The Impact of COVID-19 on the Incidence, Complexity and Microbiology of Deep Neck Space Abscesses -- A Nine-Year Retrospective Analysis

The Impact of COVID-19 on the Incidence, Complexity and Microbiology of Deep Neck Space Abscesses -- A Nine-Year Retrospective Analysis | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 12 July 2025 V1 Latest version Share on The Impact of COVID-19 on the Incidence, Complexity and Microbiology of Deep Neck Space Abscesses -- A Nine-Year Retrospective Analysis Authors : Maneet Vineet Patel [email protected] , John Bass , Jamie Dipak Patel , and Tanya Gupta 0000-0002-0251-0544 Authors Info & Affiliations https://doi.org/10.22541/au.175230923.36212367/v1 165 views 132 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective The COVID-19 pandemic significantly altered healthcare utilisation and patient presentation patterns. This study investigates the impact of the pandemic on the incidence, complexity, and microbiology of deep neck space abscesses (DNSAs) over a nine-year period. Study design Retrospective analysis was conducted on DNSA admissions from January 2013 to May 2022. Setting Tertiary University Hospital in South England. Methods A retrospective analysis was conducted on DNSA admissions at a tertiary University Hospital in South England from January 2013 to May 2022. Patients were categorised into pre-pandemic (2019 and earlier) and peri-/post-pandemic (2020–2022) groups. Outcomes measured included DNSA incidence, complication rates, and microbiological profiles. Statistical significance was assessed using independent two-tailed t-tests (p<0.05). Results A total of 51 DNSA cases were identified, with a significant increase in admissions during and after the pandemic compared to pre-pandemic years (28/51 vs. 23/51, t=4.852, p=0.001268). DNSA complexity also rose post-pandemic, with higher rates of complications such as abscess re-collection and mediastinitis (25/51 vs. 7/51, t=5.710, p=0.000449). Microbiological analysis revealed a notable increase in Streptococcus milleri and Streptococcus pyogenes (10/51 vs. 5/51, t=3.773, p=0.005443), as well as a greater prevalence of anaerobic bacteria. Conclusion The COVID-19 pandemic contributed to a significant rise in DNSA incidence and complexity, likely due to delayed healthcare-seeking behaviours and reduced primary care interventions. Changes in microbial patterns emphasise the need for robust antimicrobial stewardship. The findings underscore the importance of timely intervention and multidisciplinary management of DNSAs. Future research could explore the impact of pandemic-related healthcare disruptions on DNSA microbiology. The Impact of COVID-19 on the Incidence, Complexity and Microbiology of Deep Neck Space Abscesses – A Nine-Year Retrospective Analysis Objective The COVID-19 pandemic significantly altered healthcare utilisation and patient presentation patterns. This study investigates the impact of the pandemic on the incidence, complexity, and microbiology of deep neck space abscesses (DNSAs) over a nine-year period. Study design Retrospective analysis was conducted on DNSA admissions from January 2013 to May 2022. Setting Tertiary University Hospital in South England. Methods A retrospective analysis was conducted on DNSA admissions at a tertiary University Hospital in South England from January 2013 to May 2022. Patients were categorised into pre-pandemic (2019 and earlier) and peri-/post-pandemic (2020–2022) groups. Outcomes measured included DNSA incidence, complication rates, and microbiological profiles. Statistical significance was assessed using independent two-tailed t-tests (p<0.05). Results A total of 51 DNSA cases were identified, with a significant increase in admissions during and after the pandemic compared to pre-pandemic years (28/51 vs. 23/51, t=4.852, p=0.001268). DNSA complexity also rose post-pandemic, with higher rates of complications such as abscess re-collection and mediastinitis (25/51 vs. 7/51, t=5.710, p=0.000449). Microbiological analysis revealed a notable increase in Streptococcus milleri and Streptococcus pyogenes (10/51 vs. 5/51, t=3.773, p=0.005443), as well as a greater prevalence of anaerobic bacteria. Conclusion The COVID-19 pandemic contributed to a significant rise in DNSA incidence and complexity, likely due to delayed healthcare-seeking behaviours and reduced primary care interventions. Changes in microbial patterns emphasise the need for robust antimicrobial stewardship. The findings underscore the importance of timely intervention and multidisciplinary management of DNSAs. Future research could explore the impact of pandemic-related healthcare disruptions on DNSA microbiology. Keywords Deep neck infection; abscess; COVID; SARS-CoV-2; microbiology. Key points 1. DNSA admissions increased during and after the COVID-19 pandemic. 2. Post-pandemic cases demonstrated higher complication rates (re-collections, mediastinitis, thoracic transfers). 3. Delayed presentations and altered community antibiotic use during COVID-19 likely drove the increased incidence and complexity of DNSAs. 4. Streptococcus milleri group and S. pyogenes isolates doubled in frequency in the peri/post-COVID period, signalling shifting microbiological profiles. 5. Findings underscore the need for early presentation, multidisciplinary care, and targeted antimicrobial stewardship. Introduction Deep neck space abscesses (DNSAs) are characterised by the accumulation of pus within the deep cervical fascial planes. These abscesses often arise as complications of oropharyngeal infections such as tonsillitis, peritonsillar abscess, or dental infections. 1 Presenting symptoms can range from mild, such as sore throat and dysphagia, to severe, including sepsis and airway compromise. Management typically involves intravenous antibiotics and surgical drainage, however may require more invasive measures such as protection of the airway with tracheostomy or ITU (Intensive Treatment Unit) admission. 2 Complex DNSAs may arise due to late presentation or delayed diagnosis, multi-space collections, inadequate surgical drainage, or virulent pathogens. 3 Complications linked with DNSAs include re-collection requiring further surgical intervention, thrombophlebitis of major venous channels, airway compromise, mediastinitis, multi-organ failure, and death. Consequently, due to the significant morbidity associated with DNSAs, these cases often necessitate extensive multi-disciplinary team input and prolonged hospital stays. The COVID-19 pandemic has had profound and enduring effects on disease patterns, hospital services, and patient health-seeking behaviours. Studies have shown that during the pandemic, due to limited access to general practitioners, fewer patients were able to receive primary care for early treatments such as oral antibiotics. 4 Furthermore, changes to health-seeking behaviours, including anxiety to attend healthcare settings, resulted in delayed emergency department presentations with more advanced symptoms. 5 There is a paucity of robust data specifically addressing the impact of COVID-19 on DNSAs. Only one study to date has explored DNSA admissions during the pandemic, which indicates delayed presentations, increased complications, and prolonged hospital stays within this cohort over a two-year period. 1 Additionally, there has been no research comparing the bacterial profile of DNSAs before and after the pandemic. Objectives This study presents the first large-scale analysis examining the impact of the pandemic on DNSAs, focussing on their incidence, complexity, and microbiology pre-pandemic (2019 and earlier) and peri-/post-pandemic (2020 to 2022). Our study is the first of its kind to gather data outside of the immediate pandemic timeframe, with the dataset spanning 2013 to 2022, allowing us to investigate shifts in microbiology and their implications for antimicrobial stewardship. Materials and Methods The study aimed to evaluate whether the COVID-19 pandemic has resulted in an increased incidence of DNSAs, as observed anecdotally by the authors. Additionally, we sought to determine whether any identified trends were transient or lasting, as this may have an impact on the inpatient and surgical burden of ENT (Ear, Nose and Throat) services in the National Health Service (NHS). Other specific primary outcome measures included the complication rates of DNSAs as an indicator of increased abscess complexity. Finally, an analysis of the bacteriological profiles of the DNSAs was undertaken, to ascertain whether the pandemic has impacted our microbiome. Study Design and Setting This retrospective cohort study included all patients admitted under the ENT department at a tertiary university hospital in South England with a DNSA involving at least one of the parapharyngeal or retropharyngeal spaces between January 2013 and May 2022. Exclusion criteria encompassed abscesses not involving either of these spaces, any deep neck space infection without radiological evidence of collection, and any patient not admitted under ENT. Furthermore, we excluded paediatric patients and those admissions that could not be verified from at least two sources of patient records. Data Collection Retrospective data between January 2013 and February 2022 was accessed via the Trust Central Information Unit and validated against online patient records and inpatient lists. Prospective data was recorded from February 2022 and May 2022. Pre and post COVID-19 parameters were clearly defined. We specified pre-pandemic admissions as 2019 and earlier, and post-pandemic admissions as 2020 and later (particularly as our region was one of the earliest nationally to report cases of COVID-19). 6 Ethical Considerations National Health Service Research Ethics Committee waived ethical approval for this type of retrospective study and all the procedures being performed were part of routine care. For this type of study formal informed consent was not required. Outcome measurement The number of DNSA admissions each year was recorded and analysed. Known complications of DNSAs, including re-collection, ITU admission, mediastinitis, and transfer to specialist thoracic surgery centres, were documented. Microscopy and culture results from DNSA samples were analysed to identify trends in bacterial profiles. Basic patient demographics, including major co-morbidities, were also recorded. The independent two-tailed t-test was applied to outcome measures to assess for statistical significance, with significance defined at p<0.05. Bias STROBE guidelines were used for the reporting of our findings. To minimise classification and measurement bias, clear definitions of COVID-19 parameters and recognised complications of DNSAs were outlined. Cross-verification of administrative records with medical notes also helped to reduce these sources of potential bias. Selection bias was addressed through well-defined inclusion criteria for our study. Results Patient Demographics Our study identified 51 ENT admissions for DNSAs over a 9.5-year period at our tertiary centre. The raw data revealed a clear rise in the incidence of DNSAs during the study period (Figure 1), with a notable male preponderance showing a 50% higher occurrence in males compared to females (M:F ratio of 1.55:1). The mean age of patients was 49, with a wide age range each year. Diabetes emerged as the most common comorbidity within our cohort (20%, n=10), followed by hypertension (14%, n=7). Incidence of Deep Neck Space Abscesses Statistical analysis indicated a significant increase in DNSA incidence during and after the pandemic, compared to pre-pandemic figures (28/51 vs 23/51, t-value 4.852, p=0.001268) (Figure 1). Fig.1 Incidence of deep neck space abscesses and the gender demographics. Complication Rate There was also a statistically significant increase in the complexity of DNSAs during and after the pandemic, compared to before, specifically noting increased rates of re-collection, mediastinitis, and transfer to a specialist thoracic surgery centre (25/51 vs 7/51, t-value 5.710, p=0.000449) (Figure 2). Fig.2 Complications of DNSAs pre- and post-COVID. Bacteriology Microbiological analysis revealed a statistically significant increase in the isolation of abscess-forming bacteria from the Streptococcus milleri family and Streptococcus pyogenes during and after the pandemic, compared to before (10/51 vs 5/51, t-value 3.773, p=0.005443) (Figure 3). An increased prevalence of anaerobic bacteria was also observed. Fig.3 Microbiological profile of the bacteria isolated from DNSAs. Discussion This study provides valuable insights into the impact of the COVID-19 pandemic on the incidence, complexity, and microbiology of DNSAs over a nine-year period at a tertiary centre. The findings highlight a significant rise in the incidence (p=0.0013) and complexity (p=0.0004) of DNSAs during and after the pandemic, along with notable changes in the microbiology of these abscesses. Increased Incidence and Complexity of DNSAs The data clearly demonstrates a statistically significant rise in the incidence of DNSAs during and after the pandemic compared to pre-pandemic figures (28/51 vs 23/51, p=0.001268). The retrospective cohort study by Charlton et al. showed that patients presented significantly later after the onset of DNSA symptoms during the COVID-19 pandemic (5.96 days) compared to before (3.25 days). 1 This aligns with the hypothesis that pandemic-related changes in patient health-seeking behaviours contributed to delayed presentations and consequently increased DNSA incidence. A large-scale survey in the United States during a peak of the pandemic in June 2020 highlighted population concerns about COVID-19, with 40.9% having avoided seeking medical care and 12.0% delaying emergency presentations. 5 The findings of our study also reveal a significant increase in the complexity of DNSAs during and after the pandemic, compared to before (25/51 vs 7/51, p=0.000449). Specifically, increased rates of complications such as re-collection, mediastinitis, and the need for transfer to a specialist thoracic surgery centre were identified. Parara et al. also reported a significant increase in the severity of neck infections progressing to descending necrotizing mediastinitis during the COVID-19 pandemic, reflecting the more advanced nature of these infections at the time of presentation. 7 This significant rise in infection severity was also identified by Charlton et al., with 77.8% of the cohort having abscess formation compared to 34.6% presenting with inflammation alone (p<0.01), as well as a rise in complications from 7.7% before the pandemic to 33.3% during the pandemic (p=0.0394). 1 Non-significant findings included greater abscess volume and longer hospital stays, postulated to be due to delayed presentations allowing infections to mature into more complex collections. 1 Existing literature suggests that there was a decrease in the incidence of common precursor infections to DNSAs during the pandemic. These include cervicofacial infections of odontogenic origin, 8,9 orofacial and respiratory infections, 10 as well as oropharyngeal infections. 4 This was widely thought to be due to social distancing and infection prevention precautions, such as use of face masks and hand sanitisation. Toppi et al. presented data on all oropharyngeal infections before (2019) and during the pandemic (2020) in one Melbourne centre. They demonstrated a reduced number of infections during the pandemic period, including DNSAs. 4 Patients were symptomatic for a significantly longer time prior to presentation during the pandemic compared to before (5 days vs 4 days, p< 0.01), with a significantly reduced proportion of patients on oral antibiotics prescribed in the community (30% vs 50%, p<0.01). 4 During the pandemic, patients likely faced challenges in accessing primary care for these early-stage precursor infections, which may have resulted in their under-recording in the literature and progression into more severe cases of DNSAs, necessitating hospital admission and invasive management. The male preponderance and significant co-morbidity burden, particularly diabetes, noted in this study are consistent with prior research that associates DNSAs with certain demographic and health factors. 11 Diabetes was present in 20% of the cohort, which is known to impair immune function and may contribute to the higher incidence and increased complexity of DNSAs in affected individuals. This comorbidity is therefore an important consideration in both the prevention and management of DNSAs moving forward. Changes in Microbiology and Implications for Antimicrobial Stewardship This study has identified notable shifts in the microbiology of DNSAs during and after the pandemic. The significant increase in the isolation of abscess-forming bacteria from the Streptococcus milleri family and Streptococcus pyogenes class (p=0.005443), along with an observed increase in anaerobic bacteria, raises concerns regarding the evolving pathogenic landscape of DNSAs in the post-pandemic period. Heilig et al. analysed the microbiology of peri-tonsillar abscesses during the COVID-19 pandemic and also found an increase in the isolation of a Streptococcus milleri bacteria Streptococcus anginosus (31.4% vs 5.7% pre-pandemic, p=0.007), as well as noting an increase in Fusobacterium necrophorum (37.1% vs 8.6% pre-pandemic, p=0.008). 12 The Streptococcus milleri family of bacteria encompasses 3 different species: Streptococcus anginosus , Streptococcus intermedius and Streptococcus constellatus . 13 These are organisms commonly located in the oral cavity, pharynx, gastrointestinal and genitourinary tracts. 14 Despite being commensal organisms, they have been found to be aggressive pathogens in the head and neck with a tendency for local extension and abscess development. 15 Streptococcus milleri bacteria tend to be highly sensitive to penicillin antibiotics, but studies are showing increased resistance, highlighting the need for a more nuanced approach to antimicrobial stewardship given the high morbidity and mortality of DNSAs. 15 These changes in microbiological trends may reflect broader shifts in community-acquired infections during the pandemic, including changes in population health behaviours, antibiotic usage, and exposure to healthcare settings. Future research could explore whether changes in antibiotic resistance patterns during the pandemic have also contributed to the observed trends in DNSA complexity. Study Limitations While this study provides critical insights into the impact of COVID-19 on DNSAs, several limitations must be considered. First, as a retrospective single-centre study, the findings may not be generalisable to other regions or healthcare settings. Furthermore, while we defined clear pre- and post-pandemic parameters, the evolving nature of the pandemic and variations in healthcare access across different time periods may have introduced confounding factors that are difficult to control. Additionally, the sample size, while large for a DNSA study, may still be relatively small for detecting more subtle trends, especially in microbiology and complication rates. Conclusion This study represents the first large-scale review of DNSA trends spanning the pre-, peri-, and post-pandemic period, revealing significant increases in incidence, complexity, and microbiological diversity in the wake of the COVID-19 pandemic. These findings have critical implications for the ongoing management of DNSAs, underscoring the importance of timely intervention, multidisciplinary care, and robust antimicrobial stewardship. As healthcare systems continue to recover from the pandemic’s effects, it is essential to monitor these trends and adapt clinical practices to address the evolving challenges posed by DNSAs in the post-pandemic landscape. Future studies could explore whether the trends observed in this study persist over time and investigate the underlying causes of these microbiological changes in greater detail. References 1. Charlton AR, Simon R, Simons A. COVID-19 pandemic-Impact on deep neck space infections: A retrospective cohort study. Clin Otolaryngol . 2023;48(3):479-488. 2. Almuqamam M, Gonzalez FJ, Sharma S, Kondamudi NP. Deep Neck Infections. In: StatPearls . Treasure Island (FL): StatPearls Publishing; 2024. 3. Hurley R, Douglas C, Montgomery J, Clark L. The hidden cost of deep neck space infections. Ann R Coll Surg Engl . 2018;100(2):129-134. 4. Toppi J, Hughes J, Phillips D. Bacterial infections of the oropharynx and deep neck spaces: an investigation of changes in presentation patterns during the COVID-19 pandemic. ANZ J Surg . 2021;91:2726–30. 5. Czeisler MÉ, Marynak K, Clarke KE, et al. Delay or avoidance of medical care because of COVID-19-related concerns - United States. Morb Mortal Wkly Rep . 2020;69(36):1250–7. 6. Hodcroft EB. Preliminary case report on the SARS-CoV-2 cluster in the UK, France, and Spain. Swiss Med Wkly . 2020;150:w20212. 7. Parara E, Krasadakis C, Toursounidis I, Tsekoura K, Mourouzis C, Rallis G. Significant rise in neck infections progressing to descending necrotizing mediastinitis during the COVID-19 pandemic quarantine. J Craniomaxillofac Surg. 2021;49(12):1182-1186. 8. Politi I, McParland E, Smith R, Crummey S, Fan K. The impact of COVID-19 on cervicofacial infection of dental aetiology. Br J Oral Maxillofac Surg. 2020;58(8):1029-1033. 9. Dawoud BE, Kent P, Ho MW. Impacts of lockdown during the SARS-CoV-2 pandemic on patients presenting with cervicofacial infection of odontogenic origin: a comparative study. Br J Oral Maxillofac Surg . 2021;59(3):e109-13. 10. Haapanen A, Uittamo J, Furuholm J, Mäkitie A, Snäll J. Effect of COVID-19 pandemic on orofacial and respiratory infections in ear, nose, and throat and oral and maxillofacial surgery emergency departments: a retrospective study of 7900 patients. Eur Arch Otorhinolaryngol . 2021;1:1-6. 11. Dou K, Shi Y, Yang B, Zhao Z. Risk factors for life-threatening complications of head and neck space infections: A systematic review and meta-analysis. J Stomatol Oral Maxillofac Surg . 2024;125(4S):101954. 12. Heilig Y, Sapir A, Yafit D, Ben-Shimol S, Kaplan DM, Cohen O. Impact of the COVID-19 era on clinical presentation, management and microbiology in paediatric peritonsillar abscess: A case-control study. Clin Otolaryngol . 2024;49(2):207-213. 13. Whiley RA, Beighton D. Emended descriptions and recognition of Streptococcus constellatus, Streptococcus intermedius, and Streptococcus anginosus as distinct species. Int J Syst Bacteriol . 2021;41(1):1-5. 14. Piscitelli SC, Shwed J, Schreckenberger P, Danziger LH. Streptococcus milleri group: renewed interest in an elusive pathogen. Eur J Clin Microbiol Infect Dis . 1992;11:491-498. 15. Han JK, Kerschner JE. Streptococcus milleri: An Organism for Head and Neck Infections and Abscess. Arch Otolaryngol Head Neck Surg . 2001;127(6):650–654. Figures and Legends Fig.1 Incidence of deep neck space abscesses and the gender demographics. Fig.2 Complications of DNSAs pre- and post-COVID. Fig.3 Microbiological profile of the bacteria isolated from DNSAs. Information & Authors Information Version history V1 Version 1 12 July 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Affiliations Maneet Vineet Patel [email protected] Basingstoke and North Hampshire Hospital View all articles by this author John Bass University Hospitals Sussex NHS Foundation Trust View all articles by this author Jamie Dipak Patel Basingstoke and North Hampshire Hospital View all articles by this author Tanya Gupta 0000-0002-0251-0544 University Hospitals Sussex NHS Foundation Trust View all articles by this author Metrics & Citations Metrics Article Usage 165 views 132 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Maneet Vineet Patel, John Bass, Jamie Dipak Patel, et al. The Impact of COVID-19 on the Incidence, Complexity and Microbiology of Deep Neck Space Abscesses -- A Nine-Year Retrospective Analysis. Authorea . 12 July 2025. DOI: https://doi.org/10.22541/au.175230923.36212367/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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