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\begin{document}

\title{COVID-19 Pandemic -- Impact on Deep Neck Space Infections: a
Retrospective Cohort Study}



\author[1]{Alexander Charlton}%
\author[1]{Raul Simon}%
\author[1]{Anthony Simons}%
\affil[1]{Nottingham University Hospitals NHS Trust}%


\vspace{-1em}



  
  \date{May 27, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Abstract Background This study aimed to evaluate whether changes in
practice and patient behaviour due to the covid-19 pandemic impacted the
presentation, management, and outcomes of patients with deep neck space
infections (DNSI). Design Retrospective cohort study including all
adults presenting to the otolaryngology department at a tertiary UK
centre with a DNSI during the first 12 months of the covid-19 pandemic
(n = 27), and those from the previous 12 month period (n = 26). Patients
with peritonsillar abscess which did not involve deep neck spaces
radiologically were excluded. Results The covid-19 pandemic cohort
tended to present later after onset of symptoms (5.96 days vs 3.25 days,
p = 0.0277), have abscess formation rather than inflammation only
(77.8\% vs 34.6\%, p \textless{} 0.01), and develop complications
(33.3\% vs 7.7\%, p = 0.0394). Not reaching statistical significance,
the covid-19 pandemic cohort also had larger volume abscess (25.18cm3 vs
14.5cm3, p = 0.291), longer hospital stay (14.48 days vs 6.35 days, p =
0.114), and longer intensive care stay (7.88 days vs 1.78 days, p =
0.0992). Non-significant changes were noted in management, with the
covid-19 pandemic cohort being seven times more likely to undergo
tracheostomy (25.9\% vs 3.8\%, p = 0.0504), and more likely to undergo
transcervical drainage (37\% vs 19.2\%, p = 0.224) and hot tonsillectomy
(11.1\% vs 0\%, p = 0.236). Conclusion This study demonstrates the
covid-19 pandemic led to delayed presentation and more severe infection,
requiring more radical management in patients with DNSI.%
\end{abstract}%



\sloppy


\section*{Abstract}

{\label{abstract}}

Key words: COVID-19, pandemic, deep neck space infection, deep neck
space abscess, tracheostomy, severity, lockdown, delayed presentation,
tracheostomy, quinsy.

\textbf{Background}

This study aimed to evaluate whether changes in practice and patient
behaviour due to the covid-19 pandemic impacted the presentation,
management, and outcomes of patients with deep neck space infections
(DNSI).

\textbf{Design}

Retrospective cohort study including all adults presenting to the
otolaryngology department at a tertiary UK centre with a DNSI during the
first 12 months of the covid-19 pandemic (n = 27), and those from the
previous 12 month period (n = 26). Patients with peritonsillar abscess
which did not involve deep neck spaces radiologically were excluded.

\textbf{Results}

The covid-19 pandemic cohort tended to present later after onset of
symptoms (5.96 days vs 3.25 days, \emph{p} = 0.0277), have abscess
formation rather than inflammation only (77.8\% vs 34.6\%,
\emph{p}\textless{} 0.01), and develop complications (33.3\% vs 7.7\%,
\emph{p}= 0.0394). Not reaching statistical significance, the covid-19
pandemic cohort also had larger volume abscess
(25.18cm\textsuperscript{3} vs 14.5cm\textsuperscript{3}, \emph{p} =
0.291), longer hospital stay (14.48 days vs 6.35 days, \emph{p} =
0.114), and longer intensive care stay (7.88 days vs 1.78 days, \emph{p}
= 0.0992). Non-significant changes were noted in management, with the
covid-19 pandemic cohort being seven times more likely to undergo
tracheostomy (25.9\% vs 3.8\%,\emph{p} = 0.0504), and more likely to
undergo transcervical drainage (37\% vs 19.2\%, \emph{p} = 0.224) and
hot tonsillectomy (11.1\% vs 0\%,\emph{p} = 0.236).

\textbf{Conclusion}

This study demonstrates the covid-19 pandemic led to delayed
presentation and more severe infection, requiring more radical
management in patients with DNSI.

\subsection*{Key points}

{\label{key-points}}

\begin{enumerate}
\tightlist
\item
  There is a significant demographic shift towards females presenting
  with DNSIs during the covid-19 pandemic.
\item
  Patients diagnosed with DNSIs have a significantly delayed
  presentation during the covid-19 pandmeic.
\item
  Patients diagnosed with DNSIs are significantly more likely to have
  abscess formation rather than inflammation/phlegmon alone during the
  cpovid-19 pandemic.
\item
  Patients are significantly more likely to develop compliocations of
  DNSIs during the covid-19 pandemic.
\item
  Patients diagnosed with DNSIs are seven times more likely to undergo
  tracheostomy during the covid-19 pandemic.
\end{enumerate}

\subsection*{Introduction}

{\label{introduction}}

\subsubsection*{Background}

{\label{background}}

A deep neck space infection is a serious condition characterised by
rapid progression and severe morbidity with a high mortality rate. In
addition, it also carries a high cost burden to the National Health
Service (NHS) as management is complex necessitating input from several
specialities and often a prolonged hospital stay (1, 2). The most common
causes are dental and tonsillar infections, but also salivary gland
infections, lymphadenitis, foreign bodies and neoplasm (3). The
infection is often polymicrobial (4), resulting in inflammation of deep
neck space tissues or abscess formation within tissue planes.
Antimicrobials, surgical drainage of abscesses and supportive treatment
are the mainstay of management (4). The airway is often compromised and
requires securing with endotracheal intubation or tracheostomy (5). The
incidence and severity of DNSI reduced significantly in the era of
readily available antibiotics, partly due to early treatment of
predisposing infections. In recent years, however, the incidence of
DNSIs appears to be rising (2, 3).

In response to the covid-19 pandemic, the United Kingdom went into
lockdown on 26\textsuperscript{th} March 2020, with further national
lockdowns coming into force on 5\textsuperscript{th} November 2020 and
6\textsuperscript{th} January 2021 in England. Restrictions varied over
time and location following the first national lockdown easing, with
some form of restriction remaining in place to date (6).

The Covid-19 pandemic has caused people to avoid presentation to
hospitals and primary care (7). It has also reduced capacity for
face-to-face primary care consultation and examination, especially for
upper respiratory tract symptoms such as a sore throat. Changes in the
hospital management and allocation of hospital resources, particularly
intensive care capacity and availability also ensued (8).

Several studies have evaluated the impact of the covid-19 pandemic on
upper respiratory tract, pharyngeal and orofacial/cervicofacial
infections, including DNSIs (9, 10, 11, 12). Still, none have assessed
the effect of the pandemic on the management of these infections -- a
particularly pertinent point given the frequent requirement for airway
management in the context of concern around intensive care capacity and
aerosol-generating procedures. The published data evaluating the
presentation and outcomes of patients with DNSIs is limited and does not
exist in a United Kingdom (UK) setting.

\subsubsection*{Objectives}

{\label{objectives}}

We investigated the impact of the covid-19 pandemic on presentation,
outcomes and management of DNSIs. We hypothesised that patients were
more likely to present later with more advanced/severe disease for the
reasons discussed above. Due to the scarcity of intensive care beds (8),
we postulated that patients requiring airway management were more likely
to have tracheostomy performed as this negates the mandatory intensive
care admission associated with endotracheal intubation.

\subsection*{Methods}

{\label{methods}}

This manuscript was prepared using the STROBE checklist for cohort
studies (13). Neither ethical approval nor participant consent were
required due to the retrospective nature of this study and anonymous
handling and reporting of data.

\subsubsection*{Study design}

{\label{study-design}}

Retrospective cohort study comparing patients with DNSI presenting
during the covid-19 pandemic with those presenting beforehand.

\subsubsection*{Setting}

{\label{setting}}

Patients presenting to the ear, nose and throat (ENT) department of a
NHS teaching hospital in the UK during the period
1\textsuperscript{st}April 2019 to 31\textsuperscript{st} March 2020
(pre-covid-19 pandemic cohort) and 1\textsuperscript{st} April 2020 to
31\textsuperscript{st}March 2021 (covid-19 pandemic cohort). Data was
collected retrospectively, from April 2021 to August 2021.

\subsubsection*{Participants}

{\label{participants}}

We enrolled all patients at least 16 years of age (at time of
presentation) with a DNSI in the specified timeframes. Cases were
identified by interrogating daily ENT in-patient handover lists for the
relevant periods. Potential deep neck space infections were then
confirmed or refuted using digital health records and PACS systems. All
patients had radiological evidence of deep neck space infection, either
inflammatory changes/phlegmon or abscess. Patients with peritonsillar
abscess which did not involve deep neck spaces radiologically were
excluded.

\subsubsection*{Variables}

{\label{variables}}

Data points and outcome measures included basic patient demographics,
duration of symptoms and antibiotic administration prior to
presentation, the presence of deep neck space abscess vs
inflammation/phlegmon only, complications from DNSI (specifically
Lemierre's syndrome and mediastinitis), mortality. The management of
DNSI was divided into transoral drainage in theatre, transcervical
drainage in theatre, hot tonsillectomy, bedside peritonsillar abscess
drainage, or medical management alone, and whether a tracheostomy was
performed. Other outcome measures included intensive care admission,
duration of intensive care admission, length of hospital stay, and
abscess volume.

\subsubsection*{Data sources/measurement}

{\label{data-sourcesmeasurement}}

All data was identified from digital health records, with the exception
of the presence of deep neck space abscess vs inflammation/phlegmon only
and abscess volume which were assessed using PACS system reports.

\subsubsection*{Bias}

{\label{bias}}

A 12 month time period was used for each cohort to mitigate bias from
seasonal variation in DNSIs.

\subsubsection*{Study size}

{\label{study-size}}

The study size was dictated by the timeframe and eligibility criteria
which are key to the design of this study.

\subsubsection*{Quantitative variables/Statistical
methods}

{\label{quantitative-variablesstatistical-methods}}

Data was analysed using Microsoft Excel. Categorical variables were
presented as frequencies and percentages, and p-values calculated using
Fisher Exact Test. Continuous variables were presented as mean with
standard deviation, with p-values calculated using unpaired t-tests.
Statistical significance was attributed to p values \textless{} 0.05.

\subsection*{Results}

{\label{results}}

During the pre-covid period, 26 patients presented with deep neck space
infections, and 27 patients presented during the covid period. Patient
demographics for the two groups are shown in table 1. Results and
statistical comparison between groups are summarised in table 2.

\subsection*{Discussion}

{\label{discussion}}

\subsubsection*{Key results and
interpretation}

{\label{key-results-and-interpretation}}

A male predominance is generally observed for deep neck space infections
(14) -- this was witnessed in our pre-covid cohort, but there were more
females in our covid-19 pandemic cohort (\emph{p} = 0.0244). This may be
because women are more likely than men to avoid or delay medical
attention as a result of the covid-19 pandemic (7), resulting in
untreated predisposing infections progressing to DNSIs.

The incidence of DNSIs was similar between the two groups (pre-covid-19
pandemic cohort = 26, covid-19 pandemic = 27). Existing studies
evaluated orofacial and respiratoryinfections (9); oropharyngeal and
DNSIs (10); and odontogenic cervicofacial infections (11, 12), without
specifically focusing on DNSIs as a pathological and clinical entity.
They all showed a reduction in incidence during the covid-19 pandemic.
Despite this, during the covid-19 pandemic, DNSIs showed greater
incidence (15), likely due to progression of simple infections which
were not treated promptly.

Our results have proven our hypothesis true, demonstrating patients
present significantly later -- a mean of 5.96 days after onset of
symptoms in the covid-19 pandemic cohort compared to 3.25 days in the
pre-covid-19 pandemic cohort (\emph{p} = 0.0277). This concurs with
findings for odontogenic cervicofacial (12), oropharyngeal and DNSIs
(10).

Toppi et al. identified a reduced number of patients already having
antimicrobial treatment at presentation, hypothesised to be due to
limited access to primary care clinicians and apprehension about -- as
well as general advice against -- attending medical facilities during
the covid-19 pandemic (10). Contrarily, in our study, the likelihood of
pre-hospital antibiotic administration was similar in cohorts.
Unfortunately, we could not reliably assess when antibiotic therapy was
initiated for those who had started antibiotics before presentation. If
we were able to access this data, it might have shown that antibiotics
were initiated later in the course of the disease in the pandemic cohort
for the above reasons

As postulated, the covid-19 pandemic caused people to have more
severe/advanced disease, likely resulting from the delayed presentation.
We found a significantly (\emph{p} \textless{} 0.01) increased
likelihood of abscess formation in the covid-19 pandemic cohort (77.8\%)
compared to the pre-covid-19 pandemic cohort (34.6\%) as well as greater
volume of the abscess in the covid-19 pandemic cohort (mean = 25.18
cm\textsuperscript{3}) compared to the pre-covid-19 pandemic cohort
(mean = 14.5 cm\textsuperscript{3}). This likely reflects the delayed
presentation, allowing the infection longer to mature into an abscess in
the covid-19 cohort. Existing literature reports an increased proportion
of dental and odontogenic cervicofacial infections were considered to be
severe (11, 16), or demonstrated systemic inflamatory response syndrome
(12), during the covid-19 pandemic.

Complications were also more likely in the covid-19 pandemic cohort,
affecting 33.3\% of participants, compared with 7.7\% of the
pre-covid-19 pandemic cohort, again implying more advanced and severe
disease (\emph{p} = 0.0394). Perhaps the most significant complication
is mediastinitis with mortality rates reported as high as 40\% (17, 18).
We found a slightly higher rate of mediastinitis in the covid-19
pandemic cohort (4 vs 3 ), which could be linked to delayed presentation
and corresponding increased severity. A significant rise in neck
infections progressing to mediastinitis has been reported during the
covid-19 pandemic (19). Mortality was infrequent in both our study
groups (3.8\% and 7.4\%), with frequencies too rare to make valid
comparisons.

Probably due to the increased severity of disease and higher rate of
complications, often necessitating airway securement, the covid-19
pandemic cohort had longer hospital stay (mean days 14.48 vs
6.35,\emph{p} = 0.114), in-keeping with findings for odontogenic
cervicofacial infections (12). Intensive care stay was also longer in
the covid-19 pandemic cohort (mean days 7.88 vs 1.78, \emph{p} =
0.0992).

Tracheostomy was seven times as likely in the covid-19 pandemic cohort
(25.9\% vs 3.8\%, \emph{p} = 0.0504). With a p-value so close to
significance, we feel the seven-fold increase in tracheostomies in the
covid-19 cohort is a strong indicator of the management pattern during
the pandemic. This may represent the increased severity of disease, more
often involving complications and necessitating airway management. It
may also reflect the scarcity of intensive care beds (8), meaning
patients were more likely to undergo tracheostomy rather than
orotracheal intubation, as tracheostomy negates the need for intensive
care admission. Tracheostomy formation, however, presents its own
challenges during the covid-19 pandemic as the procedure, and associated
ward-based tracheostomy care is considered aerosol-generating (20).

Aerosol generating procedures and the risk of covid-19 transmission may
have a significant impact on the way patients with DNSIs are managed
during the covid-19 pandemic. These implications were demonstrated in a
case presentation by Ajeigbe et al (21). They highlighted several
potential impacts: hesitancy to examine the mouth/oropharynx or perform
flexible nasendoscopy; hesitancy to perform surgery or bedside drainage
of abscesses; pressure to avoid hospital admission and to discharge
patients early to maintain hospital bed occupancy (21). These factors
may result in suboptimal treatment of patients with DNSIs causing
progression to more severe disease and may contribute to our discovery
of the greater risk of complications, longer hospital stay, and
potential need for more radical interventions such as tracheostomy.

One would expect that the hesitation to perform invasive procedures
during the covid-19 pandemic would increase the number of patients
treated with medical therapy alone. However, the rate of management with
medical therapy alone was similar in the two groups. We propose this is
balanced against a cohort where abscess formation is more common and
larger, and infection is more severe with a higher incidence of
complications.

There is, however, a noticeable reduction in transoral manoeuvres,
including bedside peritonsillar abscess drainage and transoral drainage
under general anaesthesia, being performed almost twice as rarely in the
covid-19 pandemic cohort. This may indicate the intended decrease in
transmission of the virus, but has potentially hindered the progress of
these patients.

Twice as many patients had transcervical drainage in the covid-19
pandemic cohort, which is likely to reflect the increased number and
size of true abscesses and the increased severity of disease. It may
also have been selected as a preferred option over transoral procedures
to minimise risks of covid-19 transmission. Dawoud et al also noted an
increase in extra-oral drainage for odontogenic cervicofacial infections
during the covid-19 pandemic (12).

\subsubsection*{Study
Limitations/Generalisability}

{\label{study-limitationsgeneralisability}}

Our study assumes that the covid-19 pandemic is driving the identified
differences. However, the authors acknowledge that there may be
confounding factors. One such factor is the comorbid status of the
patients as this is predictive of complications (22, 23) and length of
stay (23, 24). We did not collect data on comorbidities and therefore
are unable to assess their impact in our study. The observed difference
in gender make-up of the cohorts could confound results as well.

Our study evaluated the same time period, a full calendar year, for each
cohort, which is a different methodology to others that considered brief
periods at the onset of the covid-19 pandemic only (10, 11) and would
have been subject to bias as a result, especially given the seasonal
variations in DNSIs (25).

Our relatively modest number of patients included means many of our
results lack statistical power, and larger studies would be required to
corroborate our findings. This data also represents only patients at one
centre and those under the care of the ENT team, so results may not be
generalisable to patients in other geographical locations, other
healthcare settings or other specialities such as maxillofacial
services. This point is particularly pertinent as responses to the
covid-19 pandemic varied by region or country.

Finally, DNSI does not have an agreed definition or a diagnostic code
assigned to it, which limits the reliability of our findings.

\subsubsection*{Conclusion}

{\label{conclusion}}

This study demonstrates that patients with DNSI were more likely to
present later in the course of their disease during the first year of
the covid-19 pandemic compared to the year prior. This led to increased
likelihood of developing an abscesses rather than inflammation alone,
and developing complications from their DNSI. Though not statistically
significant, patients were also found to have a longer hospital and ITU
stay, during the covid-19 pandemic. Management of DNSI differed during
the pandemic, with an increased frequency of tracheostomy and
transcervical drainage, and a reduction in transoral drainage
procedures. These findings suggest that individuals presenting in the
first year of the covid-19 pandemic tended to have more severe disease,
requiring more radical management, likely due to presenting later in the
course of their illness as well as changes in practice related to the
covid-19 pandemic. Further multicentre studies, preferably covering a
wider geographical area and examining broader, more detailed cohorts of
patients, are required to fully explain and confirm the impact of the
covid-19 pandemic on patients with deep neck space infections.

\subsubsection*{Funding}

{\label{funding}}

There is no funding to declare.

\subsection*{References}

{\label{references}}

1. Hurley RH, Douglas CM, Montgomery J, Clark LJ. The hidden cost of
deep neck space infections. The Annals of The Royal College of Surgeons
of England. 2018 Feb;100(2):129-34.

2. Pankhania M, Rees J, Thompson A, Richards S. Tonsillitis,
tonsillectomy, and deep neck space infections in England: the case for a
new guideline for surgical and non-surgical management. The Annals of
The Royal College of Surgeons of England. 2021 Mar;103(3):208-17.

3. Velhonoja J, L\selectlanguage{ngerman}ääveri M, Soukka T, Irjala H, Kinnunen I. Deep neck
space infections: an upward trend and changing characteristics. European
Archives of Oto-Rhino-Laryngology. 2020 Mar;277(3):863-72.

4. Almuqamam M, Gonzalez FJ, Kondamudi NP. Deep Neck Infections. In:
StatPearls. StatPearls Publishing, Treasure Island (FL); 2021. PMID:
30020634.

5. Cho SY, Woo JH, Kim YJ, Chun EH, Han JI, Kim DY, Baik HJ, Chung RK.
Airway management in patients with deep neck infections: A retrospective
analysis. Medicine. 2016 Jul;95(27).

6. Instituteforgovernment.org.uk: Stack Path {[}Internet{]}. Timeline of
UK government coronavirus lockdowns and restrictions {[}Cited 2021
December 23\textsuperscript{rd}{]}. Available from:
https://www.instituteforgovernment.org.uk/charts/uk-government-coronavirus-lockdowns

7. Czeisler MÉ, Marynak K, Clarke KE, Salah Z, Shakya I, Thierry JM, Ali
N, McMillan H, Wiley JF, Weaver MD, Czeisler CA. Delay or avoidance of
medical care because of COVID-19--related concerns---United States, June
2020. Morbidity and mortality weekly report. 2020 Sep 11;69(36):1250.

8. Tyrrell CS, Mytton OT, Gentry SV, Thomas-Meyer M, Allen JL, Narula
AA, McGrath B, Lupton M, Broadbent J, Ahmed A, Mavrodaris A. Managing
intensive care admissions when there are not enough beds during the
COVID-19 pandemic: a systematic review. Thorax. 2021 Mar 1;76(3):302-12.

9. 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. European Archives of
Oto-Rhino-Laryngology. 2021 Oct 1:1-6.

10. 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\selectlanguage{english}-19 pandemic. ANZ journal of
surgery. 2021 Aug 24.

11. Politi I, McParland E, Smith R, Crummey S, Fan K. The impact of
COVID-19 on cervicofacial infection of dental aetiology. British Journal
of Oral and Maxillofacial Surgery. 2020 Oct 1;58(8):1029-33.

12. 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. British Journal of Oral and
Maxillofacial Surgery. 2021 Apr 1;59(3):e109-13.

13. Von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke
JP. The Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) statement: guidelines for reporting observational
studies. Bulletin of the World Health Organization. 2007;85:867-72.

14. Hasegawa J, Hidaka H, Tateda M, Kudo T, Sagai S, Miyazaki M,
Katagiri K, Nakanome A, Ishida E, Ozawa D, Kobayashi T. An analysis of
clinical risk factors of deep neck infection. Auris Nasus Larynx. 2011
Feb 1;38(1):101-7.

15. Drew S, Lazar A, Amin D, Abramowicz S. Odontogenic Infections are
More Frequent and More Severe during COVID-19 Pandemic. Journal of Oral
and Maxillofacial Surgery. 2021 Oct 1;79(10):e88-9.

16. Long L, Corsar K. The COVID-19 effect: number of patients presenting
to The Mid Yorkshire Hospitals OMFS team with dental infections before
and during The COVID-19 outbreak. British Journal of Oral and
Maxillofacial Surgery. 2020 Jul 1;58(6):713-4.

17. Mihos, P., Potaris, K., Gakidis, I., Papadakis, D. and Rallis, G.,
2004. Management of descending necrotizing mediastinitis.~\emph{Journal
of oral and maxillofacial surgery} ,~\emph{62} (8), pp.966-972.

18. Roccia F, Pecorari GC, Oliaro A, Passet E, Rossi P, Nadalin J,
Garzino-Demo P, Berrone S. Ten years of descending necrotizing
mediastinitis: management of 23 cases. Journal of oral and maxillofacial
surgery. 2007 Sep 1;65(9):1716-24.

19. 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.
Journal of Cranio-Maxillofacial Surgery. 2021 Dec 1;49(12):1182-6.

20. Philpott C, Burrows S; Entuk.org: Aerosol-generating procedures in
ENT {[}Internet{]}. {[}Last updated 2020, March 23\textsuperscript{rd};
Cited 2021, December 23rd{]}. Available from:
https://www.entuk.org/aerosol-generating-procedures-ent

21. Ajeigbe T, Ria B, Wates E, Mattine S. Severe parapharyngeal abscess
that developed significant complications: management during the COVID-19
pandemic. BMJ Case Reports CP. 2020 Dec 1;13(12):e236449.

22. Kumar NJ, Rayanan SG, Greeshma G. A study on deep neck space
infections. Otolaryngol Online J. 2017;7(3):159.

23. Barber BR, Dziegielewski PT, Biron VL, Ma A, Seikaly H. Factors
associated with severe deep neck space infections: targeting multiple
fronts. Journal of Otolaryngology-Head \& Neck Surgery. 2014
Dec;43(1):1-7.

24. O'Brien KJ, Snapp KR, Dugan AJ, Westgate PM, Gupta N. Risk factors
affecting length of stay in patients with deep neck space infection. The
Laryngoscope. 2020 Sep;130(9):2133-7.

25. Bakir S, Tanriverdi MH, Gun R, Yorgancilar AE, Yildirim M, Tekba\selectlanguage{polish}ş \selectlanguage{english}G,
Palanci Y, Meri\selectlanguage{ngerman}ç K, Topçu \selectlanguage{polish}İ. \selectlanguage{english}Deep neck space infections: a retrospective
review of 173 cases. American journal of otolaryngology. 2012 Jan
1;33(1):56-63.

\textbf{Hosted file}

\verb`Table 1 -- demographic characteristics.docx`  available at \url{https://authorea.com/users/459034/articles/555431-covid-19-pandemic-impact-on-deep-neck-space-infections-a-retrospective-cohort-study}

\textbf{Hosted file}

\verb`Table 2 -- hospital presentation, infection and patient management characteristics .docx`  available at \url{https://authorea.com/users/459034/articles/555431-covid-19-pandemic-impact-on-deep-neck-space-infections-a-retrospective-cohort-study}

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