Cellulitis neck is a purulent–inflammatory disease, which is characterized by the involvement of deep cellular spaces of the neck and mediastinal organs in the pathological process, and poses a danger to the patient’s life. It is manifested by rapidly increasing compaction, local fever, redness of the skin, symptoms of general intoxication. Pain significantly limits the mobility of the head, the process of swallowing and breathing. Examination data, CT and MRI results of the soft tissues of the neck help to diagnose the doctor. Treatment consists in a wide opening of the affected area, washing the wound with antiseptic solutions, installing drains, prescribing antibiotics.
L03.8 Cellulitis of other localizations
The number of patients with purulent-inflammatory diseases of the neck in dental hospitals and departments of maxillofacial surgery reaches a third of the total number of patients. 42% of the cases are people aged 20 to 40 years, 24% are patients aged 40-60 years. In men, the purulent process develops 2 times more often than in women. 30% of all men and 50% of women suffering from cellulitis neck have concomitant pathology, which aggravates the course of the underlying disease. The foci of inflammation that are localized in the submandibular and chin areas prevail, are the result of chronic dental diseases.
In the vast majority of cases, the source of cellulitis neck is asymptomatic or low-symptomatic long-existing foci of bacterial infection, for which patients often do not seek medical help. Only a small percentage is due to complications of surgical pathology. The main causes of the development of cellulitis neck include:
- Odontogenic infection. Carious teeth are a chronic microbial focus that exists in the body for a long time and, with any malfunction of the immune system, leads to the spread of bacteria into the surrounding tissues. The causal tooth does not necessarily hurt or cause unpleasant sensations. With the development of pulpitis, the nerves die, then the inflammatory process in the tissues of the tooth proceeds absolutely painlessly.
- Tonsillogenic infection. The palatine tonsils perform the function of local protection against the penetration of microbes until, as a result of chronic inflammation, the lymphoid tissue is replaced by connective tissue. Then the tonsils themselves become a constant source of purulent infection. The probability of cellulitis neck formation increases the presence of a peri- or paratonsillary abscess.
- Foreign bodies of the larynx. The inner surface of the hollow organs of the neck is never completely sterile. It is populated by conditionally pathogenic microorganisms that competitively suppress the reproduction of pathogenic bacteria on the surface of the mucous membranes. The presence of a wound canal leads to the development of a diffuse focus of inflammation deep in the thickness of the tissues.
- Complications of surgical interventions. The penetration of infection can be facilitated by such medical manipulations as direct laryngoscopy, adenotomy, removal of foreign bodies of the trachea, operations on the esophagus, therefore, after these interventions, antibacterial agents are often prescribed for preventive purposes.
Diabetes mellitus, obesity, hormone-dependent bronchial asthma increase the likelihood of cellulitis neck development, contribute to its more severe course. Predisposing factors are chronic alcoholism, addiction to drugs. Complicate treatment, increase the risk of complications of chronic renal failure, hepatitis and cirrhosis of the liver, HIV infection.
The penetration of pyogenic bacteria into the neck tissue causes the development of an inflammatory process, which for a short time spreads in breadth and depth under the influence of constant oscillatory waves that create the esophagus, blood vessels and respiratory organs. The active involvement of deep tissues prevents the outflow of pus, which cannot break out. The rapid spread of pus in the tissues of the neck and cellular spaces of the mediastinum is associated with the peculiarities of the anatomical structure of these areas.
Connective tissue layers arranged in several levels divide muscles, vessels, nerves and internal organs into separate “compartments” that contain a large amount of loose fatty tissue. The fatty strands descend from the neck into the mediastinum, which creates conditions for the smooth transition of the cellulitis neck from one anatomical area to another. A certain role in the movement of pus into the mediastinal region is played by the suction action of the chest, in which negative pressure is created on inspiration.
Several classifications of cellulitis neck have been developed and applied. Maxillofacial surgeons divide inflammatory processes into odontogenic and non-odontogenic. By the nature of the microflora, anaerobic, putrefactive and other phlegmons are isolated. There is a topographic and anatomical classification of cellulitis neck and soft tissue abscesses. The greatest interest of researchers and practitioners is the systematization that takes into account the type of lesion and determines the most effective methods of surgical treatment:
- The first type. The inflammation covers the deep spaces of the neck and descends down to the level of the jugular tenderloin.
- The second type. Inflammation from the neck area spreads to the mediastinum.
- The third type. Purulent foci are determined in the mediastinum regardless of the degree of damage to the neck tissues.
The disease develops acutely. Within a few hours, sometimes a day, the general condition of the patient worsens, the body temperature rises to 38 ° C or more. Swelling gradually increases in the chin area or on one side of the neck, pain and difficulty swallowing are added. Increased pain is provoked by an attempt to shift the organocomplex of the neck with fingers, palpation of the projection of the neurovascular bundle. With severe edema, respiratory disorders, dilation of the subcutaneous veins of the neck are detected. In severe cases, functional torticollis develops, which is a reliable sign of phlegmon.
At the peak of the activity of the process, the skin over the focus of inflammation is hyperemic, tense, hot to the touch. Touching the neck in the projection of the abscess is sharply painful. The patient notes intense pain at rest, limited mobility of the neck. An uncharacteristic clinical picture of the disease can be observed in the case of cellulitis neck formation in the retropharyngeal and retrovisceral spaces of the neck, rapid transition of inflammation to the posterior mediastinum.
As a result of increasing intoxication, the patient’s condition can quickly deteriorate from moderate to agonal. The respiratory rate increases, the pulse quickens, violations of water-electrolyte metabolism progress. The development of secondary mediastinitis is indicated by the appearance of pain in the chest area, their intensification when the head is tilted back (Gerke’s symptom), rigidity of the back muscles (Ravich-Scherbo’s symptom).
In the structure of the causes of secondary mediastinitis (mediastinal lesions), 62% of cases are neck phlegmons of odontogenic origin. Mortality on the background of mediastinitis is observed in 60% of cases, joined sepsis – in 90%. According to other data, about 95% of total necrotic cellulitis neck in the early stages is complicated by the formation of secondary descending necrotizing mediastinitis with the transition of inflammation to the chest organs.
The adverse effects of cellulitis neck also include thrombosis of the deep veins of the lower extremities, damage to the respiratory system (pneumonia, pleural empyema, pyopneumothorax), pericarditis. It is particularly worth mentioning disseminated intravascular coagulation syndrome, which is one of the main causes of mortality in patients with advanced mediastinitis and cellulitis neck in the first hours after admission to the hospital.
A feature of the diagnosis of cellulitis neck is the lack of sensitivity of instrumental research methods at the early stages of pathology development. The diagnosis is established on the basis of a comprehensive examination conducted by a dentist or a maxillofacial surgeon. The following diagnostic procedures are prescribed to the patient:
- Laboratory blood tests. Changes in the general blood test are nonspecific, characteristic of inflammatory diseases of any localization. Leukocytosis, a shift of the leukocyte formula to the left, an increase in ESR is noted. According to the indicators of biochemical analysis, it is possible to judge the violation of the functions of the patient’s internal organs, which may be associated with the development of phlegmon, concomitant diseases.
- Microbiological examination. For analysis, the discharge from the wound, the exudate obtained through drains during active aspiration, is taken. Of interest to the surgeon is the composition of microflora, the sensitivity of microorganisms to antibiotics. The study is carried out repeatedly, since the microbial spectrum may change during treatment.
- Methods of medical imaging. Changes in the neck X-ray, images obtained during multi-spiral computed tomography or magnetic resonance imaging of the neck, chest and mediastinum confirm the presence of inflammation, but lag behind the actual clinical picture of the disease. Interpretation of the results may be difficult due to the conditions of the study.
- Ultrasound examination. Ultrasound of the chest organs is indicated when there is a suspicion of the presence of free fluid in the pleural cavity, damage to the mediastinal organs, in particular, with the development of pericarditis. In the diagnosis of neck phlegmon, the method has an auxiliary value.
Effective healing of the patient is possible only with his timely treatment for specialized medical care. The purulent-inflammatory process progresses rapidly, which worsens the prognosis every hour, increases the likelihood of complications and the risk of death. Medical tactics for cellulitis neck involves emergency surgical intervention, the appointment of antibacterial and anti-inflammatory drugs, detoxification therapy.
Conservative therapy is carried out mainly in the postoperative period in order to accelerate the cleansing and healing of wounds, prevention of disorders of the cardiovascular system and internal organs. The appointment of infusion therapy, enteral and parenteral use of drugs is advisable in the following cases:
- Correction of hypovolemic disorders. The serious condition of the patient, low blood pressure require infusions at the stage of preparation for the opening of the cellulitis neck to reduce the risk of intra- and postoperative complications. The introduction of saline solutions, glucose solution in combination with diuretics additionally helps to reduce the level of intoxication.
- Postoperative drug therapy. Broad-spectrum antibiotics are prescribed in the hospital, after receiving the results of a bacteriological study, drugs with maximum sensitivity of the isolated flora are introduced into the therapy regimen. According to the indications, anti-inflammatory, painkillers and other medications are used.
The only way to stop the spread of infection in the tissues is to create optimal conditions for the outflow of pus by widely opening the phegmon. The volume of surgical intervention is determined by the degree of spread of the purulent-inflammatory process, the involvement of the mediastinum and includes the following mandatory stages:
- Autopsy of the affected area. The surgeon performs a significant incision in the projection of the focus, opens the fascial space of the neck wide. The lesion of mediastinal tissues is determined, if possible, through an incision in the neck. If this is not enough, an additional incision is made in one of the intercostal spaces to revise the mediastinal fiber. With odontogenic phlegmon, the area of the retromandibular fossa, the bottom of the oral cavity, is opened.
- Cleansing the wound. The pus is being evacuated. The wound is abundantly washed with antiseptic solutions during the operation, and then repeatedly during the dressing process until it is completely cleaned. The wound is not sutured to facilitate drainage and the possibility of subsequent staged necrectomy. The average duration of cleansing of the wound surface is 18-22 days.
- Drainage. Drains are installed in incisions on the neck, and in the presence of signs of mediastinitis – in the mediastinal region. The locations of the drainage tubes are determined by the areas of the chest covered by the inflammatory process. The drainage tubes are joined by containers into which the exudate is collected. By the amount of exudate, the intensity of the pathological process in the tissues is judged.
The patient’s condition during the formation of cellulitis neck is largely determined by the high concentration of decay products of necrotic tissues, vital activity of bacteria. Toxins are excreted through the blood and lymph, the ratio of the contribution of both pathways of detoxification is 1:6. In this regard, methods for correcting the functions of the lymphatic system by indirect endolymphatic infusion of drugs are being developed and applied. The method is used as an auxiliary in relation to surgical treatment.
Prognosis and prevention
The prognosis is determined by timely admission to the hospital. From 4 to 12% of all patients with detected neck and mediastinal cellulitis neck die before surgery. Up to 21-30% of patients die after surgery from complications. According to statistics, the share of odontogenic and tonsillogenic cellulitis neck accounts for 87.8% of all cases of the disease. This means that full-fledged hygienic oral care, timely treatment of caries, removal of palatine tonsils in the presence of indications are effective measures to prevent the development of pathology.