1. Evidence Based Medicine
Deep Neck Infection
Evidence Based Medicine
Presentor 劉芃慧
Supervisor 鄒先令
Moderator 邱德發
2011/09/29

2. Introduction
Infections of the neck and upper airway include pharyngitis/tonsillitis, peritonsillar abscess, epiglottitis, retropharyngeal abscess, and odontogenic abscess.
These disorders must be recognized quickly because early airway management may be lifesaving !
Adapted from Tintinalli's Emergency Medicine 7th edition
Chap 241 Infections and Disorders of the Neck and Upper airway

3. Introduction

4. Adapted from CT AND MRI imaging evaluation of neck infection with clinical correlations
RADIOLOGIC CLINICS OF NORTH AMERICA
VOLUME 38 NUMBER 5 SEPTEMBER 2000

5. Adapted from CT AND MRI imaging evaluation of neck infection with clinical correlations
RADIOLOGIC CLINICS OF NORTH AMERICA
VOLUME 38 NUMBER 5 SEPTEMBER 2000

6. Adapted from CT AND MRI imaging evaluation of neck infection with clinical correlations
RADIOLOGIC CLINICS OF NORTH AMERICA
VOLUME 38 NUMBER 5 SEPTEMBER 2000

7. Deep Neck Infection
Adapted from 急診流程指引
台灣急診管理學會/急重症醫療發展基金會

8. Deep Neck Infection
Adapted from 急診流程指引
台灣急診管理學會/急重症醫療發展基金會

9. Deep Neck Infection
Adapted from 急診流程指引
台灣急診管理學會/急重症醫療發展基金會

10. Questions Airway management :
Tracheostomy versus endotracheal intubation ?
Abscess managements :
Does all abscesses requires surgical drainage or
intervention ?
Antibiotics selection :
The efficacy of Rocephin + Clindamycin versus
Augmentin/Unasyn

11. Q1 Airway managements in DNI
Patient population :
DNI patients requiring airway management
Intervention :
tracheostomy
Comparison :
endotracheal intubation
Outcomes :
complications/hospital stay/mortality

12. J Oral Maxillofac Surg 60:349-354, 2002

13. Meta-analysis Forest plot
THE EVIDENCE PYRAMID
Meta - analysis
Randomized Controlled Double Blind Studies
Randomized Controlled
Studies
Cohort studies
Case Control Studies
Case series/ Reports
Meta-analysis Forest plot
Ideas, Editorials, Opinions
Animal research
In vitro (test tube) research
Hierarchy of evidence that arranges study designs by their susceptibility to bias.

14. Grade of Recommendation Level of Evidence Therapy
Systemic review of RCTs 1b
Single RCT 1c
‘All-or-none’
[B] 2a
Systemic review of cohort studies 2b
Cohort study or poor RCT 2c
‘Outcomes’ research 3a
Systemic review of case-control studies 3b
Case-control study
[C] 4
Case series
[D] 5
Expert opinion, physiology, bench research

15. Patients and Methods
The hospital records for 85 patients treated for deep neck space infections at Parkland Memorial Hospital, Dallas, TX, from January 1994 through February 1999 were retrospectively reviewed.
Inclusion criteria :
*need for surgical drainage of the infection
*impending airway compromise
*involvement of 2 or more deep anatomic fascial spaces
*maintenance of an artificial airway after surgery
Group 1 (n=34) tracheotomy
Group 2 (n=51) endotracheal intubation.

16. Results Complications : *need for repeated surgical drainage
Group 1 Tracheostomy (34)
Group 2
Intubation (n=51)
Hospital Stays
4.8 days
5.9 days
ICU stays
1.1 days
3.1 days
P < 0.05
Complications
2 (6%)
5 (10%)
with 2 mortality
Average Costs $ $
Complications :
*need for repeated surgical drainage
*blindness
*extubation failure

19. Conclusion/Discussion
A majority of deep neck infections are associated with significant upper airway edema !
In the above series :
oral and maxillofacial surgeons : intubation favored
otolaryngologists : tracheostomy favored
2 Mortalities in the intubation group !
Tracheotomy is an effective and relatively safe technique for control of the airway in patients with deep neck space infections.

20. Deep Neck Infection Tracheostomy Adapted from 急診流程指引
台灣急診管理學會/急重症醫療發展基金會

21. Q2 Abscess Management Patient population :
patient with deep neck abscess confirmed by CT
Intervention :
conservative treatment with antibiotics
Comparison :
surgical drainage
Outcomes :
complications/mortality

23. Meta-analysis Forest plot
THE EVIDENCE PYRAMID
Meta - analysis
Randomized Controlled Double Blind Studies
Randomized Controlled
Studies
Cohort studies
Case Control Studies
Case series/ Reports
Meta-analysis Forest plot
Ideas, Editorials, Opinions
Animal research
In vitro (test tube) research
Hierarchy of evidence that arranges study designs by their susceptibility to bias.

24. Grade of Recommendation Level of Evidence Therapy
Systemic review of RCTs 1b
Single RCT 1c
‘All-or-none’
[B] 2a
Systemic review of cohort studies 2b
Cohort study or poor RCT 2c
‘Outcomes’ research 3a
Systemic review of case-control studies 3b
Case-control study
[C] 4
Case series
[D] 5
Expert opinion, physiology, bench research

25. Patients/Methods
All patients older than 17 years (n=80) who were admitted to the Department of Otolaryngology, University of Padua, Treviso, Italy, and the Department of Infectious Diseases, Treviso Regional Hospital,Treviso, Italy, with the diagnosis of DNAs on CECT between January 1997 and June 2005
Exclusion Criteria : Patients with superficial and peritonsillar abscesses, those with head and neck cancer, and those with posttraumatic deep abscesses
The CT scan was interpreted as showing an abscess in presence of the enhancing rim around nonenhancing central density consistent with fluid.

26. Patients and Methods
Patients who were clinically unstable ; patients with descending infection; patients with prevertebral, anterior visceral, vascular visceral, or with abscess involving more than two neck deep spaces; and patients with abscess larger than 3.0 cm underwent immediate surgical drainage. ( 24/80, 30.0%)
In all the other cases, patients were observed for 48 hours. (56/80, 70%)
 improvements : CT scan again (38/80, 47% )
 no improvements : surgical drainage (18/80, 23 %)

27. 23 % 30 % 47 % DM : the only variable predictive for lack of
response to abx,
P = 0.014
23 %
30 %
47 %

28. Results
No patients in the observed group developed life threatening complications.
Intraoperative findings confirmed the CT diagnosis of abscess in 88.1% (37/42).
CT false positive rate : 11.9% (5/42)
All patients were discharged in stable condition with a mean length of hospital stay of 11.9 days.
Mean Difference
95% CI P
Surgical Drainage
4.80
0.003 DM
5.33
1.82 – 8.83
Multiple space involvement
6.53
3.68 – 9.37
<0.001
Complications
8.16
5.34 – 10.98

29. Conclusion/Discussion
Although the mainstay of treatment for deep neck abscesses has been surgical drainage, small abscesses can respond to antibiotic alone.
The Wait and Watch Policy : Observe for 48 hrs
* Clinically Stable patients
* Abscess < 3m
* Absence of involvement of danger space
(prevertebral, anterior visceral, vascular visceral)
* Absence of multiple space involvement
* Absence of decending infection

30. Deep Neck Infection Stable patients abscess < 3m
not involving danger space or > 2 spaces
no decending infection
 Wait and Watch 48 hrs !

31. Q3 Antibiotics selection
Patient population :
patient with deep neck infection
Intervention :
augmentin/unasyn
Comparison :
ceftriaxone + clindamycin/metronidazole
Outcomes :
resistance rate and treatment failure

33. Meta-analysis Forest plot
THE EVIDENCE PYRAMID
Meta - analysis
Randomized Controlled Double Blind Studies
Randomized Controlled
Studies
Cohort studies
Case Control Studies
Case series/ Reports
Meta-analysis Forest plot
Ideas, Editorials, Opinions
Animal research
In vitro (test tube) research
Hierarchy of evidence that arranges study designs by their susceptibility to bias.

34. Grade of Recommendation Level of Evidence Therapy
Systemic review of RCTs 1b
Single RCT 1c
‘All-or-none’
[B] 2a
Systemic review of cohort studies 2b
Cohort study or poor RCT 2c
‘Outcomes’ research 3a
Systemic review of case-control studies 3b
Case-control study
[C] 4
Case series
[D] 5
Expert opinion, physiology, bench research

35. Patients / Methods
A total of 206 patients with the diagnosis of an odontogenic head and neck deep space infection were treated at the University Hospital for Craniomaxillofacial and Oral Surgery of Medical University of Vienna between January 2005 and March 2008.

38. Discussion
The routine use of the broad-spectrum combination amoxicillin/clavulanic acid proved to be of value
The use of moxifloxacin instead of clindamycin in penicillin-allergic patients seems worth considering

39. Deep Neck Infection Augmentin/Unasyn favored
Role of Moxifloxacin undetermined

40. Questions Airway management :
Tracheostomy versus endotracheal intubation ?
 Tracheostomy favored !
Abscess managements :
Does all abscesses requires surgical drainage or
intervention ?
 No !
Antibiotics selection :
The efficacy of Rocephin + Clindamycin versus
Augmentin/Unasyn
 Augmentin/Unasyn favored !
 Role of Moxifloxacin ?

41. Thank you for your attention !