Acta Otorrinolaringológica Española 73 (2022) 4---10

www.elsevier.es/otorrino

ORIGINAL ARTICLE

Ultrasound-guided Drainage vs Surgical Drainage of

Deep Neck Space Abscesses: A Randomized Controlled
Trial夽
Andrés Limardo,a,b Luis Blanco,a,b,∗ José Menéndez,a Adrían Ortegaa

a
Sección de Cirugía de Cabeza y Cuello, Hospital Prof. A. Posadas, El Palomar, Argentina
b
Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina

Received 27 May 2020; accepted 3 August 2020

KEYWORDS Abstract
Dental infection; Introduction: The most common cause of deep neck infections is dental infection. They are
Cervical infections; diagnosed with physical examination, imaging studies, ultrasound, or computed tomography.
Odontogenic abscess; Surgical drainage of collections should always be performed early in a classical or percutaneous
Drainage; way, depending on the case. The aim of the study was to compare ultrasound-guided percu-
Ultrasound taneous drainage techniques vs. surgical drainage in deep cervical abscesses of odontogenic
origin in a controlled and randomized trial.
Methods: A randomized controlled clinical trial was performed from January 2015 to Decem-
ber 2019. Hospital stay was evaluated as an efficiency variable. Epidemiological and secondary
variable data (tumour, trismus, fever, pain), leukocytosis, cosmetic result comparing both tech-
niques were analysed. Statistical analysis was carried out with STATA v 14.0.
Results: 128 patients were analysed, 51 women and 77 men. Average age 27.3 (SD = 10.13).
The percutaneous group had a mean hospital stay of 3.03 (SD = 2.86) days and the surgical
group 5.46 (SD = 2.96). The P-value was <.001. Cosmetic results showed differences favouring
the percutaneous drainage group. None of the other variables showed statistically significant
results.
Discussion: Surgical treatment (cervicotomy and debridement) should be undertaken early with
evidence of extensive collection in deep spaces. Minimally invasive image-guided procedures
are an alternative. These can be performed in well-located, unilocular collections, without com-
promising of the patient’s airway. Percutaneous drainage and suction techniques if necessary,
serially, or drainage placement may be performed.

夽
Please cite this article as: Limardo A, Blanco L, Menéndez J, Ortega A. Drenaje percutáneo ecoguiado vs. drenaje quirúrgico en abscesos
cervicales profundos de origen odontógeno. Ensayo clínico controlado y aleatorizado. Acta Otorrinolaringol Esp. 2022;73:4---10.
∗ Corresponding author.

E-mail address: lablanco@fmed.uba.ar (L. Blanco).

2173-5735/© 2020 Sociedad Española de Otorrinolaringologı́a y Cirugı́a de Cabeza y Cuello. Published by Elsevier España, S.L.U. All rights
reserved.
 Acta Otorrinolaringológica Española 73 (2022) 4---10

Conclusions: Ultrasound-guided and serially guided percutaneous drainage is the best thera-
peutic option in patients with mild and/or moderate dental infections.
© 2020 Sociedad Española de Otorrinolaringologı́a y Cirugı́a de Cabeza y Cuello. Published by
Elsevier España, S.L.U. All rights reserved.

PALABRAS CLAVE Drenaje percutáneo ecoguiado vs. drenaje quirúrgico en abscesos cervicales
Infección profundos de origen odontógeno. Ensayo clínico controlado y aleatorizado
odontógena;
Resumen
Infecciones
Introducción: La causa más frecuente de infecciones profundas del cuello son las infec-
cervicofaciales;
ciones odontógenas. Son diagnosticadas con examen físico, estudios por imágenes, ecografía o
Absceso odontógeno;
tomografía computarizada. Debe realizarse siempre el drenaje quirúrgico de forma clásica o
Drenaje;
percutánea según el caso de las colecciones en forma precoz. El objetivo fue comparar las téc-
Ecografía
nicas de drenaje percutáneo guiado por ecografía vs. drenaje quirúrgico en abscesos cervicales
profundos de origen odontógeno en forma controlada y aleatorizada.
Métodos: Se realizó un ensayo clínico controlado aleatorizado de enero de 2015 a diciembre de
2019. Se evaluó como variable de eficacia los días de ingreso. Se analizaron los datos epidemi-
ológicos y variables secundarias (tumoración, trismus, fiebre, dolor), leucocitosis, resultado
cosmético comparando ambas técnicas. El análisis estadístico se llevó a cabo con STATA v 14.0.
Resultados: Fueron analizados 128 pacientes, 51 mujeres y 77 hombres. Edad promedio 27,3
(SD = 10,13). El grupo percutáneo presentó una media de 3,03 (SD = 2,86) días de ingreso y
el grupo quirúrgico 5,46 (SD = 2,96). El valor de p resultó < 0,001. Los resultados cosméticos
mostraron diferencias favor del grupo de drenaje percutáneo. Ninguna de las demás variables
mostró resultados estadísticamente significativos.
Discusión: Ante la evidencia de una colección extensa en espacios profundos la realizacióndel
tratamiento quirúrgico (cervicotomía y desbridamiento) debe hacerse en forma precoz. Los
procedimientos mínimamente invasivos guiados por imágenes son una alternativa. Estos pueden
realizarse en colecciones bien localizadas, uniloculares, y siempre que no exista compromiso de
la vía aérea del paciente. Pueden realizarse técnicas de punción y aspiración, y si es necesario
en forma seriada, o bien punción con colocación de drenajes.
Conclusiones: Las punciones percutáneas ecoguiadas y en forma seriada son la mejor opción
terapéutica en pacientes con infecciones leves y/o moderadas.
© 2020 Sociedad Española de Otorrinolaringologı́a y Cirugı́a de Cabeza y Cuello. Publicado por
Elsevier España, S.L.U. Todos los derechos reservados.

Introduction manoeuvre if intubation or tracheostomy is involved. Par-

Involvement of the cervical spaces as a result of cervico-
facial infectious foci are infrequent, but potentially fatal
events. A substantial proportion of deep neck infections
are the result of odontogenic infection.1 Odontogenic infec-
tions (OIs) are one of the number one causes of consultation
in dental practice. They affect individuals of all ages and
account for most antibiotic prescriptions in the field of den-
tistry. These OIs can present varying degrees of severity and
some can even be quite complex and require emergency hos-
pital care, calling for the intervention of a specialist in head
and neck and/or maxillofacial surgery
Initial management of a patient with suspected deep
neck infection entails immediate hospitalization, maintain-
ing the patient’s airway, intravenous antibiotic therapy, and
surgical intervention, either minimally invasive percuta-
neous or incisional with exploration of the spaces involved.
There should be no hesitation to performing the necessary
enteral antibiotic therapy should be initiated immediately.2
Beta-lactam antibiotics are the preferred choice. How-
ever, nowadays, there are some germs that are resistant to
them. Aggressive antibiotic therapy may reduce the need for
exploratory surgery in some patients (usually in small collec-
tions and patients with no morbidities), but rarely replaces
the need for surgery. Therefore, surgical drainage becomes
more important. The presence of fluctuant, purulent collec-
tions on imaging studies should be drained immediately.
There are important predisposing factors such as socioe-
conomic status, deficient immune status, and irrational use
of antibiotics, which further worsen the prognosis of this
condition. Left to their natural evolution, OIs can evolve
toward two severe conditions, such as Ludwig’s angina and
descending mediastinitis.3 The special anatomy of the neck
makes it essential to know the cervical spaces, the pattern
of dissemination of the infection, and its initial clinical pre-
sentation. As an alternative to classic surgical drainage, it is

5
 A. Limardo, L. Blanco, J. Menéndez et al.
Figure 1 Cervicofacial areas to evaluate edema.
currently possible to consider the possibility of performing
minimally invasive, image-guided procedures that reduce
morbidity.4 Proper patient selection must be taken into
account. Nevertheless, there are still several unresolved
questions; for example, in an individual with a diagnosis
of deep cervical abscess, what are the criteria that tip the
balance in favour of initial medical treatment over surgical
treatment; what is the best treatment, surgical drainage or
percutaneous drainage, and why do some patients evolve
worse than others?
To respond to all of the above, the locations of these
infections, as well as the individual’s clinical status, must
first be ascertained, in order to establish the appropriate
treatment early on. In the case of early abscesses, surgi-
cal drainage should always be performed, either classically
or percutaneously depending on the case. The aim of the
present study is to compare ultrasound-guided, percuta-
neous drainage techniques vs. surgical drainage in deep
cervical abscesses of odontogenic origin in a controlled and
randomized manner.
Materials and Methods
A randomized controlled clinical trial was conducted from
January 2015 to December 2019. It included protocol design,
approval, patient recruitment, and statistical analysis. All
patients were included in the study who met the diagno-
sis of cervico-facial abscess of odontogenic origin larger
than 10 mm × 10 mm meeting the criteria for percuta-
neous puncture and/or surgical drainage and who required
hospital admission for treatment, who agreed to enter the
research protocol by signing the written consent form, and
with the authorization of the institution’s ethics committee.
The study complied with the bioethical guidelines put forth
in the Helsinki Declaration and international protocols for
clinical trials.
The exclusion criteria were ages under 15 years; the pres-
ence of comorbidities; being pregnant; extensive cervical
infections (more than 2 anatomical sites); cervical infec-
tions located in the pterygopharyngeal, retropharyngeal,
pterygopalatine, pretracheal, mediastinal, intracranial, and
prevertebral spaces; patients with a history of at least
one infection due to an odontogenic focus, and those who
refused to enter the protocol.
6
The number of days of hospitalization was evaluated as
an efficacy variable. Epidemiological and clinical data, such
as pain at the time of consultation, trismus, fever, tumour,
postoperative pain, oedema, and cosmetic outcome were
analysed, comparing both techniques. All patients were ran-
domized.
Considering a complication prevalence rate of this
pathology of 5% and a clinically significant complication
reduction of 40% (RR), with a statistical power of 80%, and an
alpha error of 0.05, it was determined that 64 (NNT) patients
were needed per treatment group (n = 128). To calculate
the sample size, a 40% reduction in the number of days of
hospitalization was considered in the experimental group
(percutaneous drainage). The surgical drainage group was
taken into account as a control group.
All patients underwent physical examination, laboratory
analyses, and ultrasound examination. Computed tomogra-
phy (CT) was only requested when the patients exhibited
signs that led to suspicion of airway compromise (sialorrhea,
dysphagia, and/or dyspnoea) or when the ultrasound scans
were inconclusive. Percutaneous drainage was performed
with ultrasound-guided asepsis and antisepsis techniques on
all collections larger than or equal to 10 mm × 10 mm and,
if necessary, serially.
Likewise, subjects received treatment for the primary
focus (exodontia, drains. . .), and secondary prevention
(serial dental examination and education on oral hygiene).
Similarly, samples taken from all the participants for bac-
terial culture and antibiogram.
Furthermore, simultaneous intravenous antibiotics, anal-
gesics, and corticoids were administered in all cases.
The main variable contemplated was the length of hos-
pital stay quantified as the number of days in the hospital
once the patient had been treated.
Pain was measured by means of the Visual Analog Scale
test after instructing the patient as to how to complete it.
Trismus was evaluated as the distance between the free
edge of the incisors and categorised as mild >30 mm, mod-
erate between 11 and 29 mm, and severe <10 mm.
Oedema was considered mild, moderate, or severe
depending on whether it affected one, two, or three cer-
vicofacial areas (Fig. 1).
Fever was regarded as a positive criterion [when there
was] at least one record greater than or equal to 38 ◦ C. Leu-
cocytosis was defined as a white blood cell count of greater
 Acta Otorrinolaringológica Española 73 (2022) 4---10

Table 1 Scale of Severity of Airway Compromise According

to Location of Infection.
Scale of Severity Anatomic Space
Scale of severity = 1 Maxillary bones
Slight risk to airway and/or Subperiosteal
vital structures
Submucous vestibular
Submucous palatine
Genian
Scale of severity = 2 Submandibular
Moderate risk to airway Submentonian
and/or vital structures Figure 2 Patients’ presenting complaint.
Sublingual
Pterygomandibular
Submaseterine
Temporal
Interpterygoid
Scale of severity = 3 Pterygopharyngeal
Severe risk to airway and/or
vital structures
Scale of severity = 4 Retropharyngeal
Extreme risk to airway
and/or vital structures
Source: Peterson L, Miloro M, Ghali G, Larsen P, Waite P.
Peterson’s principles of oral and maxillofacial surgery. 2nd ed.
London: BC Decker Inc., Hamilton. 2004; 277---93.
Figure 3 Statistical results comparing both groups. Variable:
3 days of hospitalization. P <0.001.
than or equal to 12,000 mm . Post-procedural complications
were defined as the appearance of fever, surgical wound
infection, and/or residual collections. Oral hygiene was
assessed by inspection using the oral hygiene index (OHI- was the left submandibular space (40%), followed by the
S). The Patient and Observer Scar Assessment Scale test right submandibular (25%), submental, masticatory space
was used to evaluate the cosmetic outcome. The location of (temporal, interpterygoid, submaseterine, . . .), and maxil-
the infection was established through clinical and imaging lary space.
studies based on anatomical spaces. CT was only required in 2 patients (3.12%). All collections
The airway was evaluated using Peterson’s numerical were drained within 6 h of consultation. According to the
severity scale.5 The risk of mild, moderate, severe, or Peterson airway severity scale,5 81.2% of the patients exhib-
extreme infection was defined in the same way (Table 1). ited level 2 airway compromise; the rest presented level 1
The statistical analysis was carried out with STATA v 14.0, severity.
which enabled the corresponding statistical techniques to be The duration of hospitalization in both groups ranged
applied, analysing the statistical variables reported and cor- from 1 to 21 days. The mean number of days of hospital-
relation analyses, such as Student’s t, Pearson[’s corelation isation in the percutaneous group was 3.03 [1.4] with a
coefficient]. A P value of P <.05 was deemed statistically standard error of 0.17 (95% CI 2.67---3.38). The surgical group
significant. had a mean of 5.46 [3.07] days of hospitalization with a stan-
dard error of 0.3. (95% CI 4.7---6.23). The P value was <.001
(Fig. 3).
Results The pain, tumour, trismus, fever, leucocytosis, days of
evolution, and oral hygiene variables were correlated with
A total of 128 patients were analysed, 51 females (39.9%) the length of hospitalisation. The differences with respect to
and 77 males (60.1%). The mean age was 27.3 [10.4] years these variables were not statistically significant between the
(range 15---62). The participants presented for consultation two groups (Tables 2---4). Only the hospitalisation variables
with pain in 87.5%, cervicofacial tumour in 92.1%, trismus and cosmetic results yielded differences in favour of the
in 57%, and fever in 28.9% of the cases (Fig. 2). Nineteen percutaneous drainage group.
percent reported some dental intervention in the previous Only two patients (1.5%) had to be reoperated with cer-
10 days. Laboratory-confirmed leucocytosis was present in vicotomy and wide drainage because of poor evolution due
55.4%. Oedema was present in all cases, but was only severe to persistent fever, collection, and increased oedema (one
in 9%. with a previous percutaneous puncture and the other with
Aggravating factors were late consultation (more than surgical drainage). Both required a CT scan, orotracheal
5 days of evolution) in 6.2% and regular/poor oral hygiene intubation for airway protection, and admission to the Inten-
in 84.2% of the cases. The most common site of collection sive Care Unit, albeit only for 24 h.

7
 A. Limardo, L. Blanco, J. Menéndez et al.

Table 2 Analysis of Epidemiological Variables in the Group Table 4 Correlation Analysis Comparing Both Groups.
of Patients who Underwent Percutaneous Treatment (n = 64).
Variable P Value 95% CI
Variable Category n (%)
Pain .11 .28---4.32
Gender Female 29 (45.31) Swelling .52 .67---4.92
Male 35 (54.69) Trismus .08 .26---2.97
Pain No 8 (12.50) Fever .08 1.42---2.04
Yes 56 (87.50) Leucocytosis .85 .90---2.33
Tumour No 4 (6.25) Oral hygiene .84 .25---2.31
Yes 60 (93.75) Airway .63 1.58---2.55
Trismus No 33 (51.56) Days of evolution .53 4.27---7.42
Yes 31 (48.44)
Fever No 47 (73.44)
Yes 17 (26.56) cillin sulbactam (in 76.2%); the rest received clindamycin.
Leucocytosis No 34 (53.12) The minimum follow-up time was 3 months, with secondary
Yes 30 (46.88) prevention in conjunction with dentistry. There were no
Simplified oral Adequate 9 (14.06) recurrences.
hygiene index6 Fair 27 (42.18)
Poor 28 (43.78)
Discussion
AW severity scale5 1 11 (17.19)
2 53 (82.81)
Yes 22 (9.73)
Cervicofacial infections are a potentially fatal type of infec-
Complications No 63 (98.44)
tion if effective treatment is not initiated promptly.7 Of all
Yes 1 (1.56)
of infections of the face and neck, those that have a den-
tal origin are the most common. They can present through
AW: airway. phlegmons or abscesses. There are predisposing factors,
such as diabetes, renal failure, obesity, immunosuppression,
Table 3 Analysis of Epidemiological Variables in the Group psychiatric illness, and poor oral hygiene, as well as aggra-
of Patients who Underwent Surgical Drainage (n = 64). vating factors such as: lack of education, limited access
to medication, self-medication, delayed consultation with
Variable Category n (%) doctors and/or dentists, and lack of social security cover-
Gender Female 22 (34.38) age, all of which are compounded by the lack of uniform
Male 42 (65.62) treatment criteria among professionals.8 The poor evolu-
Pain No 8 (12.50) tion of the patient following a dental procedure and/or
Yes 56 (87.50) late consultation also impact the evolution of the disease.9
Tumour No 6 (9.38) Odontogenic infections are the most common cervicofacial
Yes 58 (90.62) infections in our setting and, in most cases, are caused by
Trismus No 22 (34.38) dentoalveolar processes.10 Given their polymicrobial origin,
Yes 42 (65.62) these infections favour the production of bacterial symbiosis
Fever No 44 (68.75) and synergy. The process begins with caries and progresses
Yes 20 (31.25) to pulpitis. Up until to this point, bacterial proliferation will
Leucocytosis No 23 (35.94) be solely aerobic, but from this point onward, conditions of
Yes 41 (64.06) anaerobiosis will be created which, by necrotizing the pulp
Simplified oral Adequate 9 (14.06) vasculonervous bundle, will give rise to the development
hygiene index6 Fair 28 (43.78) of facultative and strict anaerobic bacteria, responsible for
Poor 27 (42.18) compromising the deep cervical planes.11
AW severity scale5 1 13 (20.32) In all cervicofacial infections, airway involvement should
2 51 (79.68) be established and evaluated according to a scale of sever-
Yes 22 (9.73) ity. We used the Peterson scale.5
Complications No 63 (98.44) Trismus is a sign that can occur in odontogenic infections.
Variable Yes 1 (1.56) It is caused by involvement of the masticatory muscles which
can be affected depending on the location and extent of the
AW: airway.
infection.
Oedema is present due to soft tissue involvement and is
In the percutaneous drainage group, 98% of the subjects an indirect sign that the infection has spread.
achieved satisfactory cosmetic results, whereas in the surgi- Fever (higher than 38 ◦ C) should be taken into account,
cal drainage group, only 62% reported satisfactory outcomes as it is a sign in the evaluation of the patient’s inflam-
for this variable. All the participants underwent exodontia matory/infectious status. One must remember that these
during admission (Fig. 4). patients have a potential risk of developing bacteraemia,
Germ cultures were negative in 85.9% of cases. The most sepsis, and/or SIRS.12
prevalent germ was S. viridans (6.2%), which as sensitive Once the diagnosis is established, empirical antibiotic
to the antibiotics prescribed. The most frequent was ampi- therapy should be established early.13 Regimens will depend

8
 Acta Otorrinolaringológica Española 73 (2022) 4---10
Figure 4 (A and B) Patient with clinical improvement after serial percutaneous drains. (C and D) Patient with odontogenic abscess
in the right masticatory region requiring incision and drainage.
on the bacterial flora of each population.14 We use beta-
lactam antibiotics. If the patient is allergic, clindamycin
is used as an alternative. It should be associated with
intravenous dexamethasone, the latter acting mainly on
the trismus, thereby achieving earlier oral opening, with
the consequent early exodontia to eliminate the infectious
focus.15
The most feared complication is that the infection pro-
gresses to the mediastinum (descending mediastinitis). This
occurs because of the communication of different cells of
the neck, which, advancing towards the cervical visceral,
lateropharyngeal, or retropharyngeal space, compromise it,
increasing patient mortality.16
This is why surgical treatment (cervicotomy and debride-
ment), when there is evidence of extensive collection in
deep spaces, should be performed early.17 Image-guided,
minimally invasive procedures are an alternative to surgi-
cally treat these infections.18
The objectives the percutaneous drainage technique pur-
sues can be twofold: on the one hand, diagnostic, to obtain
fluid for analysis, and, on the other hand, therapeutic to
resolve the collection and prevent it from recurring.
The choice of imaging modality to guide the procedures
depends on the location and characteristics of the collec-
tion, the surgeon’s skill and preferences, as well as the
availability at each centre. These techniques can be per-
formed on well-localized, unilocular collections, and as long
as there is no compromise of the patient’s airway.19
Ultrasonography is an ideal technique to evaluate neck
lesions, with the exception of deep neck lesions, for which
other imaging techniques, such as CT or MRI, must be used.
9
That is why ultrasound is considered the tool of choice to
perform interventional procedures in the neck in lesions that
are visible on ultrasound scan.
In our case, given the characteristics of the collections
and the objective of the study, we used ultrasound.
Puncture and aspiration techniques can be performed,
and, if necessary, they can be done serially, or puncture
with placement of drains. If drains are put in place, they
can be used for lavage.20 In needle aspiration, small collec-
tions can be aspirated by direct puncture with a large gauge
needle (14---18 G). Needles with an external vascular access
catheter are very useful, because they can be attached to
the skin with a dressing and maintained for 24---48 h until
the collection is completely resolved. On the other hand,
drainage catheter placement is another alternative. The
most useful sizes are 7---10 F, but choice will depend on the
viscosity of the fluid to be drained. In this study, we opted
for puncture and aspiration techniques and, when necessary,
they were performed serially.
This procedure is not indicated if the collection cannot
be visualised.
Minor complication rates of less than 10% due to damage
to structures have been reported, with haemorrhage resul-
ting from injury to blood vessels being the most serious with
a frequency of 1%.21 The risk increases with the larger gauge
of the catheter and for having to cross larger blood vessels.
These interventions have the advantages of being widely
versatile, available, and having a lower cost compared
to other diagnostic or therapeutic alternatives, and only
moderate skill is required to perform most of them. Nev-
ertheless, they are also limited when access is needed
 A. Limardo, L. Blanco, J. Menéndez et al.
to deep-seated lesions and those located behind air or
bone.
The results of culture and antibiogram are beneficial to
establish the therapy that is suitable for the patient. The
most frequent germs in our environment are Staphylococ-
cus aureus and S. viridans. Infections with anaerobic germs
such as bacteroides fragilis can also occur. The presence
of atypical germs, such as Escherichia coli and Klebsiella
pneumonaie can establish more severe infections.22
Dental treatment is valuable to remove the infec-
tious focus and establish secondary prevention in patients.
Patients should be followed up to avoid relapses and/or
recurrences of infections.23
Conclusions
Although both incidence and severity have decreased dra-
matically in recent years, OIs are generally underestimated
in terms of morbidity and mortality. Early ultrasound-guided
serial percutaneous puncture is the best option in terms
of hospital stay and cosmetic results with statistically sig-
nificant results in patients with mild and/or moderate
infections. Strict and permanent follow-up during admission
is important to avoid severe forms of infection.
Informed Consent
Patients were asked if they agreed to the publication of their
clinical cases for academic purposes. The identity of study
participants has been reserved. All subjects signed consent
forms to perform the necessary care procedures and the
publication of the cases.
Bioethics Committee
The institutional norms established by the Bioethics Com-
mittees of the institutions were complied with in conducting
this study, as were the international bioethics standards
of the Declaration of Helsinki. The Institutional Bioethics
Committee approved the protocol prior to implementation.
Protocol reference: 034 LUPoSo/15.
Funding
This work did not receive any funding.
Conflict of Interest
The authors have no conflict of interests to declare.
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