Clinical Features And Less Invasive Treatment Strategies Of Deep Neck Infection And Its Severe Complications

Purpose:The diagnosis and treatment of deep neck space infections are still challenges for surgeons.Anatomic complexity makes diagnosis and treatment of DNI difficult.DNI remains an important health risk with morbidity and mortality.With the development of microbiology,diagnosis tools,modern antibiotics and surgical techniques,the disastrous mortality has reduced in recent decades.But the recommended treatment protocol for DNI and its complications,especially DNM,is still absent.The aim of this study is to summarize the clinical features of DNI patients admitted to our department,to detect the risk factors of its deterioration to DNM,so as to conclude the clinic outcome of our management for DNI and DNM.Meanwhile,by a meta-analysis,we try to evaluate the effectiveness of less invasive management in treating DNM,to reveal the advantages to lower mortality,complication morbidity and hospital stays when compared with routine surgery.Finally,a feasible protocol of DNI and DNM is provided to assist practioners.Methods:1.According to a retrospective study protocol,we collect the clinical data of patients diagnosed DNI or DNM between 2011 and 2017,including age,gender,pathogenic factors,clinical manifestation,laboratory examination,radiologic characteristics,surgery procedures and treatment outcome.An analysis of the risk and prognosis factors of DNI onset and progress is accomplished by data statistics.2.Databases were searched for observational studies comparing postoperative morbidity,mortality and length of stay in DNM patients receiving less invasive surgery with those using traditional operation.Postsurgical mortality was the primary endpoint.We used meta-analysis with fixed-effects model or random-effects model.The pooled risk ratio(RR)with 95%confidence intervals(CI)is calculated as summary method.When analyzing hospital stays we used mean difference(MD).Statistical significance difference was investigated with the less invasive group and routine thoracotomy group.3.Integrating the result of aforementioned retrospective study and meta-analysis,we aimed to validate the feasibility and usefulness of less invasive management in treating DNI/DNM,to design the optimal strategy and reasonable flow path according to China's status quo of medical care service.Results:1.A total of 95 patients were admitted in this study with the average age 51.2 year old(ranged from 22 to 75).68.4%(65/95)were male.Patients were divided into group I(without DNM)or group II(with DNM).There was statistical significance between two groups in diabetes morbidity and hospital stays.Dental and pharyngeal infections were the two most frequent causes.More than one space was involved in 66 cases.Hospital stays lengthened obviously in these patients.Parapharyngeal space was invaded in most pharyngeal originated cases.In laboratory examination,hs-CRP showed significant difference in two groups.Bacterial culture got positive result in 48 cases,among which 11 were mixed germ infection.DNM was the most severe complication.Diabetes,multiple spaces involvement and hs-CRP were confirmed risk of severe complication.And hs-CRP was an independent factor.Enhanced CT was the "golden standard" for the diagnosis and treatment surveillance of DNI/DNM.The overall treatment efficacy was 94.7%.The mortality rate both of DNI and DNM in our study was similar to that in other studies.2.Databases were searched(update to December 2017)to identify observational studies for surgical treatment of DNM.A total of 11 studies involving 242 patients were included in this meta-analysis.Patients accepted less invasive surgery were classified as treatment group.Others were divided into control group.Six studies with high homogeneity provided complete information about postoperative mortality.Less invasive surgery was validated of its ability in reducing mortality significantly compared with routine thoracotomy.No publication bias was found.Two studies with heterogeneity were included in the analysis of postoperative complication morbidity.No statistical significance was detected between two groups.Another 2 studies with good homogeneity were included when analyzing hospital stays.Still no significant association was found.Generally speaking,less invasive surgeries were recommendable in treating DNM.3.We recommended a flowchart of diagnosis and treatment for DNI/DNM according to our experience and meta-analysis result.It is reasonable to use a less invasive management for DNI and DNM.Neck incision and drainage for all DNI patients is a routine practice.Transcervical mediastinum drainage is effective for type I and type IIA patients.? Posterolateral thoracotomy is the prime approach for mediastinum drainage in B patients.Conclusions:The mortality from DNI and DNM is still high.But aggressive treatment protocol is not necessarily favorable to every patient.Less invasive surgeries,such as transcervical mediastinum drainage,mediastinoscopy and VATS,are proved to be useful.Thus,we present a therapeutic strategy after summarizing our clinical experience and implementing a meta-analysis.All DNI patients should accept transcervical drainage.Transcervical drainage was also recommended to type I and type IIA DNM patients for mediastinum drainage.For type IIB DNM patients,relative less invasive posterolateral thoracotomy may be more feasible.Additional closed thoracic drainage,subxiphoid incision drainage and VAC could be employed as a supplement.We believe that our experience and strategy will increase the standardization and effectiveness in treating DNI and DNM,decreasing postoperative complication morbidity and mortality eventually.