with LCMIs based on univariate analysis. Older pa- 556
501 multi-space infections of the head and neck was tients more frequently developed LCMIs. 557
502 2.19% (12 of 549). Moreover, the mortality of LCMIs According to the present results, the most frequent 558
503 was as high as 18.18% (12 of 66; Table 3). Of these, 6 cause of multi-space infections of the head and neck 559
504 patients (50%) died of airway obstruction, followed was odontogenic infection. The most commonly 560

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FIGURE 5. Axial contrast-enhanced computed tomogram of the head depicts a low-density collection along the medial aspect of the right orbit
593 (red arrow) and swelling of the lateral rectus muscle (yellow arrow). 649
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Huang et al. Multi-Space Infections in the Head and Neck. J Oral Maxillofac Surg 2015.
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597 involved space was the submandibular space. Contrast- treated at an early stage. Most patients respond well 653
598 enhanced CT is very helpful for the diagnosis of multi- to medical or surgical management, including intrave- 654
599 space infections. In the present study, descending nous antibiotics and surgical incision and drainage. 655
600 mediastinitis was the most frequent complication However, despite adequate treatment, some patients 656
601 among LCMIs, followed by airway obstruction, pneu- will develop life-threatening complications, such as 657
602 monia, pericarditis, intraorbital infection, multiple airway obstruction, descending mediastinitis, and 658
603 organ failure, intracranial infection, and sudden cardiac pneumonia. The rate of complications has differed 659
604 death. Antibiotic therapy and incision and drainage are from study to study and ranged from 2.4 to 660
605 the most basic and common treatment methods. More- 33.7%.7,11,12 Moreover, some recent reports have 661
606 over, the mortality rate of multi-space infections of the suggested that severe complications of head and neck 662
607 head and neck was 2.19%. infection are increasing in incidence, and they remain 663
608 Multi-space infections of the head and neck are com- a major challenge to clinicians. To the authors’ 664
609 mon in clinical practice. Previous studies have shown knowledge, this is the first report focusing on the 665
610 that the most common etiology of multi-space infec- types, incidence, risk factors, treatment, and 666
611 tions is odontogenic infection.7,10 There was a high outcomes of LCMIs in a large consecutive case series 667
612 morbidity for multi-space infections in the era before of 8 years’ duration. According to these results, 668
613 antibiotics. With the wide use of antibiotics and the morbidity from LCMIs is as high as 12.02%. This 669
614 improvement of medical conditions, the morbidity shown that life-threatening complications resulting 670
615 from multi-space infections has clearly decreased. from head and neck infections are not rare. Therefore, 671
616 Even when multi-space infections occur, they can be it is necessary to provide early and adequate treatment 672

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707 FIGURE 6. Axial contrast-enhanced magnetic resonance image of the head shows an abscess in the left frontal lobe (yellow arrow). 763
708 Huang et al. Multi-Space Infections in the Head and Neck. J Oral Maxillofac Surg 2015. 764
709 765
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711 for patients with head and neck infection to decrease 767
Table 2. ALL STUDY VARIABLES VERSUS UNDERLYING
712 SYSTEMIC DISEASES the occurrence of severe complications. Baldassari 768
713 et al9 investigated 138 pediatric patients with deep 769
714 With USD Without USD neck space abscess. They reported that the total 770
715 Variables (n = 231) (n = 318) P Value complication rate was 9.4%, and the most common 771
716 complication was descending mediastinitis. Other 772
717 Gender, n (%) .277* complications included airway obstruction, necessi- 773
718 Male 150 (64.94) 192 (60.38) tating intubation, persistent disease requiring repeat 774
719 Female 81 (35.06) 126 (39.62) drainage, and jugular vein thrombosis. Yang et al7 775
Age (yr), 58.11  15.37 42.57  17.91 <.001y
720 analyzed the life-threatening complications of deep 776
mean  SD
721 neck abscess in 105 patients. They found that 23.8% 777
722 Note: There was no statistically significant difference be- of patients had complications, including airway 778
723 tween male and female patients (P > .05). obstruction, pneumonia, and descending mediastinitis. 779
Abbreviations: SD, standard deviation; USD underlying sys-
724 Of these, 56.0% had more than 1 complication. As in 780
temic disease.
725 * By c2 test. other studies, the authors found that head and neck in- 781
726 y By Student t test. fections usually spread downward. At the beginning, 782
727 Huang et al. Multi-Space Infections in the Head and Neck. J Oral the infections are often restricted to an isolated area 783
728 Maxillofac Surg 2015. of cellulitis in the soft tissues adjacent to the source 784

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785 Table 3. ALL STUDY VARIABLES VERSUS LCMI OF THE HEAD AND NECK
841
786 842
787 With LCMI Without LCMI All Patients 843
788 Variables (n = 66) (n = 483) (N = 549) P Value 844
789 845
790 Gender, n (%) .435* 846
791 Male 44 (66.67) 298 (61.70) 342 (62.30) 847
792 Female 22 (33.33) 185 (38.30) 207 (37.70) 848
793 Age (yr), mean  SD 55.41  15.74 48.25  18.73 49.11  18.53 .001y 849
USDs, n (%) .007*
794 850
Yes 38 (57.58) 193 (39.96) 231 (42.08)
795 No 28 (42.42) 290 (60.04) 318 (57.92)
851
796 Outcome, n (%) .000z 852
797 Cure 54 (81.82) 483 (100.00) 537 (97.81) 853
798 Death 12 (18.18) 0 (0.00) 12 (2.19) 854
799 855
Note: There was no statistically significant difference between men and women (P > .05).
800 856
Abbreviations: LCMI, life-threatening complication of multi-space infections; SD, standard deviation; USDs, underlying sys-
801 temic diseases. 857
802 * By c2 test. 858
803 y By Student t test. 859
804 z By Fisher exact test. 860
805 Huang et al. Multi-Space Infections in the Head and Neck. J Oral Maxillofac Surg 2015. 861
806 862
807 863
808 of infection.1,13 Infections of these spaces can the body fail to prevent further spread and the treat- 864
809 intercommunicate with one another and thus ment is not immediate and adequate, infections can 865
810 potentiate the extension and complication of the course along fascial planes, nerves, or blood vessels 866
811 disease.14 When the natural defense mechanisms of into the mediastinum, facilitated by gravity, breathing, 867
812 and negative intrathoracic pressure.15,16 The 868
813 infection also can spread upward to the orbital cavity 869
814 Table 4. LCMI OF THE HEAD AND NECK IN PATIENTS or into the cranium. In this study, intraorbital and 870
815 WHO DIED intracranial spread was found in 2 patients, 871
816 respectively. When pathogens enter the blood 872
Patient Age
817 stream, sepsis can develop and induce multiple organ 873
Number Gender (yr) LCMI
818 failure. One patient had multiple organ failure. 874
819 1 F 40 airway obstruction
Therefore, the results in this study show that local 875
820 2 F 32 airway obstruction spread of multi-space infections is common, and sys- 876
821 3 F 81 descending mediastinitis, temic spread is relatively rare. 877
822 airway obstruction LCMIs that are not diagnosed promptly or treated 878
823 4 F 66 airway obstruction, multiple adequately can lead to lethal results. Early diagnosis 879
824 organ failure is very important for the prognosis of LCMIs, which 880
825 5 M 76 descending mediastinitis, mainly depends on typical symptoms and imaging re- 881
826 pneumonia, pericarditis, sults. Patients with descending mediastinitis usually 882
827 multiple organ failure complain of odynophagia, dysphagia, dyspnea, and 883
828 6 F 71 sudden cardiac death chest congestion. Patients with pericarditis can have 884
7 F 29 pneumonia
829 different levels of shortness of breath, cough, 885
8 M 50 airway obstruction
830 9 M 55 descending mediastinitis,
increased heart rate, precordial pain, and failure to 886
831 airway obstruction lie flat. Furthermore, the symptoms of intracranial 887
832 10 F 82 descending mediastinitis, infection are sleepiness and mental haziness. Once 888
833 pericarditis suspected symptoms appear, further sensitive imaging 889
834 11 M 70 intracranial infection examinations are needed to make an accurate and 890
835 12 M 54 intracranial infection prompt diagnosis. In this study, contrast-enhanced 891
836 CT was widely used in the diagnosis of multi-space in- 892
Note: Some patients had more than 1 LCMI.
837 Abbreviations: F, female; LCMI, life-threatening complica- fections and LCMIs. It can identify the extent of the in- 893
838 tion of multi-space infections; M, male. fections and the location of pus in 3 dimensions, 894
839 Huang et al. Multi-Space Infections in the Head and Neck. J Oral which is very helpful for surgical drainage. In a previ- 895
840 Maxillofac Surg 2015. ous study, the authors strongly recommended using 896

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897 contrast-enhanced CT as a routine examination for the composed of oral and maxillofacial surgeons, 953
898 early detection of descending mediastinitis.10 For thoracic surgeons, internists, and anesthesiologists is 954
899 airway obstruction, the characteristic CT findings are suggested for the management of these life- 955
900 pharyngeal cavity coarctation and tracheal constric- threatening complications. 956
901 tion by nearby abscesses, resulting in trachea displace- The present study investigated 549 patients, 66 of 957
902 ment. In addition, CT has important value in the whom were diagnosed with LCMIs. Such a large sam- 958
903 diagnosis of intracranial infection. For some special pa- ple makes the results more reliable. However, this is 959
904 tients, B ultrasound and MRI also are used. B ultra- a retrospective study and might be less convincing 960
905 sound is usually applied for pregnant patients and than a prospective study. Only univariate analysis 961
906 patients with pericarditis, and MRI also can clearly was performed to assess the risk factors for LCMIs in 962
907 show whether there is intracranial spread. this study. The authors hope to conduct a multiple 963
908 Surgical drainage is of utmost importance in the regression analysis in the near future. Interestingly, 964
909 treatment of multi-space infections. Antibiotic therapy cavernous sinus thrombosis was not found in this 965
910 also is essential in eliminating aerobic and anaerobic study. Thus, to some extent, the results of the type 966
911 pathogens. In this study, all patients with LCMIs under- and mortality of each LCMI are not comprehensive. 967
912 went antibiotic therapy and surgical incision and In conclusion, the morbidity of LCMIs of multi-space 968
913 drainage for facial and cervical abscesses. Neverthe- infections of the head and neck was 12.02%. Descend- 969
914 less, 66 patients developed life-threatening complica- ing mediastinitis was the most common LCMI. The 970
915 tions. These results showed that underlying systemic mortality of patients with LCMIs was as high as 971
916 diseases in older patients might increase the risk of 18.18%, and airway obstruction was the most frequent 972
917 LCMIs. Underlying systemic diseases (such as diabetes cause of death. Older patients with underlying sys- 973
918 mellitus and hematologic disease) can result in temic diseases had an increased risk of devel- 974
919 derangement of the immune system, including cellular oping LCMIs. 975
920 immunity and complement and neutrophil function.17 976
921 Any abnormality of the immune system increases the 977
922 risk of infections.18 Moreover, resistance to acute 978
923 inflammation can be decreased in elderly patients.19 References 979
924 However, only 3 separate factors were analyzed to 1. Daramola OO, Flanagan CE, Maisel RH, et al: Diagnosis and treat- 980
925 determine the relation to life-threatening complica- ment of deep neck space abscesses. Otolaryngol Head Neck 981
926 tions in this study. In the future, logistic regression Surg 141:123, 2009 982
2. Huang TT, Liu TC, Chen PR, et al: Deep neck infection: Analysis
927 will be used to determine which factors are related of 185 cases. Head Neck 26:854, 2004 983
928 to LCMI, such as duration before treatment, therapy 3. Bottin R, Marioni G, Rinaldi R, et al: Deep neck infection: A 984
929 modality, and pathogens. present-day complication. A retrospective review of 83 cases 985
(1998-2001). Eur Arch Otorhinolaryngol 260:576, 2003
930 Descending mediastinitis was the most common 4. Ridder GJ, Technau-Ihling K, Sander A, et al: Spectrum and 986
931 complication in the present study. Early surgical management of deep neck space infections: An 8-year expe- 987
932 drainage remains the main treatment for cervical infec- rience of 234 cases. Otolaryngol Head Neck Surg 133:709, 988
2005
933 tion with descending mediastinitis. A different surgical 5. Sanchez R, Mirada E, Arias J, et al: Severe odontogenic infections: 989
934 approach was reported in a previous study.11 Twenty- Epidemiological, microbiological and therapeutic factors. Med 990
935 seven patients with the LCMI of airway obstruction un- Oral Patol Oral Cir Bucal 16:e670, 2011 991
6. Santos Gorjon P, Blanco Perez P, Morales Martin AC, et al: Deep
936 derwent tracheotomy or tracheal intubation, 6 of neck infection. Review of 286 cases. Acta Otorrinolaringol Esp 992
937 whom 6 died during treatment. Airway obstruction 63:31, 2012 993
938 is the most frequent cause of death in patients with 7. Yang SW, Lee MH, Lee YS, et al: Analysis of life-threatening 994
complications of deep neck abscess and the impact of
939 LCMI. Such a finding is similar to that of a previous empiric antibiotics. ORL J Otorhinolaryngol Relat Spec 70: 995
940 study of deep neck space infections.15 To save pa- 249, 2008 996
941 tients’ lives, control of the airway by tracheotomy or 8. Suehara AB, Goncalves AJ, Alcadipani FA, et al: Deep neck 997
infection: Analysis of 80 cases. Braz J Otorhinolaryngol 74:
942 endotracheal tube should be a priority in the manage- 253, 2008 998
943 ment of LCMI.16,20 The authors also found that 9. Baldassari CM, Howell R, Amorn M, et al: Complications in 999
944 patients with multiple organ failure and intracranial pediatric deep neck space abscesses. Otolaryngol Head Neck 1000
Surg 144:592, 2011
945 infection had a high mortality, and all died in this 10. Boffano P, Roccia F, Pittoni D, et al: Management of 112 hos- 1001
946 study. Altogether, 12 patients with LCMIs died, and pitalized patients with spreading odontogenic infections: Cor- 1002
947 the mortality of LCMIs was 18.18%. These patients relation with DMFT and oral health impact profile 14 1003
indexes. Oral Surg Oral Med Oral Pathol Oral Radiol 113:
948 present a major challenge to clinicians who manage 207, 2012 1004
949 LCMIs of the head and neck. Prompt and aggressive 11. Cai XY, Zhang WJ, Zhang ZY, et al: Cervical infection with 1005
950 surgical incision and drainage with antibiotic therapy descending mediastinitis: A review of six cases. Int J Oral 1006
Maxillofac Surg 35:1021, 2006
951 is recommended for multi-space infections, especially 12. Sanchez R, Mirada E, Arias J, et al: Severe odontogenic infections. 1007
952 for LCMIs.21,22 In addition, a multidisciplinary team Med Oral Patol Oral Cir Bucal 16:e670, 2011 1008

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1009 13. Brook I: Microbiology and management of peritonsillar, retro- 18. Tzermpos F, Iatrou I, Papadimas C, et al: Function of blood 1021
pharyngeal, and parapharyngeal abscesses. J Oral Maxillofac monocytes among patients with orofacial infections. J Cranio-
1010 1022
Surg 62:1545, 2004 maxillofac Surg 41:88, 2013
1011 14. Chang CM, Lu FH, Guo HR, et al: Klebsiella pneumoniae fascial 19. Yamaoka M, Ono Y, Takahashi M, et al: Acute inflammation in 1023
1012 space infections of the head and neck in Taiwan: Emphasis on horizontal incompletely impacted third molar with radiolu- 1024
diabetic patients and repetitive infections. J Infect 50:34, 2005 cency in the elderly. Clin Interv Aging 4:337, 2009
1013 15. Potter JK, Herford AS, Ellis E, et al: Tracheotomy versus endotra- 20. Karkos PD, Leong SC, Beer H, et al: Challenging airways in deep
1025
1014 cheal intubation for airway management in deep neck space in- neck space infections. Am J Otolaryngol 28:415, 2007 1026
1015 fections. J Oral Maxillofac Surg 60:349, 2002 21. Stalfors J, Adielsson A, Ebenfelt A, et al: Deep neck space infec- 1027
16. Brook I: The role of anaerobic bacteria in upper respiratory tract tions remain a surgical challenge. A study of 72 patients. Acta
1016 and other head and neck infections. Curr Infect Dis Rep 9:208, Otolaryngol 124:1191, 2004
1028
1017 2007 22. Plaza Mayor G, Martinez-San Millan J: Martinez-Vidal A: Is conser- 1029
1018 17. Hasegawa J, Hidaka H, Tateda M, et al: An analysis of clinical risk vative treatment of deep neck space infections appropriate? 1030
factors of deep neck infection. Auris Nasus Larynx 38:101, 2011 Head Neck 23:126, 2001
1019 1031
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