Deep Fascial Space Infection of the Neck: A Continuing Challenge

Abstract

We present our clinical experience with two complex cases of deep fascial space infections of the neck. The first was a case of cervical necrotizing fasciitis involving the submental space. The second was an infection beginning at the soft palate and extending to the anterior mediastinum. Both infections emanated from an oral source in patients with diabetes mellitus, and both patients required multiple surgical debridements and endotracheal intubation for airway protection. Despite the declining incidence of deep space neck infections, our cases illustrate the challenging diagnostic and treatment dilemmas for the clinician managing patients with diabetes.

Methicillin Resistant Staphylococcus Aureus Infection in Descending Necrotizing Mediastinitis From Retropharyngeal Perforation

“…Cultures often grow multiple species of common oral flora such as microaerophilic streptococci and Klebsiella pneumoniae, as well as anaerobes such as Fusobacterium, anaerobic Streptococcus, and Bacteroides. 3 Cultures of abscess drainage in this case persistently revealed clindamycin and MRSA. DNM is an infrequent presentation of community-acquired MRSA (CA-MRSA); most cases present as superficial skin infections.…”

“…The retropharyngeal space accounts for 70% of cases of DNM. 3 It lies behind the esophagus and anterior to the prevertebral fascia, extending from the base of the skull to the posterior mediastinum. Retropharyngeal abscesses from pharyngeal perforations can spread along these planes.…”

“…Early endotracheal intubation is vital to prevent asphyxiation. 3 Broad spectrum antibiotics are initiated empirically and may be modified based on results of cultures and sensitivity testing. Cultures often grow multiple species of common oral flora such as microaerophilic streptococci and Klebsiella pneumoniae, as well as anaerobes such as Fusobacterium, anaerobic Streptococcus, and Bacteroides.…”

“…1 Infection of the deep fascial space may follow pharyngeal abscesses, dentoalveolar abscesses, cervical esophageal trauma, traumatic foreign body ingestion, and injecting drug abuse. [2][3][4] Predisposing factors for DNM include diabetes mellitus, immunodeficiency, heavy alcohol consumption, and excessive smoking. 5 Delayed diagnosis and inadequate drainage are the main causes of mortality.…”

Infekte der tiefen Halsweichteile mit begleitender Mediastinitis

“…Bei einer begleitenden Thrombose der Vena jugularis interna braucht keine Ligatur oder Resektion der thrombosierten Vene zu erfolgen; bei Vergröûerung des Thrombus oder septischen Emboli sollte jedoch eine Antikoagulation durchgeführt werden [19]. Bei Verschwellung der Atemwege kann eine temporäre Schutzintubation notwendig werden [20].…”