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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 125-130

Organism growth and antibiotic treatment for patients diagnosed with deep neck space infection in asir central hospital, Saudi Arabia, 2022


1 Department of ORL-HNS, Asir Central Hospital, Abha, Kingdom of Saudi Arabia
2 Clinical Pharmacy Section, Pharmacy Department King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
3 College of Dentistry, Jazan University, Jazan, Kingdom of Saudi Arabia
4 Department of ENT, College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia
5 Department of ORL-HNS, King Fahad Central Hospital, Jazan, Kingdom of Saudi Arabia
6 Department of ORL-HNS, Armed Forces Hospitals Southern Region, Khamis Mushat, Kingdom of Saudi Arabia

Date of Submission17-Jun-2022
Date of Decision02-Aug-2022
Date of Acceptance03-Aug-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Dr. Albaraa Abdullah Najmi
Department of ORL-HNS, Asir Central Hospital, AL-Rabwah Street, Abha 62312
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoh.sjoh_26_22

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  Abstract 


Background: Deep neck infections (DNIs) are characterized by inflammation in the deep spaces and fasciae of the head and neck, with or without pus. Parapharyngeal, infratemporal, pterygomaxillary, temporal, parotid, masticator, submandibular, visceral, carotid sheath, peritonsillar-pharyngeal mucosal, retropharyngeal, danger, and prevertebral spaces are the different types of DNIs. These infections are potentially fatal, and they spread quickly, causing serious problems. Even in recent research on DNSI cases, potentially life-threatening complications have been recorded at a rate of 10%–20%. Objective: The objective of this study was to identify the most common organisms causing DNIs in Asir Central Hospital (ACH), Saudi Arabia in addition to identifying the most common sensitive antibiotic using to treat DNIs in ACH. Results: Data were retrieved from the records of 108 patients with DNIs (67.6% males, 91.7% Saudis). These included 23 patients in the pediatric group (21.3%) and 85 patients (78.7%) in the adult group. The most common sites for neck abscesses in the whole sample included the submandibular abscess (46.3%). Two types of DNIs were predominating in the pediatric group, including submandibular abscess and anterior neck abscess (30.4% for each type), while submandibular neck abscess was the most common type in the adult group (50.6%). Regarding the previous onset of a recent infection, a total of 67 infections were reported in 63 patients. Upper respiratory tract infections represented the majority of infectious conditions (77.6%) followed by dental infections (22.4%). Among the whole sample, the most commonly isolated pathogen was Staphylococcus species (n = 14, 13.0%), of which 12 Staphylococcus aureus isolates were detected. The 25 isolates with positive cultural growth had undergone culture sensitivity analysis; these showed sensitivity to 89 antibiotics. Bacterial isolates were predominantly sensitive to vancomycin (n = 16, 18.0%), linezolid (n = 14, 15.7%), and ciprofloxacin (n = 13, 14.6%). Conclusion: DNIs in children feature different characteristics from those in adults regarding severity and preceding illness. However, the causative microorganisms and antibiotics sensitivity were similar. S. aureus and vancomycin were the most common bacteria and sensitive antibiotic, respectively.

Keywords: Deep neck infections, peritonsillar-pharyngeal mucosal, Staphylococcus aureus, vancomycin


How to cite this article:
Najmi AA, Alqahtani MS, Najmi AH, Gohal NM, Al Hamoud MA, Alqahtani AJ, Alzahrani M, Mubarki M, Magboul NA. Organism growth and antibiotic treatment for patients diagnosed with deep neck space infection in asir central hospital, Saudi Arabia, 2022. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:125-30

How to cite this URL:
Najmi AA, Alqahtani MS, Najmi AH, Gohal NM, Al Hamoud MA, Alqahtani AJ, Alzahrani M, Mubarki M, Magboul NA. Organism growth and antibiotic treatment for patients diagnosed with deep neck space infection in asir central hospital, Saudi Arabia, 2022. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2022 Nov 28];24:125-30. Available from: https://www.sjohns.org/text.asp?2022/24/3/125/357636




  Introduction Top


Deep neck infections (DNIs) are characterized by inflammation in the deep spaces and fasciae of the head and neck, with or without pus. Parapharyngeal, infratemporal, pterygomaxillary, temporal, parotid, masticator, submandibular, visceral, carotid sheath, peritonsillar-pharyngeal mucosal, retropharyngeal, danger, and prevertebral spaces are the different types of DNIs.[1]

DNIs continue to be lethal, despite advances in diagnostic tools (imaging and microbiological procedures). This is especially true in immunocompromised patients or those with major comorbidities.[2]

Adult DNIs are more likely to involve numerous areas, resulting in significant problems, and they appear to be more serious than children's DNIs. Furthermore, analgesics, anti-inflammatory medications, and corticosteroids might disguise symptoms by suppressing immunological responses. Because the clinical manifestations are variable and depend on the affected regions, it can be difficult to track the source of infection, especially when the primary source of infection may occur weeks before the clinical manifestation.[3],[4],[5]

Tonsillar and peritonsillar infections were the source of infection in 70% of instances of DNSI before the discovery of antibiotics; however, the most prevalent cause is now thought to be dental in origin.[6],[7]

DNSI can advance quickly and lead to death, especially in immunocompromised people with diabetes mellitus (DM), chemotherapy, steroid therapy, or HIV infection.[8]

These infections are potentially fatal, and they spread quickly, causing serious problems. Even in recent research on DNSI cases, potentially life-threatening complications have been recorded at a rate of 10%–20%.[9]

Antibiotics, airway care, and surgical intervention are all used to treat DNSI. In the case of cellulitis, DNSI is traditionally treated with immediate surgical draining of the abscess followed by antibiotics or nonsurgical treatment with suitable antibiotics.[10]

Antimicrobial agents used for the treatment of DNIs include the intravenous infusion, alone or in combination, of penicillin, amoxicillin plus clavulanic acid, ampicillin plus sulbactam, clindamycin, and metronidazole. DNSIs are usually polymicrobial in nature. Streptococci, Peptostreptococcus species, Staphylococcus aureus, and anaerobes are the most commonly cultured organisms from DNSI.[10]

A study was conducted by Kerem Sami Kaya in Turkey in the year 2021 on the same topic. A total of 109 patients who were hospitalized and treated in our ear, nose, and throat clinic with the diagnosis of DNSI were included in the study. Approximately 60.6% of the patients were male and the mean age was 31 years (3.5 months–103 years). It was observed that the most frequent admissions to the clinic were in the months of April and January. The most common anatomical locations of infection and abscess were the submandibular region and level 2 in neck, respectively. The most common complaint at presentation was pain (92%), 47.7% of the patients (52) developed DNSI on the right side, and microorganism growth was reported in 52% of 48 patients whose culture results could be reached; in 32% of these patients (8/25) Staphylococcus spp. and in 20% (5/25) M. tuberculosis growth was observed. The average age of the patients who required multiple antibiotics was found to be significantly higher.[11]

Another study was done by Despoina Beka in Greece in the year 2019 to determine the epidemiology of DNIs, regarding the detection, the identification, and the susceptibility to antimicrobials of causative microorganisms, in Thessaly-Central Greece. Among the 610 patients (1.9/1: male-to-female ratio, mean age: 39.24 ± 17.25 years) with DNIs, 579 had a single space (94.9%), while the remaining 31 had a multi-space (5.1%) DNI. The most common areas affected were the peritonsillar space (84.6%) followed by the submandibular space (6.5%). Clinical samples were obtained from 462 patients and were tested by culture and by the application of 16S rRNA polymerase chain reaction (PCR). Two hundred and fifty-five samples (55.2%) gave positive cultures, in which Streptococcus pyogenes and S. aureus were predominant. The application of the 16S rRNA PCR revealed that 183 samples (39.6%) were positive for bacterial DNA; 22 of them, culture negative, were found to be positive for anaerobic (Fusobacterium necrophorum, Actinomyces israellii, etc.) and for fastidious microorganisms ( Brucella More Details mellitensis, Mycobacterium avium).[12]

In addition to that, Yang Weiqiang MM conducted a study in China in the year 2015. One hundred and thirty patients were included, of which 44 (33.8%) were younger than 18 years (the children group) and 86 patients (66.2%) were older than 18 years (the adult group). Fever, trismus, neck pain, and odynophagia were the most common symptoms in both groups. Forty children (90.9%) and 49 adults (57.0%) had been treated with broad-spectrum antibiotic therapy before admission. Thirty-one children (70.5%) and 24 adults (27.9%) had a history of antibiotics abuse. In the children group, the site most commonly involved was the parapharyngeal space (18 patients, 40.9%). In adults'group, the site most commonly involved was multispace (30 patients, 34.9%). In the children group, the most common cause was branchial cleft cyst (5 patients, 11.4%) and the cause remained unknown in 31 patients (70.5%). In adults'group, the most common cause was pharyngeal infection (19 patients, 22.2%). All of the 27 patients with associated disease comorbidity were adults and 17 had DM. Streptococcus viridans was the most common pathogen in both children and adults'groups. Eighty-six (66.2%) patients underwent surgical drainage, and complications were found in 31 patients (4 children and 27 adults).[13]

Meanwhile in Brazil, Thiago Pires Brito conducted a study in the year 2015. There was predominance in the male gender (55.5%) and young people (mean age: 28.1 years). All of the 51 patients with associated disease comorbidity were adults. The most frequent etiologies were bacterial tonsillitis (31.68%) and odontogenic infections (23.7%). The most common cervical areas affected were the peritonsillar (26.7%), submandibular/mouth floor (22.7%), and parapharyngeal spaces (18.8%). In children group, the site most commonly involved was the peritonsillar space (10 patients, 37%). In adults'group, the site most commonly involved was multispace (31 patients, 41.8%). Streptococcus pyogenes (23.3%) was the most common microorganism present. Amoxicillin associated with clavulanate (82.1%) was the most commonly used antibiotic. The main complications of abscesses were septic shock (16.8%), pneumonia (10.8%), and mediastinitis (1.98%). Tracheostomy was necessary in 16.8% of patients. The mortality rate was 1.98%.[14]

Lastly, a study was done in Brazil in the year 2008 by Alexandre BabáSuehara on the same topic. Odontogenic and tonsillar causes were the more frequent ones. Submandibular and parapharyngeal spaces were the most frequent location of DNIs. S. aureus and Streptococcus sp were the microorganisms more commonly isolated.[15]


  Materials and Methods Top


The present study was conducted at the ear, nose, and throat (ENT) surgical department in Asir Central Hospital (ACH), Abha, Saudi Arabia. The study design was retrospective chart review for medical record. Files for all cases with DNI patients who attended and were evaluated at the ENT surgical department in ACH from September 2011 to September 2020 were included.

Sample size and sampling technique

The study included all files of DNI patients who attended and were evaluated at ACH and underwent surgical Incision and Drainage (I and D) at ENT surgical department during the last 9 years (from September 2011 to September 2021). We included patients who diagnosed with DNIs and surgically treated with incision and drainage and excluded patient with incomplete files and patients with DNIs outside Asir region.

Study tools and data collection

We constructed a standard data collection sheet that fulfilled the purpose of the study to avoid errors in data extraction. The sheet was sent to two expert ENT surgeons from ACH to check the content validity and clarity of the sheet. The data extracted included patients' demographic information, causes of DNIs among patients, and comorbidities. DNI data included duration, complaint, type of intervention, type of antibiotic used, type of organism found, and clinical outcome.

Ethical considerations

The ethical approval of institutional review board at ACH was obtained before starting to collect the data of patients. An informed consent was secured from the patients if needed. All the collected data were kept confidential and were not used except for research purposes.

Statistical analysis

The Statistical Package for Social Sciences version 26.0 (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Data were expressed as frequencies and percentages. The analysis of comorbid conditions and the history of infections was carried out using a multiple response analysis in order to account for the existence of more than one condition in a single patient. Differences in frequencies between pediatric and adult groups as well as patients with and without complications were analyzed using Fisher's exact test or Chi-square test, where applicable. A P < 0.05 was considered statistically significant.


  Results Top


Characteristics of patients

Data were retrieved from the records of 108 patients with DNIs (67.6% males, 91.7% Saudis). These included 23 patients in the pediatric group (21.3%) and 85 patients (78.7%) in the adult group. The most common sites for neck abscesses in the whole sample included the submandibular abscess (46.3%) followed by anterior neck abscess (15.7%). Two types of DNIs were predominating in the pediatric group, including submandibular abscess and anterior neck abscess (30.4% for each type), while submandibular neck abscess was the most common type in the adult group (50.6%). The difference between the pediatric and adult groups in terms of neck abscess location was statistically significant [P = 0.022, [Table 1]].
Table 1: Characteristics of the patients and sites of neck abscesses

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Medical history

More than half of the patients (n = 70, 64.8%) had no history of an immunocompromising disease or they did not receive an immunosuppressive medication. The remaining patients (n = 38) had a positive history of 42 comorbid conditions. DM was the most common comorbid condition, accounting for 81.0% of the conditions [Figure 1]a. Regarding the previous onset of a recent infection, a total of 67 infections were reported in 63 patients. Upper respiratory tract infections (URTIs) represented the majority of infectious conditions (77.6%) followed by dental infections [22.4%, [Figure 1]b].
Figure 1: The prevalence of comorbid conditions (a, n = 42) and previous infections (b, n = 67) among patients with DNIs. DNIs: Deep neck infections

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  Microbial growth and culture sensitivity results Top


Culture growth was positive for the isolates of 25 patients (23.1%) with no differences in the rates of bacterial growth between the pediatric and adult groups (P = 0.583). Among the whole sample, the most commonly isolated pathogen was Staphylococcus species (n = 14, 13.0%), of which 12 S. aureus isolates were detected. The frequencies of other isolated species are listed in [Table 2]. There were no differences in the isolated bacterial species between the pediatric and adult groups [Table 2]
Table 2: Culture results

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The 25 isolates with positive cultural growth had undergone culture sensitivity analysis; these showed sensitivity to 89 antibiotics. Bacterial isolates were predominantly sensitive to vancomycin (n = 16, 18.0%), linezolid (n = 14, 15.7%), and ciprofloxacin (n = 13, 14.6%).

Complications

In general, approximately one-third of the patients developed complications (n = 33, 30.6%). Extension of infection to other spaces was the most commonly reported complication (20.4%) followed by airway obstruction (8.3%). The incidence of overall complications and each individual complication did not differ significantly by patient age group [Table 3]. Upon investigating the factors associated with complications, we found that a significantly higher proportion of patients with other immunocompromising conditions had developed airway obstruction (22.4%) compared to those without airway obstruction (4.0%, P = 0.023). Furthermore, significantly higher proportions of patients whose localized infections were extended were diagnosed with DM (50.0% vs. 27.9% without infection extension, P = 0.048) and a recent URTI (68.2% vs. 43.0% without infection extension, P = 0.035) [Table 4].
Table 3: The reported complications among patients with deep neck infections

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Table 4: Factors associated with complications among patients with deep neck infections

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  Discussion Top


DNIs remain frequent, as demonstrated by our study. DNI can develop at any age and is still linked with a significant complication, particularly in those with concomitant systemic diseases such as DM.[11] In our study, there was a slight predominance of males [Table 1], whereas other studies showed an equal distribution.

In terms of preceding illnesses, pediatric DNI differed significantly from adult DNI, neck abscess location, and complications. Males were impacted more than females among adults with DNI, with a male-to-female (M/F) ratio of 2.0. This outcome is consistent with earlier findings.[16],[17] Similarly, the M/F ratio in pediatric patients is three. Previous studies on pediatric DNI have been contradictory in terms of sex preference. Some studies revealed a female preponderance,[12] whereas others found a male predominance.[7] These variations might be explained by the small number of pediatric DNI patients compared to adult DNI cases.

URTIs and oral infections were the most common preceding illnesses in both adult and pediatric DNI. It has been proposed that infections in the retropharyngeal or parapharyngeal area and lateral neck are more common in younger children.[7],[12] Adult DNI, on the other hand, has been linked to the direct transmission of infection from a nearby structure, including oral infection, pharyngitis, and sialadenitis.[4],[8],[12] Our new findings contradict these pathogeneses, which revealed that the most prevalent location of infection in adult and pediatric patients was a submandibular neck abscess.

In an adult, a DNI is frequently primarily limited by a fascial space, to prevent it from spreading vertically a (i.e., extension into the mediastinum). Suppurative adenitis in children, on the other hand, is generally well confined inside the inflammatory rind of the diseased node.[12] In our investigation, vertical transmission of infection in both adults and children to the retropharyngeal or parapharyngeal area was primarily observed in diabetic individuals.[12]

Aerobic Gram-positive organisms, mainly Staphylococcus species (13%), were identified in pediatric patients, which is consistent with prior pediatric investigations.[3],[5] Another study found an increased incidence of methicillin resistant staphylococcus aureus Scientific Name Search  (MRSA) in children under the age of two, as well as a link between MRSA and complications.[5] Among the pediatric cases positive for S. aureus, only one case had MRSA, a 2-year-old boy with an anterior neck abscess. Streptococcus species was the most common pathogen in the adult group (12.9%). Interestingly, Gram-negative Enterobacter cloacae bacteria were found in just one juvenile patient who tested positive, but 5 of 25 (6%) adult patients tested positive for Klebsiella pneumonia. Staphylococcus have been linked to the pathogenesis of DNI by releasing tissue-destroying enzymes and immunosuppressive toxins, resulting in fast spread or synergic infection.[5],[11]

In terms of antibiotic therapy, we normally start the above-mentioned organisms on penicillin with b-lactamase inhibitors (e.g., piperacillin/tazobactam) as soon as the diagnosis is made. If required, therapy may be modified later based on microbiological investigations and antibiograms. Because the prevalence of community-acquired MRSA infection in our location is unclear, we employ anti-MRSA medications on a trial basis. Previously, regardless of bacteria or antimicrobial susceptibility, we employed carbapenems (meropenem). However, unless the patient is immunocompromised, we seldom utilize these agents [Figure 2].
Figure 2: The proportion of antibiotics against which bacterial isolates were sensitive (n = 89)

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The retrospective study design, small sample size because of the inclusion of only patients who underwent incision and drainage, and findings from a single medical center are all limitations of this study.

Differences in pathophysiology and causative microorganisms between pediatric and adult DNIs are still unknown. Furthermore, the microbiological data may have been influenced by empirical antibacterial coverage. To overcome these constraints, more study, including basic research and multicenter, prospective trials examining the distinct properties of pediatric and adult DNIs, would be beneficial.


  Conclusion Top


DNIs in children feature different characteristics from those in adults regarding severity and preceding illness. However, the causative microorganisms and antibiotics sensitivity were similar. S. aureus and vancomycin were the most common bacteria and sensitive antibiotic, respectively.

Recommendations

  • Early detection of the causative organism should be done so that septic shock is avoided
  • The most common causative agents should always be well known in every location so that antibiotics can be provided in early stages
  • More studies on this topic should be conducted in Saudi Arabia to strengthen this evidence base for clinical decision-making.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Christian JM, Goddard AC, Gillespie MB. Deep neck and odontogenic infections. In: Cummings Otolaryngol: Head Neck Surgery. 6th ed. Philadelphia, PA: Elsevier Saunders; 2015.  Back to cited text no. 1
    
2.
Sakaguchi M, Sato S, Ishiyama T, Katsuno S, Taguchi K. Characterization and management of deep neck infections. Int J Oral Maxillofac Surg 1997;26:131-4.  Back to cited text no. 2
    
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Raffaldi I, Le Serre D, Garazzino S, Scolfaro C, Bertaina C, Mignone F, et al. Diagnosis and management of deep neck infections in children: The experience of an Italian paediatric centre. J Infect Chemother 2015;21:110-3.  Back to cited text no. 3
    
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Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, González-Valdepeña H, Bluestone CD. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995;112:375-82.  Back to cited text no. 7
    
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Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am 2008;41:459-83, vii.  Back to cited text no. 8
    
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Radhakrishnan S. Neck Abscess- An epidemiological study in a tertiary care centre. Journal of Medical Science And clinical Research 2018;6:923-7.  Back to cited text no. 9
    
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Marioni G, Rinaldi R, Staffieri C, Marchese-Ragona R, Saia G, Stramare R, et al. Deep neck infection with dental origin: Analysis of 85 consecutive cases (2000-2006). Acta Otolaryngol 2008;128:201-6.  Back to cited text no. 10
    
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Kaya KS, Yağcı I, Doğan U, Seyhun N, Turgut S. Deep Neck Space Infection: Clinical Outcomes of Patients Treated in a Tertiary Care Center. University of Health Sciences Turkey, Şişli Hamidiye Etfal Research and Training Hospital, Clinic of Otolaryngology, Division of Head and Neck Surgery, İstanbul, Turkey; 2021.  Back to cited text no. 11
    
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Beka D, Lachanas VA, Doumas S, Xytsas S, Kanatas A, Petinaki E, et al. Microorganisms involved in deep neck infection (DNIs) in Greece: Detection, identification and susceptibility to antimicrobials. BMC Infect Dis 2019;19:850.  Back to cited text no. 12
    
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Yang W, Hu L, Wang Z, Nie G, Li X, Lin D, et al. Deep neck infection. Medicine 2015;94:e994.  Back to cited text no. 13
    
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Brito TP, Hazboun IM, Fernandes FL, Bento LR, Monteiro Zappelini CE, Chone CT, et al. Deep Neck Abscesses: Study of 101 Cases. Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Otorrinolaringologia, Campinas, SP, Brazil; 2015.  Back to cited text no. 14
    
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Suehara AB, Gonçalves AJ, Alcadipani FA, Kavabata NK, Menezes MB. Deep neck infection: Analysis of 80 cases. Braz J Otorhinolaryngol 2008;74:253-9.  Back to cited text no. 15
    
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Shimizu Y, Hidaka H, Ozawa D, Kakuta R, Nomura K, Yano H, et al. Clinical and bacteriological differences of deep neck infection in pediatric and adult patients: Review of 123 cases. Int J Pediatr Otorhinolaryngol 2017;99:95-9.  Back to cited text no. 16
    
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Ridder GJ, Technau-Ihling K, Sander A, Boedeker CC. Spectrum and management of deep neck space infections: An 8-year experience of 234 cases. Otolaryngol Head Neck Surg 2005;133:709-14.  Back to cited text no. 17
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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