Clinical Presentation and Factors Leading to Complications of Deep Neck Space Infections at CHUK
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Rwanda Journal of Medicine and Health Sciences Vol.4 No.1, March 2021 https://dx.doi.org/10.4314/rjmhs.v4i1.2
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Original article
Clinical Presentation and Factors Leading to Complications of
Deep Neck Space Infections at CHUK
Isaie Ncogoza1*2, Eric Munezero1, Jean Paul Mvukiyehe3, David Shaye4
1Department of Ear Nose Throat, College of Medicine and Health Sciences, University of Rwanda,
Kigali, Rwanda
2University Teaching Hospital of Kigali (CHUK), Kigali, Rwanda
3Department of Anesthesia, Critical Care and Emergency Medicine, College of Medicine and
Health Sciences, University of Rwanda, Kigali, Rwanda
4Department of Facial Plastic and Reconstructive Surgery, Harvard Medical School, Boston,
Massachusetts, United States
*Corresponding author: Isaie Ncogoza Department of Ear Nose Throat, College of Medicine
and Health Sciences, University of Rwanda, Kigali, Rwanda. Email: uncogoza@gmail.com
____________________________________________________________________________
Abstract
Background
Deep neck space infection (DNSI) mostly arise from the local extension of dental, tonsils
and parotid gland infections. Early diagnosis and management is the key to avoid
associated complications.
Objective
Our study aimed at evaluating the clinical presentation and factors related to
complications of DNSIs at the University Teaching Hospital of Kigali.
Methods
This cross-sectional study was conducted at the University teaching hospital of Kigali
from September 2017 to November 2018. It enrolled 66 participants. Patient
information was recorded using a questionnaire and analyzed using Epidata 3.1
software. The data were processed using SPSS 16.0. Comparison of categorical variables
were performed using the chi-square test. Associations with p-values=0.05 were
considered statistically significant.
Results
Males accounted for 35 (53%) of DNSIs. The majority (97%) presented with neck pain
and 21% with a history of tooth extraction. The submandibular space was the most
involved in 33 (50%) cases. The average duration of symptoms at presentation was 11
days. Delayed consultation and advanced age (>40years) were associated with
complications and hospital stay with (p value=0.022) and (p=0.015) respectively.
Conclusion
Neck pain on background of tooth extraction is the most common presentation of
patients with DNSIs. Delayed presentation and advanced age are central factors for
complications and longer hospital stay.
Rwanda J Med Health Sci 2021;4(1):8-19
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Keywords: Deep neck space infections, presentation, complications.
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8Rwanda Journal of Medicine and Health Sciences Vol.4 No.1, March 2021 https://dx.doi.org/10.4314/rjmhs.v4i1.2
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Background gland infections, trauma to the aero-
digestive tract, and benign and
Deep neck space infections (DNSIs) malignant neck tumors. Dental
are defined as infections in potential infections are associated with the
spaces and fascial planes of the neck, majority of DNSIs while the etiology
characterized by rapid progression of DNSIs is not identified in 20-50%
and life-threatening of cases.[6] Clinical presentation of
complications.[1–4] DNSIs vary according to the neck
The fascial planes are of two types: space involved. Common symptoms
superficial and deep layers. include dysphagia, odynophagia,
According to the relationship with pain, neck swelling, respiratory
the hyoid bone, deep neck spaces are difficulties, fever and features of
classified as follows: There are inflammation on physical
spaces localized above the hyoid examination.[11,12] Medical history
bone level including the peritonsillar, may reveal comorbidities such as
submandibular, parapharyngeal, previous dental diseases or
buccal, parotid and masticatory procedures, upper respiratory tract
spaces. There are also spaces that infections (URTIs), maxillofacial or
involve the entire circumference of neck trauma, immunosuppressive
the neck and these include the drug intake (steroids,
retropharyngeal, danger, chemotherapy), HIV, Diabetes and
prevertebral and carotid sheath, and Tuberculosis.
the anterior or pre-tracheal visceral The presence of comorbidities
spaces below the hyoid bone.[5–7] predispose to complications of
DNSIs.[3,13–15] and delayed
Globally, the incidence of DNSIs consultation predisposes to
decreased significantly following the complications and high morbidity
widespread use of antibiotics for and mortality rate.[7,11,15]
infection, development of new
diagnostic modalities and Diagnosis of DNSIs is based on
improvement in oral hygiene.[8] clinical assessment. Needle
However, DNSIs continue to be a aspiration (proof puncture) is a
significant health problem in useful and cost efficient diagnostic
developing countries, resulting in tool as it helps to differentiate an
significant morbidity and abscess from cellulitis. Furthermore,
mortality.[7,9,10] proof puncture has been reported as
an effective initial treatment for
The common etiological factors of pediatric neck abscesses.[16]
DNSIs are dental infections, Microbiology reveals mixed bacterial
pharyngotonsillar infections, salivary flora including gram positive
89Rwanda Journal of Medicine and Health Sciences Vol.4 No.1, March 2021 https://dx.doi.org/10.4314/rjmhs.v4i1.2
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organisms (streptococcus viridans, and inappropriate management have
staphylococcus aerius) and gram shown to be the factors leading to
negative organisms (Escherichia coli, complications.[10,12,16] There are
haemophilus influenza). Anaerobic very few studies published on DNSIs
germs are responsible for in sub-Saharan Africa.[18–20] yet it
fulminating necrotizing fasciitis is the region of the world where poor
which is severe complication of oral hygiene and other social
DNSIs.[5] economic factors contributing to the
development of DNSIs are identified.
Imaging helps in delineating the
There is no published data about
exact anatomical extent of DNIs and
deep neck spaces infections (DNSIs)
detecting complications.[7]
in Rwanda nor the East African
Ultrasonography is useful as initial
region. The aim of the study was to
or alternative modality for evaluation
evaluate the clinical presentation
of abscess collection or cellulitis and
and factors related to the
assist in drainage by good
complications of deep neck space
localization of the abscess. However
infections at CHUK.
the exact localization of the
infections focus is often difficult with Material and Methods
this modality.[9] The CT scan with
contrast is a modality of choice as it This was a cross-sectional study
helps in identifying the extent of the conducted at the University Teaching
infections and differentiates cellulitis hospital of Kigali (CHUK) from
from abscess.[7] The role of MRI in September 2017 to February 2018. It
DNSIs is limited by long acquisition was approved by the Research Ethics
times, high cost, unavailability in Committee of CHUK and CMHS-IRB.
most places and the unstable general Patients were enrolled into the study
status of these patients. after giving their written informed
The treatment of DNSIs consists consent. The study enrolled 66
mainly of IV antibiotics, incision and patients who consulted the
drainage of the abscess and airway department of Otorhinolaryngology
maintenance.[9,13] Delays in at CHUK with confirmed deep neck
diagnosis and treatment can result space infections (DNSIs).
in life-threatening complications,
namely, airway compromise, The data was collected using a pre-
necrotizing fasciitis, mediastinitis established questionnaire. The
and sepsis.[17] Elderly patients, following information was recorded:
delayed consultation, associated demographic characteristics
comorbidities, odontogenic infections including age, gender, comorbidities,
risk factors, clinical symptoms and
10 8Rwanda Journal of Medicine and Health Sciences Vol.4 No.1, March 2021 https://dx.doi.org/10.4314/rjmhs.v4i1.2
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signs, timing of consultation, Table 1. Demographic
microbiology results, diagnostic characteristics
modalities, treatment options,
complications and hospital stay. Variables Frequency Percentage
Time for consultation was classified Gender (n) (%)
into three categories: Early (7days).Data was
0-10 22 33.3
recorded using Epidata 3.1 software.
11-20 9 13.6
Data processing and statistical 21-30 11 16.7
analyses were performed using SPSS 31-40 8 12.1
16.0. Comparisons of categorical 41-50 4 6.1
variables were performed using the >50 12 18.2
chi-square test. The limit of Origin
significance was established at p ≤ Rural 51 77.3
0.05. Urban 15 22.7
Results Table 2 shows clinical presentation,
timing for consultation,
complications and hospital stay of
The distribution of demographic
patients of DNSIs. The majority of
characteristics is shown (Table 1).
patients with DNSIs presented with
Males accounted for 35(53%) and
severe pain in 97%, neck swelling in
females 31(47%). The predominant
95.5% and fever in 72.7%. The mean
age group was 0-10 years accounting
period of time since the onset of
for 33.3% of all DNSIs, followed by
symptoms was 10.82 ±7.69 days
the group of more than 50 years
with a minimum of 2 days and
(18.2%). The majority of cases were
maximum of 45 days. The majority
from rural areas.
(40.9%) presented after 7days of
onset of symptoms while only 25.8%
consulted for features of DNSIsRwanda Journal of Medicine and Health Sciences Vol.4 No.1, March 2021 https://dx.doi.org/10.4314/rjmhs.v4i1.2
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Ludwig’s angina was found in Table 2. Presentation, timing for
13.63%. consultation, complications and
hospital stay
Tooth extraction or infection was the
most prevalent of predisposing Variables Frequency Percentage
factors in 21.21% cases followed by (n) (%)
tonsillitis or pharyngitis in Symptoms
Pain 64 97
9(13.63%). In the majority of cases
Swelling 63 95.5
(70.4%) the diagnosis was made by Fever 48 72.7
needle aspiration and imaging was Odynophagia 29 43.9
done by using ultrasound (15.5%) Signs
and contrast CT scan (11.3%). Needle Tenderness 64 97
aspiration and CT scan were used Fluctuation 61 92.4
Trismus 26 39.4
together in 4% and the majority of
Pus discharge 21 31.8
patients were treated by incision and Location
drainage with antibiotics in Submandibular 33 50
60(90.9%) cases. Ludwig's Angina 9 13.63
Peritonsillar
Out of 66 cases of DNSIs, 14 (21.2%) space 9 13.63
had complications and Necrotizing Parapharyngeal
space 8 12.13
fasciitis represented the majority
Others 7 10.6
with 8 out of 14 cases (66.7%), Timing for
followed by upper airway obstruction presentation
in 4 out of 14 cases (28.6%). The Early
mean hospital stay duration was presentation
10.23 days (SD±11.64, range 0-60) ( 7days) 27 40.9
Complications
Septic shock 2 14.3
Necrotizing
Fasciitis 8 57.1
Upper airways
obstruction 4 28.6
Hospital stay
Shorter
(Rwanda Journal of Medicine and Health Sciences Vol.4 No.1, March 2021 https://dx.doi.org/10.4314/rjmhs.v4i1.2
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Factors associated with occurrence The advanced age (>40 years) was a
of complications of DNSIs are shown significant factor of complications of
in table 3. Delayed consultation DNSIs (p=0.015).
(>7days) was significantly associated
to the presence of complications
(p=0.022).
Table 3. Factors associated with complications of DNSIs
Complications
Variables
Any complication None p value
Duration of symptoms
≤7 days 3 (9.7%) 28 (90.3%)
>7 days 11 (33.3%) 22 (66.7%) 0.022
AgeRwanda Journal of Medicine and Health Sciences Vol.4 No.1, March 2021 https://dx.doi.org/10.4314/rjmhs.v4i1.2
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Table 4. Factors associated with the duration of hospital stay
Hospital stay
VariableRwanda Journal of Medicine and Health Sciences Vol.4 No.1, March 2021 https://dx.doi.org/10.4314/rjmhs.v4i1.2
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symptoms was 10.82 days (SD±7.69, consistent with what have been
range 2-45). Findings in Brazil found in Nigeria where
demonstrated similar duration of submandibular location was the
onset, with an average of 8 days. most prevalent with 43.9%.[10] The
Symptoms at arrival were neck pain submandibular space is the first
(97%), swelling (95.5%) and fever deep neck space to be affected by
(72.7%).[3] In a South Korea study spread of infection of dental origin.
findings were consistent, with This finding serves to emphasize the
symptoms of DNSIs were neck importance of dental hygiene, and
swelling (74.7%), neck pain (41.1%) DNSIs can be thought of as an
and fever (14.6%).[21] Duration of extreme complication of poor oral
symptoms being nearly 10 days hygiene.
implies a delay to access care.
Exploring the reasoning for delay, Dental extractions or infections were
either patient or health system the most common predisposing
factors would be an area of future factor associated with DNSIs with
research. Decreasing the time of 14(21.21%). Many studies identified
onset to time to seek care would odontogenic origins to DNSIs, citing
likely decrease complications, odontogenic sources in 28%, 12%,
morbidity and mortality. Physical 70.6%, and 92.7% of
exam revealed that tenderness was cases.[7,11,17,21] This is common
the most common finding in 97% of for low income countries with
patients with DNSIs, followed by inappropriate equipment for basic
fluctuation (92.40%). These findings dental care, delayed extractions, a
are similar to what have been found lack of dentists, and high numbers of
in Brazil where the main physical patients with poor oral hygiene.
finding of DNSIs were neck
swelling(84.6%) and Contrast CT scan is the gold
tenderness(76.9).[5] Reports from standard method of diagnosis for
India found that pus discharge in the DNSIs. In our setting, needle
oral cavity was 44.23% at arrival.[13] aspiration was the predominant
Initial physical exam findings should modality of diagnosis in 70.4%, while
inform district level practitioners CT scan was used in only 11.3%.
who can be aware of symptoms of This may be a result of increased wait
DNSIs. times for CT scan, higher associated
cost, inability to acquire contrast,
The submandibular space was the and the need for immediate diagnosis
most common site involved in our in patients with DNSIs. In fact,
study (50%) followed by the needle aspiration is rarely mentioned
peritonsillar space (15%). This is in the literature as a diagnostic
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15Rwanda Journal of Medicine and Health Sciences Vol.4 No.1, March 2021 https://dx.doi.org/10.4314/rjmhs.v4i1.2
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modality of DNSIs. It is recalled as a of presentation was significantly
modality of surgical treatment under associated with duration of hospital
ultrasound guidance.[2] A study stay (p value=0.027). [11] This is
done in South Africa has mentioned consistent with our findings whereby
that needle aspiration can be used the delayed care influenced the
for both diagnosis and treatment of occurrence of complications and
DNSIs.[22] Adoption of needle longer hospital stay.
aspiration as the primary and
immediate mode of diagnosis has Conclusion
assisted to increase speed of
treatment, namely incision and Neck swelling and pain on
drainage. background of tooth extraction are
the most common risk factors for
In our study, 14 (21.2%) of patients patients with DNSIs. Delayed
had complications and the majority presentation and advanced age are
of them were necrotizing fasciitis associated with higher levels of
(57.1%), followed by airway complications of DNSIs and
obstruction (28.6%) and septic shock prolonged hospital stay.
(16.70%). In Latvia, a study
performed found 11.4% of Conflict of interests
complications with airway No conflict of interests to declare.
obstruction representing 27.9%.[17]
Delayed consultation and advanced Acknowledgement and funding
age were significantly associated with None
complications (p value=0.02 and
0.015 respectively). Patients in these This article is published open access under the
age groups should warrant Creative Commons Attribution-NonCommercial
NoDerivatives (CC BYNC-ND4.0). People can copy
additional concern when presenting
and redistribute the article only for
with DNSIs. noncommercial purposes and as long as they give
appropriate credit to the authors. They cannot
distribute any modified material obtained by
The mean hospital stay was 10.23
remixing, transforming or building upon this
days (SD±11.64, range 0-60), which article. See
was in agreement with other reports https://creativecommons.org/licenses/by-nc-
nd/4.0/
in the literature. [7,21] The duration
of symptoms prior to consultation
and presentation of complications
were significantly associated with
hospital stay (p value=0.007 and
0.022 respectively). A study
performed in Nigeria found that time
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8Rwanda Journal of Medicine and Health Sciences Vol.4 No.1, March 2021 https://dx.doi.org/10.4314/rjmhs.v4i1.2
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