Large-Volume Infusions into the Brain: A Comparative Study of Catheter Designs.

BACKGROUND/AIMS: "Whole-brain" infusions have emerged as a potential need with the promise of disease-modifying therapies for neurodegenerative diseases. In addition, several current clinical trials in brain cancer utilize direct delivery of drugs that are required to fill large volumes. Such requirements may not be well served by conventional single port catheters with their "point source" of delivery. Our aim is to examine infusions into large volumes of heterogeneous tissue, aiming for uniformity of distribution. METHODS: A porous catheter (porous brain infusion catheter, PBIC), designed by Twin Star TDS LLC, for brain infusions was developed for this study and compared with another convection-enhanced delivery catheter (SmartFlowTM NGS-NC-03 from MRI Interventions, a step end-port catheter, SEPC) in current use in clinical trials. The studies were in vivo in porcine brain. A total of 8 pigs were used: the size of the pig brain limited the porous length to 15 mm. The placements of the tips of the two catheters were chosen to be the same (at the respective brain hemispheres). RESULTS: The PBIC and SEPC both performed comparably and well, with the PBIC having some advantage in effecting larger distributions: p ∼ 0.045, with 5 infusions from each. CONCLUSIONS: Given the performance of the PBIC, it would be highly appropriate to use the device for therapeutic infusions in human clinical trials to assess its capability for large-volume infusions.

A pilot study in intraparenchymal therapy delivery in the prostate: a comparison of delivery with a porous needle vs standard needle.

BACKGROUND: New biologic therapies directly injected into the prostate are in clinical trials for prostatic diseases. There is a need to understand distribution of injected therapies as a function of prostatic anatomy, physiology, and device design. METHODS: A needle with a porous length of customizable-length was tested and its performance compared with a standard needle. Injections of magnetic resonance contrast reagent were placed into ex-vivo human prostates after surgical excision in standard of care therapy for invasive bladder cancer patients. Magnetic resonance images were acquired using sequences to quantify volume delivered, distributed, and backflow. RESULTS: Magnetic resonance images analysis revealed heterogeneity distribution with injection into the specimens. There was low resistance to flow along ductal pathways and high resistance to flow into glandular nodules and smooth muscle/fibrous parenchyma. Data confirm previous studies showing injection loss via urethra backflow, urethra, and prostatic ducts. Tissue fraction of dose was significantly higher with porous needle compared with standard needle (p = .03). We found that a greater volume of distribution divided by the amount infused (Vd/Vi) increased by 80% with the porous needle, though no statistically significant association due to small sample size. CONCLUSIONS: This study demonstrated that prostatic tissue is anatomically heterogenic and limits distribution of needle injection. There is greater distribution in the ex-vivo prostate using a porous needle. The complexity of intra prostatic flow pathways suggests preoperative imaging and pre-treatment planning will enhance therapy.

Theory of porous catheters and their applications in intraparenchymal infusions.

Multiport catheters and catheters with a porous surface have been proposed for intraparenchymal infusions of therapeutics in fluid suspensions. Target diseases include brain cancer and serious neurodegenerative diseases, as well as peripheral tumors, for example in the prostate and the liver. We set up the theory for infusions from such devices, in particular the fluid flow equations which demand a coupling between the flow within the catheter and that in tissue. (Such a coupling is not necessary in the theory of infusion from single port catheters.) The new feature of such catheters, treated by our model, is revealed by infusions into inhomogeneous media. Multiport designs have the potential to overcome the limitation of single port catheters, for which the path of the fluid leaving the port is dominated by the inhomogeneities. We solve these equations for some simple cases to illustrate the key design features of porous catheters that show such advantages. The mathematics required for numerical solution with more realistic assumptions is also developed. We confirm the robustness of such catheters, when the ports are sufficiently resistive, against leakage paths that would compromise the infusions from catheters with one or a few large ports. The methods of this paper can be incorporated into a larger planning system for intraparenchymal infusions involving such devices.

Computed tomography scan does not correlate with patient experience of nasal obstruction.

OBJECTIVES/HYPOTHESIS: Third-party payors have begun to demand imaging studies to document septal deviation prior to authorizing septoplasties. This study aims to determine whether septal deviation findings on computed tomography (CT) correlate with symptoms of nasal obstruction as determined by the Nasal Obstruction Symptom Evaluation (NOSE) scale. STUDY DESIGN: Prospective and retrospective chart review. METHODS: Patients 18 years or older undergoing CT scans, which included the nasal septum, were asked to complete a NOSE scale survey and report the laterality of any possible obstruction. Coronal CT images of subjects were graded by two blinded otolaryngologists and two blinded neuroradiologists using a grading system devised by the authors. RESULTS: Seventy-three subjects met inclusion/exclusion criteria. Interobserver reliability about the degree of septal deviation on CT scans was moderately good to substantial (κ values, 0.43 to 0.72). There was poor correlation between NOSE scores and degree of deviation on CT scans (Kendall's τ, 0.031 to 0.045; P values all >.05). There was poor concordance between the side of symptoms that patients reported and the side that observers thought was most deviated on CT. CONCLUSIONS: There is little correlation between septal deviation findings on CT scans and symptoms of nasal obstruction. The results do not support a role for CT scans as either a clinically meaningful or necessary test to investigate uncomplicated nasal obstruction. LEVEL OF EVIDENCE: 4.

Clival fibrous dysplasia: Case series and review of the literature.

Slightly more than 30 cases of fibrous dysplasia involving the clivus have been reported in the international literature, primarily in the neurosurgery and radiology literature. In this article we present a series of 4 cases involving patients with clival fibrous dysplasia. In a retrospective chart review, 4 patients presenting to tertiary care centers from January 1, 2006, to January 31, 2008, were identified and their presenting symptoms and radiologic findings reviewed. Based on our literature review, we describe the presenting symptoms of patients with clival fibrous dysplasia and characterize the findings of imaging studies associated with this disorder. All patients in this series had a presenting complaint of headache or cranial nerve deficits, which is consistent with previous reports found in our literature review. Additional presenting symptoms that have been reported include dysphagia and a nontender occipital mass; there was also an incidental asymptomatic finding. Magnetic resonance imaging findings are consistent with those associated with fibrous dysplasia at other sites of the body. We conclude that clival involvement in monostotic fibrous dysplasia may not be as rare as previously perceived.

Morbidity and cost of odontogenic infections.

OBJECTIVE: Cost analysis of deep neck space infections from odontogenic origin and review of the morbidity of potentially preventable complications. STUDY DESIGN: Case series with chart review. SETTING: Level 1 trauma center and academic safety net hospital. SUBJECTS AND METHODS: Patients treated for deep neck space infections due to an odontogenic source between 2001 and 2010 were reviewed. Two hundred patients were included in the study. Ninety-eight patients required inpatient admission. Twelve percent of these patients had difficult airways, and 16% had at least 1 day in the intensive care unit. Cost data were available only for the later 3.5 years of the study period. RESULTS: The overall cost of treatment for these 71 individuals exceeded $1.1 million. CONCLUSION: The cost of treatment for odontogenic infections is staggering. Based on assumptions of the percentage of infections in the metropolitan area captured at Hennepin County Medical Center, extrapolation to the total national cost of inpatient care approaches $200 million annually. This study highlights the importance of access to medical and preventative dental care for the general population and demonstrates the cost benefit that could be achieved through prevention of disease and, therefore, avoidance of its complications.

Implanted upper airway stimulation device for obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Previous feasibility studies have shown that electrical stimulation of the hypoglossal nerve can improve obstructive sleep apnea (OSA). The current study examined the safety and preliminary effectiveness of a second generation device, the Upper Airway Stimulation (UAS) system, and identified baseline predictors for therapy success. STUDY DESIGN: Two consecutive open prospective studies. METHODS: UAS systems were implanted in patients with moderate to severe OSA who failed or were intolerant of continuous positive airway pressure (CPAP). The study was conducted in 2 parts. In part 1, patients were enrolled with broad selection criteria. Apnea hypopnea index (AHI) was collected using laboratory-based polysomnography at preimplant and postimplant visits. Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ) were also collected. In part 2, patients were enrolled using selection criteria derived from the experience in part 1. RESULTS: In part 1, 20 of 22 enrolled patients (two exited the study) were examined for factors predictive of therapy response. Responders had both a body mass index ≤32 and AHI ≤50 (P < .05) and did not have complete concentric palatal collapse. Part 2 patients (n = 8) were selected using responder criteria and showed an improvement on AHI from baseline, from 38.9 ± 9.8 to 10.0 ± 11.0 (P < .01) at 6 months postimplant. Both ESS and FOSQ improved significantly in part 1 and 2 subjects. CONCLUSIONS: The current study has demonstrated that therapy with upper airway stimulation is safe and efficacious in a select group of patients with moderate to severe OSA who cannot or will not use CPAP as primary treatment.

Comparison of intraprostatic ethanol diffusion using a microporous hollow fiber catheter versus a standard needle.

PURPOSE: Transurethral intraprostatic ethanol chemoablation of the prostate has shown promising preliminary clinical results for benign prostatic hyperplasia with some variability in clinical outcome. This is likely due to the uneven prostate diffusion caused by varying resistance of the tissue type in which the tip of the needle is embedded. We examined whether the distribution of the injectable in the canine prostate could be improved using a microporous hollow fiber catheter (Twin Star Medical, Minneapolis, Minnesota). MATERIALS AND METHODS: The prostate was exposed in 9 mongrel dogs. A single injection of 98% ethanol was delivered in each lobe using a microporous hollow fiber catheter and a standard needle. Prostates were harvested and fixed in 10% formalin. After injection 2.5 mm step sections were obtained and scanned. The ethanol induced tissue lesions were traced on hematoxylin and eosin sections. Three-dimensional reconstructions were created and the volume of each prostate lesion was calculated using stereology. RESULTS: Ethanol induced tissue changes were seen bilaterally in 8 of 9 ethanol injected prostates. In all cases the lesion created by microporous hollow fiber catheter injection was larger than that in the contralateral lobe injected with the control needle. When data were pooled, the hollow fiber catheter injection produced significantly greater tissue changes than the control needle injection (p = 0.03). CONCLUSIONS: Improved distribution and absent backflow were seen when using the microporous hollow fiber catheter, supporting its potential as a new method to treat prostate disease.

Hypertonic saline reduces intracranial hypertension in the presence of high serum and cerebrospinal fluid osmolalities.

BACKGROUND: Osmotherapy has been the cornerstone in the management of patients with elevated intracranial pressure (ICP) following traumatic brain injury (TBI). Several studies have demonstrated that hypertonic saline (HTS) is a safe and effective osmotherapy agent. This study evaluated the effectiveness of HTS in reducing intracranial hypertension in the presence of a wide range of serum and cerebrospinal fluid (CSF) osmolalities. METHODS: Forty-two doses of 23.4% saline boluses for treatment of refractory intracranial hypertension were reviewed retrospectively. Thirty milliliters of 23.4% NaCl was infused over 15 min for intracranial hypertension, defined as ICP >20 mmHg. The CSF and serum osmolalities from frozen stored samples were measured with an osmometer. The values of serum sodium, hourly ICP, blood urea nitrogen (BUN), and creatinine were obtained directly from the medical records. RESULTS: The serum and CSF osmolalities correlated very closely to serum sodium (r > 0.9, P < 0.0001). The reduction in ICP from the baseline (measured from either the mean ICP or the lowest ICP measurement in the first 6 h after bolus HTS treatment) was statistically significant regardless of serum osmolality. The mean reduction from baseline to follow-up values was 8.8 mm Hg (P < 0.0001). The decrease in ICP was as evident with serum osmolalities >320 as it was at ≤320. CONCLUSION: This study demonstrates that 23.4% HTS bolus is effective for the reduction of elevated ICP in patients with severe TBI even in the presence of high serum and CSF osmolalities.

Efficacy of reductive ventricular osmotherapy in a swine model of traumatic brain injury.

BACKGROUND: The presence of osmotic gradients in the development of cerebral edema and the effectiveness of osmotherapy are well recognized. A modification of ventriculostomy catheters described in this article provides a method of osmotherapy that is not currently available. The reductive ventricular osmotherapy (RVOT) catheter removes free water from ventricular cerebrospinal fluid (CSF) by incorporating hollow fibers that remove water vapor, thereby providing osmotherapy without increasing osmotic load. OBJECTIVE: To increase osmolarity in the ventricular CSF through use of RVOT in vivo. METHODS: Twelve Yorkshire swine with contusional injury were randomized to external ventricular drainage (EVD) or RVOT for 12 hours. MR imaging was obtained. Serum, CSF, and brain ultrafiltrate were analyzed. Histology was compared using Fluor-Jade B and hematoxylin and eosin (H & E) stains. RESULTS: With RVOT, CSF osmolality increased from 292 ± 2.7 to 345 ± 8.0 mOsmol/kg (mean ± SE, P = 0.0006), and the apparent diffusion coefficient (ADC) in the injury region increased from 0.735 ± 0.047 to 1.135 ± .063 (P = 0.004) over 24 hours. With EVD controls, CSF osmolarity and ADC were not significantly changed. Histologically, all RVOT pigs showed no evidence of neuronal degeneration (Grade 1/4) compared to moderate degeneration (Grade 2.6 ± .4/4) seen in EVD treated animals (P = 0.02). The difference in intracranial pressure (ICP) by area under the curve approached significance at P = .065 by Mann Whitney test. CONCLUSION: RVOT can increase CSF osmolarity in vivo after experimental traumatic brain injury (TBI). In anticipated clinical use, only a slight increase in CSF osmolarity may be required to reduce cerebral edema.

Compartment syndrome ultrafiltration catheters: report of a clinical pilot study of a novel method for managing patients at risk of compartment syndrome.

OBJECTIVES: To demonstrate that tissue ultrafiltration catheters are safe to place and use in an injured lower extremity, measure tissue pressures as well as the current standard of care, and effectively remove interstitial fluid for analysis of biomarkers. DESIGN: Institutional Review Board-approved, prospective pilot study. SETTING: Metropolitan Level I trauma center. PATIENTS: All patients who presented to the emergency department with a tibial fracture met the inclusion and exclusion criteria and gave informed consent were enrolled. A total of 10 patients were studied. INTERVENTION: All subjects were treated with two types of percutaneous intramuscular catheters in both the anterior and deep posterior compartments of the leg for 24 hours. One catheter was a conventional indwelling intramuscular pressure catheter (Stryker Quick Pressure Monitor, Kalamazoo, MI), whereas the other was an experimental combined pressure monitoring/tissue ultrafiltration catheter (Compartment Monitoring System [CMS] catheter; Twin Star Medical, Inc, Minneapolis, MN). MAIN OUTCOME MEASUREMENTS: Safety of device, intramuscular pressure values, and quantity of fluid removed (from CMS catheter only). RESULTS: No serious device-related complications occurred. There was reasonable correlation between the pressures measured by the CMS and Stryker catheters. Average decrease in intramuscular pressure from baseline to final pressure was 11.3 ± 2.8 mm Hg in the anterior compartment (P = 0.003 by two-tailed paired t test) and 5.9 ± 1.4 mm Hg in the deep posterior compartment (P = 0.01). Ultrafiltrate analysis revealed that lactate dehydrogenase and creatine kinase levels were markedly elevated over serum levels. No patient needed fasciotomy or developed compartment syndrome during the study period. CONCLUSIONS: This pilot study of CMS catheters demonstrates safety of CMS catheter use. Assay of the ultrafiltrate may provide greater sensitivity to muscle injury; further research of this approach is warranted.

Extremity compartment syndrome in pigs during hypobaric simulation of aeromedical evacuation.

INTRODUCTION: Extremity compartment syndrome (ECS) is diagnosed when the pressure within a muscle compartment increases to within 45 mmHg of mean arterial pressure. Increased pressure limits perfusion and eventually produces tissue necrosis. This can result in disability or loss of the affected limb. Hypobaric pressure during aeromedical evacuation (AE) has been hypothesized to increase the incidence of ECS. This was tested in a threshold model of ECS in swine. METHODS: Injury was induced by placing an angioplasty balloon between the tibia and the anterior muscle compartment and inflating the balloon to produce an intracompartmental pressure (ICP) 30 mmHg greater than mean arterial pressure for either 5 h or 6 h. Afterwards, animals were maintained either at ground level pressure or at a pressure equivalent to a simulated altitude of 2135 m above sea level for 8 h. ICP was monitored for signs of ECS development. At the end of the period the muscle was collected and evaluated for pathological changes and expression of various molecules associated with inflammation and tissue injury. RESULTS: Simulated altitude did not increase incidence of ECS, peak intracompartmental pressures, or time to onset of ECS. However, muscle degeneration and formation of microvascular thrombi were reduced by exposure to altitude. TNF, IL-1 b, IL-6, IGFBP5, and TGFB2 were increased (P < 0.05) by exposure to altitude, whereas FGF, IGF1, IGFBP4, BMP4, nitrotyrosine, and nitrate were unchanged (P > 0.05). DISCUSSION: Simulated altitude did not increase incidence of ECS. Inflammatory protein expression was increased in muscle, but some aspects of pathology were less severe following altitude exposure.

Threshold model for extremity compartment syndrome in swine.

BACKGROUND: Extremity compartment syndrome occurs when swelling develops within a muscle compartment to such an extent that the microvasculature is compressed and tissue perfusion is compromised. Untreated, this condition can result in widespread tissue destruction and loss of the affected limb. METHODS: Swine were subjected to diffuse muscle compression injury using a balloon catheter inserted between the anterior muscle compartment of the hind limb and the anterior face of the tibia. Balloons were inflated with saline to produce a sustained intramuscular pressure (IMP) of approximately 30 mmHg greater than mean arterial pressure. Following injury the IMP was monitored for up to 8 h. At the end of the monitoring period, the tibialis anterior muscle was collected and examined for injury. RESULTS: One animal receiving 6 h injury dislodged the implanted pressure transducers and was dropped from the data analysis. In all other limbs (n = 8) receiving 6 h injury, significant spontaneous increases in IMP were observed following injury. The tibialis anterior in all of the 6 h injury limbs also showed extensive tissue damage. In the limbs injured for 5 h (n = 10), only three showed a significant increase in IMP. The magnitude and duration of this increase closely resembled that seen following 6 h injury. Tissue damage was reduced in comparison with 6 h injury. CONCLUSIONS: The injury technique described here provides a potential useful threshold model for studying extremity compartment syndrome and the influence of related factors on the progression of this condition.

Severe nasal frostbite injury from nasal cannula supplemental oxygen malfunction.

We describe the presentation and management of a patient who presented to our institution with severe nasal frostbite from nasal cannula supplemental oxygen malfunction. This rare complication has not previously been reported in the English Literature. We describe the physical properties of compressed oxygen release that may contribute to these malfunctions and the role of the otolaryngologist in the management of the resulting injuries.

The effect of reductive ventricular osmotherapy on the osmolarity of artificial cerebrospinal fluid and the water content of cerebral tissue ex vivo.

The purpose of this study was to explore a novel treatment involving removal of free water from ventricular cerebrospinal fluid (CSF) for the reduction of cerebra]l edema. The hypothesis is that removal of free water from the CSF will increase the osmolarity of the CSF, which will favor movement of tissue-bound water into the ventricles, where the water can be removed. Reductive ventricular osmotherapy (RVOT) was tested in a flowing solution of artificial CSF (aCSF) with two end-points: (1) the effect of RVOT on osmolarity of the CSF, and (2) the effect of RVOT on water content of ex vivo cerebral tissue. RVOT catheters are made up of membranes permeable only to water vapor. When a sweep gas is drawn through the catheter, free water in the form of water vapor is removed from the solution. With RVOT treatment, aCSF osmolarity increased from a baseline osmolarity of 318.8 ± 0.8 mOsm/L to 339.0 ± 3.3 mOsm/L (mean ± standard deviation) within 2 h. After 10 h of treatment, aCSF osmolarity approached an asymptote at 344.0 ± 4.2 mOsm/L, which was significantly greater than control aCSF osmolarity (p <<0.001 by t-test, n = 8). Water content at the end of 6 h of circulating aCSF exposure was 6.4 ± 0.9 g H2O (g dry wt)⁻¹ in controls, compared to 6.1 ± 0.7 g H2O (g dry wt)⁻ after 6 h of RVOT treatment of aCSF (p = 0.02, n = 24). The results support the potential of RVOT as a treatment for cerebral edema and intracranial hypertension.

Novel In Situ Collection of Tumor Interstitial Fluid from a Head and Neck Squamous Carcinoma Reveals a Unique Proteome with Diagnostic Potential.

INTRODUCTION: Tumors lack normal drainage of secreted fluids and consequently build up tumor interstitial fluid (TIF). Unlike other bodily fluids, TIF likely contains a high proportion of tumor-specific proteins with potential as biomarkers. METHODS: Here, we evaluated a novel technique using a unique ultrafiltration catheter for in situ collection of TIF and used it to generate the first catalog of TIF proteins from a head and neck squamous cell carcinoma (HNSCC). To maximize proteomic coverage, TIF was immunodepleted for high abundance proteins and digested with trypsin, and peptides were fractionated in three dimensions prior to mass spectrometry. RESULTS: We identified 525 proteins with high confidence. The HNSCC TIF proteome was distinct compared to proteomes of other bodily fluids. It contained a relatively high proportion of proteins annotated by Gene Ontology as "extracellular" compared to other secreted fluid and cellular proteomes, indicating minimal cell lysis from our in situ collection technique. Several proteins identified are putative biomarkers of HNSCC, supporting our catalog's value as a source of potential biomarkers. CONCLUSIONS: In all, we demonstrate a reliable new technique for in situ TIF collection and provide the first HNSCC TIF protein catalog with value as a guide for others seeking to develop tumor biomarkers. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s12014-010-9050-3) contains supplementary material, which is available to authorized users.

Interstitial delivery of vascular endothelial growth factor to skin flaps.

OBJECTIVES: To demonstrate the feasibility of using microporous catheters to deliver a growth factor in a skin flap model, and to determine whether removal of excess fluid by ultrafiltration catheters reduces edema. METHODS: In a controlled study at a research laboratory associated with major teaching hospital, vascular endothelial growth factor was delivered to porcine skin flaps by direct infusion using hollow fiber catheters. Treated flaps received either infusion alone or infusion and ultrafiltration via hollow fibers inserted into the distal portion of the flap. Controls had neither type of catheter placed. The main outcome measure was flap survival and edema. RESULTS: Treated anterior flaps were found to have increased survival (mean [SD] increase, 49.9% [9.4%]) compared with control flaps (44.1% [4.5%]) for group (P = .005) and side (P = .01) but not by interaction (P = .14). Water content was significant by analysis of variance for group, position, and interaction (all P < .001, df = 31) for treated (55.3% [9.7%]) and control (61.9% [8.2%]) groups. CONCLUSIONS: This study demonstrated feasibility of using hollow fiber technology to deliver a growth factor to skin flaps. Further study may yield clinical applications for human patients undergoing reconstructive procedures.

A preliminary theoretical model of hydrodynamics in the inner ear.

Head movement should create a transient pressure imbalance across the membranous inner ear. We used basic concepts of fluid dynamics to develop a theoretical model of the inner ear. According to this model, two contiguous fluidic systems-the perilymphatic system and the endolymphatic system-are in hydrostatic equilibrium across a compliant membrane. Our model demonstrates that changes in resistance or compliance in one system results in a transient distortion of the membranous inner ear until equilibrium between the two systems is restored. The concept of hydrodynamic pressure changes in the inner ear has received little attention, but it may represent a new approach to understanding the inner ear and treating inner ear diseases.

Diagnosis and treatment of deep neck space abscesses.

OBJECTIVE: To review our experience with deep neck abscesses and identify unique trends in our patient population. STUDY DESIGN: Case series with chart review. SUBJECTS AND METHODS: Evaluation of patients with deep neck space abscesses between 2001 and 2006. Peritonsillar abscess, superficial craniocervical infection, and salivary gland infections were excluded from selection of study population. A total of 106 cases were reviewed. RESULTS: Dental infections were the most common cause of deep neck abscesses (49.1%). Comorbidities included substance abuse (53.7%), psychiatric illness (10.4%), hypertension (9.4%), head and neck cancer (6.6%), and diabetes mellitus (5.7%). All patients received systemic antibiotics, eight patients required tracheotomy, 85 patients underwent surgical drainage in the operating room, and 11 had bedside drainage. Median and lower quartile of time in hospital was 2 and 3 days, respectively, whereas upper quartile was 4 days (range, 1 to 27 days). Patients with comorbidities or concurrent illness tended to stay longer (P<0.05, Mann-Whitney test). There were six complications and no mortality. CONCLUSION: Substance abuse and poor orodental hygiene are important predisposing factors to deep neck abscesses. Appropriate management continues to favor a combination of early surgical drainage and systemic antibiotics.