Phlegmon of the neck with an atypical manifestation and severe course

Introduction

Phlegmon of the neck is an infection of the neck tissues, which can be potentially life-threatening. The primary cause of these infections is bacterial infection, often arising as a complication of pharyngitis, tonsillitis, or odontogenic inflammation [1, 2]. Predisposing factors include compromised immunity, diabetes, obesity, and poor oral hygiene. Symptoms typically include neck pain and swelling, trismus, swallowing difficulties, fever, and dyspnea.

Case report

A 43-year-old male patient was admitted to the ENT Department as an emergency, transferred from the Internal Medicine Ward in Ostrow Wielkopolski with a diagnosis of phlegmon of the neck and mediastinum.
On admission, the patient presented with neck edema, neck and shoulder pain, difficulty breathing, and fatigue. He had comorbidities including type 2 diabetes and hypertension.
Physical examination revealed bilateral inflammatory infiltration on the neck, extending below the sternal notch, tenderness to palpation, redness, and warmth of the skin, swollen mucous membrane of the hypopharynx and larynx, saliva retention, and unobstructed air passage. Laboratory tests showed white blood cell count (WBC) 13 k/µl (N: 4–11), C-reactive protein (CRP) 262 mg/l (N: < 5), and procalcitonin 1.13 ng/ml (> 2 indicates a high risk of sepsis).
The patient had previously been admitted to the Internal Medicine Ward due to shoulder pain and dyspnea, with blood tests showing WBC 19 k/mcl, CRP 464 mg/l, and procalcitonin 4.4 ng/ml. A neck computed tomography (CT) indicated bilateral abscesses originating from the tonsils and extending through various neck spaces. Initial treatment with ceftriaxone and clindamycin was started.
Immediately after the patient had been transferred to the Otolaryngology Department, tracheotomy, incision, and drainage of bilateral neck and supraclavicular abscesses were performed. Thoracic surgical consultation concluded that thoracic surgical intervention was not required.
A CT scan of the neck and chest, performed 5 days after the initial surgical intervention, revealed fluid collections in the right oropharyngeal space (fig. 1), along the vascular space, from the level of C2 to the peritracheostomal space, and on the left side from the hyoid bone to the level of the tracheostomy. Bilateral fluid collections were noted within the sternocleidomastoid muscles (figs. 2 A, B) and in both supraclavicular fossae, descending into the anterior mediastinum along the manubrium (fig. 3) and beneath the pectoral muscles. The patient underwent another operation for incision and drainage of the neck abscesses.
Wound swab revealed Streptococcus agalactiae. Vancomycin was initiated, and wound swabs later showed Streptococcus agalactiae and Streptococcus anginosus. Following microbiological consultation, antibiotics were changed to piperacillin, tazobactam and linezolid pending antibiogram. Wound swabs continued to reveal Streptococcus anginosus. Crystalline penicillin was initiated according to the antibiogram.
The second follow-up neck and chest CT, performed after the last drainage, showed stable abscesses in the neck but progression of abscesses within the anterior chest wall. Thoracic surgical consultation confirmed no need for intervention. Wound swab revealed Candida albicans, and fluconazole was initiated.
Due to no clinical improvement, metronidazole was added to crystalline penicillin following microbiological consultation. The result of the treatment was noticeable in the next CT scan, which showed partial regression: a small abscess within the right sternocleidomastoid muscle remained stable, the abscess in the area of the right greater horn of the hyoid bone remained stable, complete regression of the abscess on the left side of the larynx, and decreased intensity of the supraclavicular abscess. A flat 5 mm fluid collection in the mediastinum was stable, with multiple abscesses within the pectoral muscles showing partial regression.
An operation for incision and drainage of the neck and chest abscesses was performed. Meropenem was initiated, and continuous irrigation of the wounds with microdacyn was introduced (fig. 4), leading to a decrease in CRP to < 100 in the following days. Wound swab revealed Enterobacter cloacae, Klebsiella pneumoniae, Candida albicans, Enterococcus faecalis, and Prevotella nigrescens. Pain management consultation was conducted.
The final neck and chest CT scan showed significant regression with a small abscess in the right sternocleidomastoid muscle (2–3 mm), partial regression of the abscess in the area of the right greater horn of the hyoid bone, and lesser intensity of the abscess in the soft tissues above the clavicle. The flat fluid collection of 5 mm in the mediastinum remained stable, with partial regression of abscesses within the pectoral muscles.
The patient, in good clinical condition, was discharged home with recommendations. Follow-up visit at the ENT Outpatient Clinic confirmed continued improvement.

Discussion

The patient’s initial symptoms of phlegmon of the neck were atypical, and diagnosis was confirmed through imaging studies and laboratory tests. The treatment approach involved securing the airways, intravenous antibiotic therapy, and repeated surgical drainage. Continuous wound irrigation with antiseptic proved beneficial. Initial symptoms of phlegmon of the neck may be atypical, necessitating comprehensive diagnostic approaches including laboratory and imaging tests. Effective treatment relies on securing the airways, intravenous antibiotics, and drainage of abscesses. Multidisciplinary collaboration is often required, involving ENT specialists, anesthesiologists, and thoracic surgeons [3, 4].

Funding

No external funding.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.

References