Deep Neck Space Infections (DNSIs)

- Acknowledgements

Chief Editor: Reda Kamel1

General Secretary: Ahmed Ragab²

General Coordinator: Baliegh Hamdy³

Scientific Board: Ashraf Khaled,⁴ Mohamed Ghonaim,⁵ Mahmoud Abdelaziz,⁶ Tarek Ghannoum,⁷ Mahmoud Yousef⁸

Assembly Board: Eslam farid Abu shady ¹¹, Mohammed Roushdy ⁹, Mohamed El rabiee ¹³, Mostafa Ammar ⁶

Grading Board (In alphabetical order): Ahmed Abdel Fattah,¹⁰ Hazem Abdel Tawab,¹ Heba Abo Elnaga,² Sherif Askar,¹² Khaled Dahy,¹³ Ahmed El Batawi,¹ Ahmad Eltelety,¹ Ibrahim Khaled,¹² Yaser Khalil,² Emad Shehata,⁶ Mohamed Zahran¹⁴

Reviewing Board: Ali Tawfik,⁵ Mohamed Hegazy,¹ Abdellatif Elrashidy²

Other related specialties Reviewing Board: Engy Adel Asker¹⁵.

¹Otorhinolaryngology Department Faculty of Medicine/Cairo University, ²Otorhinolaryngology Department Faculty of Medicine/Menoufia University, ³Otorhinolaryngology Department Faculty of Medicine/Minia University, ⁴Otorhinolaryngology Department Faculty of Medicine/ Beni-Suef University, ⁵Otorhinolaryngology Department Faculty of Medicine/Mansoura University, ⁶Otorhinolaryngology Department Faculty of Medicine/Tanta University, ⁷Audiovestibular Unit, Otorhinolaryngology Department Faculty of Medicine/Cairo University, ⁸Phoniatrics Unit, Otorhinolaryngology Department Faculty of Medicine/Ain Shams University, ⁹Otorhinolaryngology, Department Faculty of Medicine / Assuit University, ¹⁰Otorhinolaryngology Department Faculty of Medicine / Al Azhar University, ¹¹Otorhinolaryngology Department Faculty of Medicine / Banha University,¹²Otorhinolaryngology Department Faculty of Medicine / Zagazig University, ¹³Otorhinolaryngology Department Faculty of Medicine / Sohag University, ¹⁴Otorhinolaryngology Department Faculty of Medicine / Alxandria University,¹⁵ Head nurse at Tanta University Hospitals.

Sincere thanks extend to the secretaries: Samar Hussein and Eman Ragab, as well as the editor: Mohamed Salah

- Acronyms and Abbreviations

DNSI Deep neck space infection

- Executive Summary

The following statement and flowchart were adopted/adapted/ from Controversies in the management of deep neck space infection in children: an evidence‐based review. Clinical Otolaryngology, 2017, which had the highest scores as regards the currency, contents and quality.

1- Definition: Deep neck space infection (DNSI) is defined as infection in the potential spaces and fascial planes of the neck. (Strong recommendation)

2- detailed history, physical examination, and identification of any immediate or impending airway compromise: A detailed history and physical examination are both vital in identifying the presence, source and any complications of infection. (Strong recommendation)

3- Aetiology:

a. Most cases of DNSI are bacterial in aetiology; however, the causative pathogens in the paediatric population differ to those in the adult. Sources in paediatric cases include tonsillitis, pharyngitis, haematogenous and suppurative cervical adenitis compared with adult DNSI, which often have an odontogenic origin. (Conditional recommendation)

b. Sharp objects may cause perforation of the pharynx or oesophagus and may result in abscess formation in the adjacent neck spaces (Strong recommendation)

4- The management of a DNSI: The management of a DNSI is highly dependent on the location and extent of deep neck involvement (Conditional recommendation)

5- imaging in DNSI:

a. Lateral neck radiographs are useful tool for screening of retropharyngeal and parapharyngeal abscesses (Conditional recommendation)

b. Contrast enhanced CT imaging is an accurate and sensitive tool to differentiate a drainable abscess from cellulitis (Strong recommendation)

c.MRI provides better soft tissue definition than CT and in addition avoids exposure to radiation. (Conditional recommendation)

6- Medical treatment in DNSIs:

a. All patients with a DNSI should be given initial empiric antibiotic therapy (even if the patient is also being managed surgically) until culture and sensitivity results are available (Strong recommendation)

b. Either penicillin in combination with a ß-lactamase inhibitor (such as amoxicillin with clavulanic acid) or a ß-lactamase–resistant antibiotic (such as cefoxitin, cefuroxime, imipenem or meropenem) in combination with a drug that is highly effective against most anaerobes (such as clindamycin or metronidazole) is recommended for optimal empiric coverage. (Strong recommendation)

7- Surgical drainage of DNSIs:

a. Indications for surgical drainage include airway compromise, septicaemia, complications, extending or descending infection or no clinical improvement within 48 hours of the initiation of IV Antibiotics abscess >2.2 cm on CT imaging. (Strong recommendation)

b. An external cervical approach is required for submandibular, prevertebral and carotid space infection. Parapharyngeal abscesses that are not obviously ‘pointing’ in the pharynx and complicated retropharyngeal abscesses that cannot be fully drained using an intraoral approach also require an external approach. (Strong recommendation)

8- Minimally invasive techniques in DNSIs: Minimally invasive techniques such as image-guided needle aspiration of abcesses measuring <3 cm in diameter (Strong recommendation)

9- Acute airway obstruction: Acute airway obstruction is one of the most alarming complications of DNSI. It is commonly encountered in Ludwig’s angina and is a significant risk with a retropharyngeal abscess due to the potential for rupture into the airway (Strong recommendation)

10- Monitoring of the airway in DNSIs: Monitoring of the airway is a priority when managing DNSI patients and should continue for at least 48 h after surgical intervention (Strong recommendation)

- Introduction, scope and audience

➡️Introduction and background

Deep neck space infection (DNSI) is defined as infection in the potential spaces and fascial planes of the neck. Early recognition of DNSI can be challenging due to the complex head and neck anatomy; hence, a high index of suspicion is required to prevent a delay in diagnosis and appropriate management.

➡️Scope

to identify quality improvement opportunities in the management of DNSIs and to create explicit and actionable recommendations in the clinical practice.

➡️Target audience: Target users are ENT clinicians and specialists and residents to be used for the management of patients present with deep neck space infection (DNSI

- Methods

➡️Stakeholder Involvement: Individuals who were involved in the development process. included the above-mentioned Head and Neck Chief Manager, Head and Neck Executive Manager, Assembly Board, Grading Board and Reviewing Board.

Information about target population experiences, views and preferences were applicable for this topic.

The adaptation cycle passed over: set-up phase, adaptation phase (Search and screen, assessment: currency, content, quality & /decision/selection) and finalization phase that included revision and external reviewing and Other related specialties Reviewing Board including a nurse.

➡️Search sources included other previous guidelines:

Pubmed, Medline, Egyptian Knowledge Bank, Medscape, WebMD, Google Scholar

➡️Search sources included other previous guidelines:

▪️ Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management,2021.

▪️ Controversies in the management of deep neck space infection in children: an evidence‐based review. Clinical Otolaryngology, 2017.

Time periods searched: from 2017 to 2021.

➡️Results

Three guidelines were assessed by 4 experts Laryngologists and Controversies in the management of deep neck space infection in children: an evidence‐based review. Clinical Otolaryngology, 2017had the highest scores as regards the currency, contents, and quality. It was graded GRADE by 11 expert Laryngologists and reviewed by 3 expert reviewers. (Annexes tables 1-3) [1].

Interpretation of strong and conditional recommendations for an intervention

Audience	Strong recommendation	Conditional recommendation
Patients	Most individuals in this situation would want the recommended course of action; only a small proportion would not. Formal decision aides are not likely to be needed to help individuals make decisions consistent with their values and preferences.	Most individuals in this situation would want the suggested course of action, but many would not
Clinicians	Most individuals should receive intervention. Adherence to the recommendation could be used as a quality criterion or performance indicator.	Different choices will be appropriate for individual patients, who will require assistance in arriving at a management decision consistent with his or her values and preferences. Decision aides may be useful in helping individuals make decisions consistent with their values and preferences.
Policymakers	The recommendation can be adopted as policy in most situations.	Policymaking will require substantial debate and involvement of various stakeholders.

WHO handbook for guideline development – 2nd ed. Chapter 10, page 129

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to Decision frameworks (GRADE Working Group 2013)

Grade

Definition

High

We are very confident that the true effect lies close to that of the estimate of the effect.

Moderate

We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different

Low

Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

Very Low

We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

[2] http://www.gradeworkinggroup.org.

- Recommendations

The following statement and flowchart were adopted/adapted/ from Controversies in the management of deep neck space infection in children: an evidence‐based review. Clinical Otolaryngology, 2017(1), which had the highest scores as regards the currency, contents and quality.

Recommendations statements

Statement topic

Action recommendation

Evidence quality

Strength of Recommendation

Study type

Reference

1- Definition

Deep neck space infection (DNSI) is defined as infection in the potential spaces and fascial planes of the neck. Early recognition of DNSI can be challenging due to the complex head and neck anatomy; hence, a high index of suspicion is required to prevent a delay in diagnosis and appropriate management.

Moderate

Strong recommendation

Systematic review

(1)

2. detailed history, physical examination and identification of any immediate or impending airway compromise

A detailed history and physical examination are both vital in identifying the presence, source and any complications of infection. The priority in all patients should be the identification of any immediate or impending airway compromise, which should be imminently managed.

Moderate

Strong recommendation

Systematic review

(1)

3. Aetiology

a.Most cases of DNSI are bacterial in aetiology; however, the causative pathogens in the paediatric population differ to those in the adult. Sources in paediatric cases include tonsillitis, pharyngitis, haematogenous and suppurative cervical adenitis compared with adult DNSI, which often have an odontogenic origin. The organisms commonly isolated in DNSIs are Staphylococcus aureus and group A Streptococcus. Anaerobic species include Fusobacterium, Peptostreptococcus and Porphyromonas

Low

Conditional recommendation

Observational study

(2)

b.Sharp objects may cause perforation of the pharynx or oesophagus and may result in abscess formation in the adjacent neck spaces, such as the retropharyngeal space and should therefore be considered in the history taking and differential diagnosis process.

Low

Strong recommendation

4. The management of a DNSI

The management of a DNSI is highly dependent on the location and extent of deep neck involvement, and diagnostic imaging is essential in nearly every case.

Moderate

Conditional recommendation

Systematic review

(1)

5. imaging in DNSI

a. Lateral neck radiographs are useful tool for screening of retropharyngeal and parapharyngeal abscesses, Ultrasound more accurate role than CT imaging in differentiating a drainable abscess from cellulitis and can guide diagnostic and therapeutic needle or catheter aspiration of superficial, uniloculated fluid collections when imminent airway compromise is not evident.

Moderate

Conditional recommendation

Systematic review

(3, 4)

b. Contrast enhanced CT imaging is an accurate and sensitive tool to differentiate a drainable abscess from cellulitis and also significantly contribute to surgical planning to drain deep neck space collections.

Moderate

Strong recommendation

c.MRI provides better soft tissue definition than CT and in addition avoids exposure to radiation. However, the time taken to perform MRI, and the nature of the scanner, often means that a general anaesthetic is required for this investigation in pediatric population. Magnetic resonance angiography (MRA) is used to evaluate potential vascular complications, such as IJVT and carotid artery aneurysm or rupture.

Moderate

Conditional recommendation

6.Medical treatment in DNSIs

a.All patients with a DNSI should be given initial empiric antibiotic therapy (even if the patient is also being managed surgically) until culture and sensitivity results are available and advised that therapy should be effectively targeted against the aerobic and anaerobic bacteria.

Low

Strong recommendation

Systematic review

(5)

b. Either penicillin in combination with a ß-lactamase inhibitor (such as amoxicillin with clavulanic acid) or a ß-lactamase–resistant antibiotic (such as cefoxitin, cefuroxime, imipenem or meropenem) in combination with a drug that is highly effective against most anaerobes (such as clindamycin or metronidazole) is recommended for optimal empiric coverage.

Low

Strong recommendation

7. Surgical drainage of DNSIs

a. Indications for surgical drainage include airway compromise, septicaemia, complications, extending or descending infection or no clinical improvement within 48 hours of the initiation of IV Antibiotics abscess >2.2 cm on CT imaging.

Low

Strong recommendation

Observational study

(6, 7)

b. An external cervical approach is required for submandibular, prevertebral and carotid space infection. Parapharyngeal abscesses that are not obviously ‘pointing’ in the pharynx and complicated retropharyngeal abscesses that cannot be fully drained using an intraoral approach also require an external approach.

Low

Strong recommendation

8. Minimally invasive techniques in DNSIs

Minimally invasive techniques such as image-guided needle aspiration of abcesses measuring <3 cm in diameter, and ultrasound-guided catheter placement for unilocular abscesses measuring >3 cm in diameter, extending into deep neck spaces or located within a glandular structurehave been used to treat well-defined, unilocular abscesses in patients who do not have airway compromise.

Low

Strong recommendation

Observational study

(6, 7)

9. Acute airway obstruction

Acute airway obstruction is one of the most alarming complications of DNSI. It is commonly encountered in Ludwig’s angina and is a significant risk with a retropharyngeal abscess due to the potential for rupture into the airway leading to aspiration in addition to potential airway obstruction. Most cases are successfully managed with endotracheal intubation. Rarely, and in severe cases, intubation with general anaesthesia may be difficult and may precipitate complete airway obstruction that necessitates an emergency tracheostomy.

Moderate

Strong recommendation

Systematic review

(3)

10. Monitoring of the airway in DNSIs

Monitoring of the airway is a priority when managing DNSI patients and should continue for at least 48 h after surgical intervention because of the potential for increasing oedema in the postoperative period. The routine use of intravenous steroids in patients who have impending airway obstruction has been advocated with the aim of minimising oedema and thereby reducing the need for aggressive airway intervention.

Moderate

Strong recommendation

Systematic review

(3)

- Research needs

Research questions

▪️ Further research on aetiopathogenesis of deep neck space infections in pediatric age group.

▪️ Further research on efficacy of Minimally invasive techniques in DNSIs.

- Monitoring and evaluating the impact of the guideline

Monitoring/ Auditing Criteria:

▪️ Monitoring of the airway is a priority when managing DNSI patients and should continue for at least 48 h after surgical intervention.

▪️ A detailed history and physical examination of patients with DNSIs.

▪️ Proper imaging study of patients with DNSIs.

▪️ All patients with a DNSI should be given initial empiric antibiotic therapy (even if the patient is also being managed surgically) until culture and sensitivity results are available.

▪️ Surgical drainage of patients with DNSIs when indicated.

▪️ Clinicians should document resolution, improvement, or worsened symptoms of neonatal stridor after treatment or observation.

All clinicians should be aware and informed to consider the following:

▪️ Red Flags that need urgent referral for Assessment/ Management must be taken into consideration.

▪️ For Assessment it is crucial to perform a detailed history/ clinical examination as a minimum patient assessment.

- Updating of the guideline

Updating Procedure:‎

Any recommendation of this guideline will be updated when new evidence that could potentially impact the ‎current evidence base for this recommendation is identified. If no new reports or information are identified ‎for a particular recommendation, the recommendation will be revalidated. The focus will be on ‎recommendations supported by very-low- or low certainty evidence and where new recommendations or a ‎change in the published recommendations may be needed.‎

- References

1. Lawrence R, Bateman N. Controversies in the management of deep neck space infection in children: an evidence‐based review. Clinical Otolaryngology. 2017;42(1):156-63.

2. Pardal-Peláez B, Pardal-Refoyo JL, Ochoa-Sangrador C, González-Serrano J, Montero-Martín J, López-Quiles J. Analysis of the prevalence of dental origin of deep neck infections. Journal of oral and maxillofacial surgery, medicine, and pathology. 2018;30(2):180-6.

3. Vieira F, Allen SM, Stocks RMS, Thompson JW. Deep neck infection. Otolaryngologic Clinics of North America. 2008;41(3):459-83.

4. Yellon R. Head and neck space infections. Pediatric otolaryngology. 2003;2:1681-701.

5. Carbone PN, Capra GG, Brigger MT. Antibiotic therapy for pediatric deep neck abscesses: a systematic review. International journal of pediatric otorhinolaryngology. 2012;76(11):1647-53.

6. Biron VL, Kurien G, Dziegielewski P, Barber B, Seikaly H. Surgical vs ultrasound-guided drainage of deep neck space abscesses: a randomized controlled trial: surgical vs ultrasound drainage. Journal of Otolaryngology-Head & Neck Surgery. 2013;42(1):18.

7. Yeow K-M, Liao C-T, Hao S-P. US-guided needle aspiration and catheter drainage as an alternative to open surgical drainage for uniloculated neck abscesses. Journal of Vascular and Interventional Radiology. 2001;12(5):589-9

- Further Reading

▪️ Lawrence, R. and N. Bateman, Controversies in the management of deep neck space infection in children: an evidence‐based review. Clinical Otolaryngology, 2017. 42(1): p. 156-163. https://pubmed.ncbi.nlm.nih.gov/27288654/

▪️ Maharaj, S., S. Ahmed, and P. Pillay, Deep neck space infections: a case series and review of the literature. Clinical Medicine Insights: Ear, Nose and Throat, 2019. 12: p. 1179550619871274.

▪️ Bakir, S., et al., Deep neck space infections: a retrospective review of 173 cases. American journal of otolaryngology, 2012. 33(1): p. 56-63.

▪️ Das, R., G. Nath, and A. Mishra, Clinico-pathological profile of deep neck space infection: a prospective study. Indian Journal of Otolaryngology and Head & Neck Surgery, 2017. 69(3): p. 282-290.

▪️ Kataria, G., et al., Deep neck space infections: a study of 76 cases. Iranian journal of otorhinolaryngology, 2015. 27(81): p. 293.

▪️ Pankhania, M., et al., Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management. The Annals of The Royal College of Surgeons of England, 2021. 103(3): p. 208-217. https://pubmed.ncbi.nlm.nih.gov/33645267/

- Annexes

Annex 1: Guideline development contributors and participants, with their declarations of interests

Editorial Independence:

▪️ This guideline was developed without any external funding.

▪️ All the guideline development group members have declared that they do not have any competing interests.

Annex 2: Guideline Flowchart

Annex 3: Tables of appraisal of selected guidelines: content (table 1), quality (table 2), , and currency (table 3), of the selected guidelines .

Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management	Controversies in the management of deep neck space infection in children: an evidence‐based review
9	7	Credibility
7	7	Observability
7	9	Relevance
8	8	Relative advantage
8	7	Easy to install/understand
7	7	Testability
7	8	Compatibility
53	63	Total score

1. Assessment of content table:

Controversies in the management of deep neck space infection in children: an evidence‐based review had the highest scores.

2. Assessment of quality (CPG Appraisal tool):

Domain

Controversies in the management of deep neck space infection in children: an evidence‐based review

Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management

1.Transparency

A

A

2. Conflict of interest

A

A

3. Development group

A

B

4. Systematic review

A

A

5. Grading of evidence

A

B

6.Recommendations

A

B

7. External review

A

B

8.Updating

A

C

3.Assessment of Currency table:

No

Guideline Name

Year

of publication

The organization

Age demo-graphy

1

Controversies in the management of deep neck space infection in children: an evidence‐based review

2017

Clin Otolaryngol

.

Adults and children

2

Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management

2021

Ann R Coll Surg Engl

Adults and children

No statements of the original guidline were modified, added nor omitted.

Site:	EHC \| Egyptian Health Council
Course:	Otorhinolaryngology, Audiovestibular & Phoniatrics Guidelines
Book:	Deep Neck Space Infections (DNSIs)

Printed by:	Guest user
Date:	Monday, 23 December 2024, 9:34 PM

Deep Neck Space Infections (DNSIs)

Description

"last update: 5 August 2024"

Table of contents

- Acknowledgements

- Acronyms and Abbreviations

- Executive Summary

- Introduction, scope and audience

- Methods

- Recommendations

- Research needs

- Monitoring and evaluating the impact of the guideline

- Updating of the guideline

- References

- Further Reading

- Annexes

Annex 2: Guideline Flowchart

Annex 3: Tables of appraisal of selected guidelines: content (table 1), quality (table 2), , and currency (table 3), of the selected guidelines .

Grade	Definition
High	We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate	We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low	Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very Low	We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

Domain	Controversies in the management of deep neck space infection in children: an evidence‐based review	Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management
1.Transparency	A	A
2. Conflict of interest	A	A
3. Development group	A	B
4. Systematic review	A	A
5. Grading of evidence	A	B
6.Recommendations	A	B
7. External review	A	B
8.Updating	A	C