I have very recently purchased a Bose L-1 Compact System for sound reinforcement with my classical guitar while playing some weddings, cocktail parties and other venues where I need a bit of a boost to maintain parity with high(er) ambient background noise. Yesterday I tried it at a bigger-than-recommended venue with a louder than normal ambient level. I play at a number of bridal shows and expos to drum up trade and yesterday I did the 'Saratoga Living' extravaganza at the Saratoga Springs City Center. Anyone familiar with the venue will recognize it: I played the long rectangular entrance hall--about 175(+/-) feet long, about 25 feet wide with a thirty foot ceiling. If you're not familiar with it, well, there are the approixmate dimensions. Bose advertizes the L-1 Compact for audiences up to 100 people. There were about 250 queued up to get in during the first hour or so, with conversation, foot traffic etc. passing directly in front of me to get into the show. So how did the L-1 cope?
First, let me describe my utilization. I play an Eric Marczak guitar which are very loud instruments yet still possessing good tone. I use a (cheap but effective) John Pearse contact microphone because I refuse to drill holes in an expensive instrument AND my experience has been that traditional mics (and stands) pick up too much ambient sound and increase my 'footprint' too much. The L-1 has a setting for tone match to a guitar. I assume that this is Bose's EQ for a steel string acoustic interfaced by a piezo setup. It is not the best sound for my classicals. I also hook my iPod up to the L-1 on breaks so having to remember to keep turning on and shutting off this guitar EQ for the two uses gets irksome. Also, the L-1 has nop reverb and sometimes a bit of 'sweetness' in a small acoustically dead room is nice. SO.... I use a Roland Mini Cube for a preamp and keep teh tone match setting off. The Roland allows for some EQ as well as the reverb. Plus it boosts the signal of the John Pearse contact mic.
With this setup, I was running--in the aforementioned space-- at about one third (ten o'clock or so on the volume control of the L-1. No clipping whatsoever. The sound quality was described as totally natural (which it also sounded to me) and I carried about half way down the room. Far enough. This was over very loud conversation. and walking in boots on hard tile. Had this been a cocktail party on carpet, I would have been much too loud--at least until the drinks really kicked in! It also would have filled the room. Dispersion -- I sounded like I was coming from everywhere, not just a single acoustic source. This is the part that is truely amazing. There are no 'hot spots' just seamless sound. The volume doesn't jump up drastically as you approach the system. All in all, I think I'm in love! Plus the portability factor, even considering the Roland added on, is so much an improvement over my old rig, makes the L-1 ideal for my needs.
I witnessed this system at a local bar recently... amazing sound.
thanks for info i was considering this or a soloamp, but liked the look and ease of the bose.
I know exactly what you mean! The Bose is just so simple -- and light in weight. I have not heard the soloamp, but I can;t imagine it having a more natural non-directional sound. If you can get a chance to try one out or hear it, I think you'll be impressed.
Thanks for the info, I have been seriously considering getting one of these. It seems like the perfect fit for classical guitar, a full PA is just overkill and a real pain to set up.
The two biggest pluses for me -- after the sound quality-- are the light weight and ease of setup. I used to lug either as tradtional PA or a heavy amplifier. Now, one trip from the car and I'm good to go! Also, the dispersion of the sound is so non-directional. I've played at restaurants where I had to keep it down to not BLAST a table near me and then received requests to turn up because the tables at the back couldn't hear. The Bose system has the bass down low (about ten inches off the floor) and the higher frequency speaker array is about six feet off the ground -- right over the heards off people seated at a table up front. There are no hot spots so the volume you hear is what the everyone hears--even at a a distance. Please hear one of these systems for yourself -- I'm beginning to sound like a factory shill, which I'm not!--they really sound good!
When I'm playing a recital in a room with a dry acoustic (which I hate!) I use a good quality mic in front of the guitar and run it through a good reverb unit into the Bose.
I balance the reverb level so there is hardly any original sound,just the 'wet' sound (I'm not trying to amplify, this is not about volume) and can often achieve a very natural 'enhanced acoustic' effect.
It makes the concert far more enjoyable for me since I'm not 'fighting the room' all the time and I do it very subtly so it's not obvious to the audience.
If possible I also place the amp between the stage curtains, so often the Bose (thanks to its unconventional shape) isn't even visible.
All thanks to the great spread and transparency of sound that the amp produces.
... interesting product 'solution' for performers and presenters ... for ~$1,000. Thanks for sharing that.
I might add (I own 3 L1 systems) that if one is utilizing a pickup like Harry is, then an effective and inexpensive solution to the "dryness" of the sound is a Zoom A2 acoustic processor, which has reverbs, EQs, compression, etc., etc. for under $100 (also a built-in tuner). Once a little reverb is added, it's very hard to think of a better system than this is. I have sold off all of my conventional amplification equipment except a Crate Limo battery-powered amp for garden weddings or sailboat gigs (I do several a year on Newport Harbor, suffering for my art). Bose has changed everything for the better.
ronjazz wrote: I might add (I own 3 L1 systems) that if one is utilizing a pickup like Harry is, then an effective and inexpensive solution to the "dryness" of the sound is a Zoom A2 acoustic processor, which has reverbs, EQs, compression, etc., etc. for under $100 (also a built-in tuner). Once a little reverb is added, it's very hard to think of a better system than this is. I have sold off all of my conventional amplification equipment except a Crate Limo battery-powered amp for garden weddings or sailboat gigs (I do several a year on Newport Harbor, suffering for my art). Bose has changed everything for the better.
That sounds like a lighter solution to lugging my Roland Micro Cube just for the reverb --- thanks for the info; I'll be checking into the Zoom!
I've just been over the the Bose website; it does look an impressive piece of design - but fairly pricey!
The pianist that I work frequently work with has this system and swears by it. We have used it auditoriums, theatres, town halls, recording studios etc...and it is spot on worth while. I have been seriously considering purchasing one (with the additional sub) for my bass playing. It would certainly be less work to load-in and -out with this than my current rig. The only thing holding me back (and it isn't the cost) is the inabilty to truly shape the sound of the amp proper.
pogmoor wrote: I've just been over the the Bose website; it does look an impressive piece of design - but fairly pricey!
Yeah, it isn't cheap, but I consider it worth the money in convenience and sound.
You have to hear it!
yep, Bose, like Apple, provides slick industrial design ... in exchange for PREMIUM price$.
Note that the actual speakers (drivers), installed by Bose, are pretty mediocre, as far as frequency response and durability etc. ... just cheap-to-produce paper, rather than polypropylene, for example. What makes Bose units appealing is the angled sound dispersion and all-in-one designs.
Last edited by aNovitiate on Wed Mar 02, 2011 4:36 pm, edited 1 time in total.
anyone here have comments on this versus the SoloAmp?


front of the cases LEDs wires question. .. .
Thread: front of the cases LEDs wires question. .. .
connecting front panel to motherboard.. . ..
Last edited by altangerel20; 07-15-2005 at 02:08 PM.
Re: front of the cases LEDs wires question. .. .
Your wiring harness should have a common color in all cases. If I recall in the Tt models this color is black... and is the ground. While it won't do harm to your to your system or motherboard to hook them up backwards, it will cause some of the functions (mainly lights) to work properly. If you check out your mainboard manual it should have a detailed diagram of this portion of the motherboard as well as a chart that shows which pin is positive and which is negative.


text:
Bad Overshadows Good in Candy Crush Maker King.com's Earnings
King.com reported its first-quarter earnings Tuesday. Though it beat expectations, it still needs to find life after Candy Crush Saga.
By Matthew Lynley
Matthew Lynley BuzzFeed News Reporter
Posted on May 7, 2014, at 10:53 a.m. ET
Brendan Mcdermid / Reuters / Reuters
Things aren't looking good for the maker of Candy Crush Saga, and Wall Street knows it — it's seen this song and dance before.
King.com, the creator of Candy Crush Saga, reported its first earnings as a public company Tuesday, and while it generally beat expectations across the board, it also began to show slowing growth sequentially. That led Wall Street to slam the stock, which is down more than 9% after market open.
Normally, quarter-over-quarter comparisons aren't apples to apples, and investors tend to look at how a company has grown in a quarter compared to the previous year. In that respect, King.com has grown tremendously, nearly tripling its gross bookings and profit. But for a gaming business like King.com, the company's growth essentially happens based on the number of hits it has, and showing slowing growth in the next quarter means the company hasn't found another hit.
The company is also starting to make less money off Candy Crush Saga, with 67% of its gross bookings coming from the game, compared 78% in the fourth quarter last year. Monthly unique payers fell from 12.2 million in the fourth quarter to 11.9 million in the first quarter.
This sort of thing is familiar to investors, who faced a similar dilemma when Zynga went public on the strength of its FarmVille and CityVille game. The comments in the earnings release are eerily similar as well, down to the company pointing to it having three of the top ten grossing apps on the App Store — while, at the time, Zynga would point to having a number of games in the top monthly active user charts on AppData when it was the largest game maker on Facebook.
Again, year over year, King is showing stunning growth — it has 143 million people playing its games daily, up from 36 million in the same quarter a year ago. But 2013 was also the year of Candy Crush Saga, when the company's growth came from what was arguably the most popular and biggest game of all time, propelling King.com to its initial public offering. Its daily active users increased just 15% quarter over quarter, meaning that it is still finding some growth — though part of that likely came from a recent partnership with Tencent to bring Candy Crush Saga to its messaging networks in China.
The company's perennial problem — and the problem with basically any large gaming company — still exists: It needs a hit. Electronic Arts reported its earnings yesterday and beat analyst estimates across the board, but it also revealed that it has built a hit in Titanfall, an aggressive first-person shooting game. King.com said this quarter was led by Farm Heroes Saga, but that app is still behind Candy Crush Saga on Apple's top grossing charts.
Wall Street is still waiting for King.com to find life after Candy Crush Saga, and until it does, the company is basically going to get the Zynga treatment. The question remains whether it can.
Matthew Lynley is a business reporter for BuzzFeed News in San Francisco. Lynley reports on Silicon Valley and the tech industry.
Contact Matthew Lynley at matthew.lynley@buzzfeed.com.

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: Is it possible to use autoscaler for google SQL as it is possible for compute engine Let me explain the problem. I have a magento project with 3 million products and more than 6 million urls. The problem ist only the database because of this much products. I would like to only autoscale the google cloud sql database. Then it would always respond adequate. I know its possible for google compute engine and that also includes the database. So is it possible with google or another cloud sql provider?

A: You cannot scale databases the same way Autoscaler is doing for Compute Engine managed instances. Autoscaling capabilities of Compute Engine works for stateless VMs. Databases are stateful. You can use read replications to scale Cloud SQL. Read Replica instances allow data from the master instance to be replicated to one or more slaves. This setup can provide increased read throughput. Visit this artcile for different read replica scenarios.

redpajama_set_name: RedPajamaStackExchange


Of all the bikes presented at the London Bike Show, this little Saracen certainly deserves a mention. The Kili Flyer is the company's new 130/120mm travel 650b rig and it's so fresh it doesn't even feature in their 2013 catalogue.
The undeniably Yeti-like paintwork helps set the bike apart from other full suspension Saracens, while a tapered head tube, thru-axles at each end and relaxed geometry ensure it's up to a lot more than its travel might suggest. Like the rest of Saracen's full-sus 2013 bikes, the Kili Flyer's frame is made from 6066 grade alloy – stronger than the more common 6061 type.
The Kili Flyer is available in one build and for a retail price of £2,799, and Saracen have made sure to include a selection of good kit – you can check out the full spec listing below. Keep your eyes peeled for a first ride of the Kili Flyer on BikeRadar.


The Guardian has an article on declining UK natural gas production - North Sea gas production falls 25%.
North Sea gas production has slumped by 25% in the second quarter of the year, an alarming increase in the rate of decline that will cut tax revenues and could put more pressure on government to agree controversial shale gas developments.
Figures from the Department of Energy and Climate Change (DECC) also show a 36% rise in coal imports, but a leap from 6.3% to 9.6% for the amount of electricity generated by wind and other renewables.
The department records that the output of oil and associated gas liquids fell by 16% in the three months to the end of June, compared with a year earlier – the biggest decline since records began 16 years ago.
This left Britain importing 3.6m tonnes of oil in the second quarter, compared with 2.8m tonnes in the same period of 2010, even though total oil demand fell by 1.7%.


text:
Columbia international affairs online ist ein Fachportal für internationale Beziehungen. Es bietet Zugang zu Zeitschriften (2009:77 Zeitschriften), Büchern, Fallstudien etc.

Es handelt sich um ein kostenpflichtiges Angebot der Columbia University Press, das von in Deutschland wohnhaften Personen über das System der Nationallizenzen kostenlos genutzt werden kann.

Weblinks
 Columbia International Affairs Online (CIAO), About CIAO, Columbia University Press (englisch).

Siehe auch
IREON (Internetportal)

Digitale Bibliothek
Internationale Beziehungen

redpajama_set_name: RedPajamaWikipedia


Maybe you'll be shouting about Trying Dry from the rooftops (or at least on social media), or maybe you'll only want to tell your closest friends and family. Choosing who to tell (and when and how) ahead of time can boost your chances of success. That said, telling people that you're going dry – especially if you drank quite a bit before – can be daunting. Welcome to your 'coming out' phase.
As much as your dry journey is about you, I'm afraid you're bound to encounter at least a few other humans during your month and they will have a bearing on how you experience it. Some of them will make things a lot easier and more fun, some will be curious and others may do their best to get you back to your old ways. Who will it be useful to have on side? Who might be affected by your month? And what will you say when people offer you a drink?
So there are quite a few people you might need or want to tell. But how to do it? Obviously some people will need you to talk this through with them in more detail than others: your partner, close friends (especially the ones you often drink with) and maybe your kids. A good place to start, though, is by developing an elevator pitch.
The principle behind the elevator pitch is that you imagine answering a question about your Dry January – what you're doing, why you're doing it – in the time it takes an elevator (er, lift) to travel between floors. Your pitch should work for pretty much anyone: your friends from work, the guy you usually see at the pub, your nosy neighbour who's wondering why your recycling bin is suddenly so empty.
1. Fake it 'til you make it. Just saying the words can help you to focus on your goal.
2. Others are less likely to question your challenge if you sound convincing.
3. Having a set response means you're not going to stumble over your words or start justifying your reasons.
1. Tell them what you're doing – one month alcohol-free – but also why. People will want to know what's in it for you, so sell the benefits.
2. Keep your language positive – this is a challenge, not a punishment.
3. Keep it brief – this is not a justification or an explanation, just your way of letting people know. You can always lengthen it for certain people if necessary.
4. Practise your pitch out loud. No, really. You need to feel comfortable saying the words and you need to run through it a few times to remember what it is you're going to say. Feel free to write it on your hand if it will help.
Take some time to get the wording of your pitch right, then note it down.
What if I don't want to tell someone – or anyone – that I'm dry?
If you're going dry for a month, you have absolutely NOTHING to be embarrassed about, and no one should make you feel like you have. You're doing something to be pretty proud of. That said, you might decide that telling some people isn't worth the hassle. That's OK too. If there are people around you who are struggling with their own relationship with booze, or friends and family who may not be over the moon about your choice, then you might want to keep it to yourself. If you want to just dip your toes into dry and see how it feels before letting everyone know, give it a week and see how you feel then. Don't forget the Dry January app and Facebook group can give you virtual support in the meantime.
Not telling anyone is possibly not the best idea. Having some support through the month can make a massive difference. Even if your friends and family aren't super supportive, just having them know about your dry month can be helpful so they don't keep offering you drinks (though knowing might not always stop them). If you do decide to Try Dry without anyone knowing, it's doable but it might take a bit of subterfuge.
Have you downloaded our app yet? You can use it year-round to track your drinking, savings and more! Find out more and download it here. You can also buy our book, Try Dry: the Official Guide to a Month Off Booze, here. It's full of handy tips and advice for giving dry a go - whether that's January or any other month!
A key skill for taking part in Dry January is learning how to say no to alcoholic drinks.
Dry January - it's nowhere near as fun as Drunk December, right?


Due to an incorrect usage of an ownCloud internal file system function the passed path to the file scanner was resolved relatively. An authenticated adversary may thus be able to get a listing of directories (but not the containing files) existing on the filesystem. However, it is not possible to access any of these files.
Martin Macht – SySS GmbH – Vulnerability discovery and disclosure.


Thank you for participating in the enduring materials activity "The Best Practice for Inflammatory Breast Cancer (IBC)."
This is the opportunity for PHYSICIANS to claim their CME credit and evaluate the program. The Medical Society of Delaware designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™.
If you are NOT a PHYSICIAN, please contact the planners of this activity in order to obtain a link to a credit form & evaluation for you.
If you have any questions, please contact the Medical Society of Delaware at (302) 224-5193. Thank you.
At the end of the survey you will be re-directed to a Certificate of Attendance. If you would like to print this out for your records, you must have your printer ready before you begin the survey.
* 1. This survey is for Physicians only.
Please provide your full name for awarding CME credit. Thank you.
I claim 1 AMA PRA Category 1 credit™ for this session.


text:
Phantom Of The Paradise Blu-ray
Studio: Scream Factory
Sep 08, 2014 Web Exclusive By Austin Trunick
It's hard to imagine—40 years later—what might have been going through distributors' heads as they engaged in a heated bidding war for Brian De Palma's independently-financed, totally nutso rock musical Phantom of the Paradise. Twentieth Century Fox won out, paying a (then) record-breaking $2 million dollars for the film's rights. The film hit theaters and was a resounding flop. (To add insult to injury, Fox also had to settle with Universal over the movie's surface similarities to Phantom of the Opera.) The film not only failed to court the young rock-and-roll audience Fox purportedly hoped to haul in, but barely rivaled the success that The Rocky Horror Picture Show—produced by Fox less than a year later—found on the midnight circuit. De Palma, of course, continued on to bigger and better things, while Phantom languished in cult film circles as something akin to Rocky Horror's lesser-seen little cousin.
That's not the fault of Phantom being a bad film; its rabid fans certainly will argue otherwise, and both the music and De Palma's creative direction make sure the film isn't forgettable. But compared to Rocky Horror—it's very hard not to—Phantom of the Paradise lacks clarity in its vision. Rocky shot for a low-budget, classical b-movie aesthetic, all the way down to its shoddy, theatrical sets and purposefully hammy performances. Meanwhile the bad acting in Phantom just feels, well, bad—rather than a winking bad. And the direction works in richly-orchestrated set pieces and cutting-edge techniques such as split screen, but will cut to a bafflingly goofy Benny Hill-speed chase scene. And not only is it difficult to discern what effect Phantom is going for in any given moment, but sometimes you can't even tell what's going on. The story is a convoluted, herky-jerky mess, pulling elements from Phantom of the Opera, Faust, and Dorian Gray and tying them together with abrupt and confusing exposition.
To roughly summarize, the film centers around Swan (Paul Williams), a devilish, Phil Spector-esque record producer who seems to hold sway over the entirety of pop music fandom. At a talent search he discovers Winslow Leach, a brilliant but totally unmarketable singer-songwriter. Swan steals Leach's music; while attempting to get credit for his work, Leach is chased out of Swan's studio and horribly disfigured in a freak record-pressing accident. Leach dons a chrome helmet and becomes the phantom of The Paradise—Swan's fancy theatrical venue—sabotaging Swan's efforts to find his next great musical act.
While Phantom of the Paradise is a mess, it's an extremely interesting mess. Even in this silly flick it's hard to miss that there's a skilled director is at work behind the camera. But even more memorable than the direction is the soundtrack. Phantom of the Paradise received an Academy Award nomination for Best Original Song Score, but lost to Nelson Riddle's soundtrack for the Robert Redford-starring The Great Gatsby. All words and music were composed by Paul Williams, who plays Swan in the film and actually penned several pop hits (including "We've Only Just Begun" by The Carpenters, Barbra Streisand's "Evergreen (Love Theme From A Star Is Born)"—and "The Rainbow Connection" (!?) from The Muppet Movie.) In particular, the numbers sung by Jessica Harper—who plays Swan's protégé, Phoenix, and would be seen later starring in Suspiria—are memorable for her strong performance style, along with the '50s throwback rock songs performed in the film by The Juicy Fruits. On the other hand, one particular song – "Life At Last!" – sung in the film by glam rock caricature Beef, hasn't aged very well, as much the fault of the cringe-worthy stereotype played by actor Gerritt Graham as just being a lousy musical number.
As far as the blu-ray goes, Scream Factory has given Phantom of the Paradise an absolutely royal treatment. The film itself looks and sounds spectacular; the movie boasts a dizzying color palette, which really pops out in this new HD transfer. There's a ridiculous number of extra features spread across the package's two discs, including two brand new audio commentaries and interviews with De Palma, Williams, and others. There are also a handful of features carried over from old editions, including a Paul Williams interview moderated by Guillermo Del Toro, 40 minutes of alternate takes, trailers, galleries, outtakes, and a 50-minute behind-the-scenes documentary. In all, there are hours and hours of extras to sift through. Scream Factory continues to give Criterion a run for their money, heaping seemingly-endless amounts of love on cult cinema with these eccentric genre releases in robust special editions. Phantom of Paradise is no exception, and it's hard to imagine the film's fans being able to ask for much more than what's included here.
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text:
Deep Neck Infections
Author: Alan D Murray, MD; Chief Editor: Arlen D Meyers, MD, MBA
For centuries, the diagnosis and treatment of deep neck space infections have challenged physicians and surgeons. The complexity and the deep location of this region make diagnosis and treatment of infections in this area difficult. These infections remain an important health problem with significant risks of morbidity and mortality. See the image below.
CT scan of the neck demonstrating left peritonsillar abscess.
See 10 Patients with Neck Masses: Identifying Malignant versus Benign, a Critical Images slideshow, to help identify several types of masses.
History of the Procedure
In the past, infections of the deep neck spaces were associated with high rates of morbidity and mortality. The overwhelming complication rate of the past has been reduced with the advent of modern microbiology and hematology, the development of sophisticated diagnostic tools (eg, CT, MRI), the effectiveness of modern antibiotics, and the continued development of medical intensive care protocols and surgical techniques.
Infections of the deep neck spaces present a challenging problem for the following reasons:
Complex anatomy: The anatomy of the deep neck spaces is highly complex and can make precise localization of infections in this region difficult.
Deep location: The deep neck spaces are located deep within the neck. This makes diagnosis of infections difficult because they are often covered by a substantial amount of unaffected superficial soft tissue. Deep neck infections may be difficult to palpate and impossible to visualize externally.
Access: Superficial tissues must be crossed to gain surgical access to the deep neck spaces, placing all of the intervening neurovascular and soft tissue structures at risk of injury.
Proximity: The deep neck spaces are surrounded by a network of structures that may become involved in the inflammatory process. Neural dysfunction, vascular erosion or thrombosis, and osteomyelitis are just a few of the potential sequelae that can occur with involvement of surrounding nerves, vessels, bones, and other soft tissue.
Communication: The deep neck spaces have real and potential avenues of communication with each other. Infection in one space can spread to adjacent spaces, thus gaining access to increasingly larger portions of the neck. In addition, certain deep neck spaces extend to other portions of the body (eg, mediastinum,[1] coccyx), placing areas outside of the head and neck at risk of involvement when these spaces are involved.
No accurate estimate of the overall frequency of deep neck space infections in the United States or worldwide presently exists. However, to assume that the incidence of infection in the United States is significantly lower than that of countries in which patients do not benefit from early medical intervention is reasonable. The complication rate is also likely to be greater in areas without wide access to modern medical treatment, including antibiotics, imaging modalities, and intensive care support.
A study by Adil et al, using information from the 2009 Kids' Inpatient Database, estimated that there are more than 3400 US hospital admissions annually for pediatric deep neck space infections.[2]
Before the widespread use of antibiotics, 70% of deep neck space infections were caused by spread from tonsillar and pharyngeal infections. Today, tonsillitis remains the most common etiology of deep neck space infections in children, whereas odontogenic origin is the most common etiology in adults.[3, 4, 5, 6] A study by Adoviča et al found that out of 263 patients hospitalized for deep neck space phlegmons and/or abscesses, 70.6% of the cases arose from dental infections.[7] Causes of deep neck infections include the following:
Tonsillar and pharyngeal infections
Dental infections or abscesses
Oral surgical procedures or removal of suspension wires
Salivary gland infection or obstruction[8]
Trauma to the oral cavity and pharynx (eg, gun shot wounds, pharynx injury caused by falls onto pencils or Popsicle sticks, esophageal lacerations from ingestion of fish bones or other sharp objects)
Instrumentation, particularly from esophagoscopy or bronchoscopy
Foreign body aspiration
Cervical lymphadenitis
Branchial cleft anomalies
Thyroglossal duct cysts
Mastoiditis with petrous apicitis and Bezold abscess
Laryngopyocele
IV drug use[9]
Necrosis and suppuration of a malignant cervical lymph node or mass
As many as 20-50% of deep neck infections have no identifiable source.
Other important considerations include patients who are immunosuppressed because of human immunodeficiency virus (HIV) infection, chemotherapy, or immunosuppressant drugs for transplantation. These patients may have increased frequency of deep neck infections and atypical organisms, and they may have more frequent complications.
A retrospective study by Alotaibi et al indicated that in patients with odontogenic infection, criteria for hospital admission based on a risk of deep neck space infection should include not just the well-known risk signs—fever, trismus, leukocytosis, swollen neck, dysphagia, dyspnea, and elevated C-reactive protein levels—but also the presence of mandibular (as opposed to maxillary) odontogenic infection and/or dental abscess. The study included a cohort of 97 patients.[10]
Deep neck space infections can arise from a multitude of causes. Whatever the initiating event, development of a deep neck space infection proceeds by one of several paths, as follows:
Spread of infection can be from the oral cavity, face, or superficial neck to the deep neck space via the lymphatic system.
Lymphadenopathy may lead to suppuration and finally focal abscess formation.
Infection can spread among the deep neck spaces by the paths of communication between spaces.
Direct infection may occur by penetrating trauma.
Once initiated, a deep neck infection can progress to inflammation and phlegmon or to fulminant abscess with a purulent fluid collection. This distinction is important because the treatment of these 2 entities is very different.
The signs and symptoms of a deep neck abscess develop because of the following:
Mass effect of inflamed tissue or abscess cavity on surrounding structures
Direct involvement of surrounding structures with the infectious process
For example, tonsillitis may lead to peritonsillar abscess. If not treated successfully, peritonsillar abscess may spread to the lateral pharyngeal space. From there, infection spreads to the posterior pharyngeal and prevertebral spaces and into the chest. Mediastinitis and empyema may ensue, leading to death. Alternatively, infection may spread from the lateral pharyngeal space to the contents of the carotid sheath, leading to internal jugular vein thrombosis, subacute bacterial endocarditis, pulmonary emboli, carotid artery thrombosis and cerebrovascular insufficiency, or Horner syndrome. Lateral pharyngeal space abscess alone may cause airway obstruction at the level of the pharynx. Ungkanont et al reviewed 117 children treated for deep neck infections during a 6-year period.[11] The following distribution results were revealed:
Peritonsillar infections (49%)
Retropharyngeal infections (22%)
Submandibular infections (14%)
Buccal infections (11%)
Parapharyngeal space infections (2%)
Canine space infections (2%)
The microbiology of deep neck infections usually reveals mixed aerobic and anaerobic organisms,[12] often with a predominance of oral flora. Both gram-positive and gram-negative organisms may be cultured. Group A beta-hemolytic streptococcal species (Streptococcus pyogenes), alpha-hemolytic streptococcal species (Streptococcus viridans, Streptococcus pneumoniae), Staphylococcus aureus, Fusobacterium nucleatum, Bacteroides melaninogenicus, Bacteroides oralis, and Spirochaeta, Peptostreptococcus, and Neisseria species often are found together in various combinations. Pseudomonas species, Escherichia coli, and Haemophilus influenzae are occasionally encountered.
A German study, by Cordesmeyer et al, of 63 patients with deep neck space infections, found Streptococcus viridans to be the most prevalent aerobic gram-positive pathogen to be isolated (26.7% of infections), with Staphylococcus epidermidis and Staphylococcus aureus each being isolated in 16.7% of infections. Among the aerobic gram-negative pathogens, Escherichia coli, Klebsiella oxytoca, and Haemophilus influenzae were the most frequently isolated. Malignancy was found in 1.6% of patients.[13]
In a retrospective study by Shimizu et al of patients with deep neck infection, bacterial cultures revealed Staphylococcus species in 60% of pediatric patients but in only 9% of adults, with Streptococcus species, on the other hand, being more common in adults (56%) than in children (27%).[14]
A study by Asmar of retropharyngeal abscess microbiology demonstrated polymicrobial culture results in almost 90% of patients.[15] Aerobes were found in all cultures, and anaerobes were found in more than 50% of patients. Other studies have shown an average of at least 5 isolates from cultures.
May et al found evidence that biofilm phenotypes may be associated with the pathogenesis of deep neck infections, as well as with the recalcitrance to treatment experienced with larger deep neck abscesses. The investigators obtained biopsy samples from abscess walls located in the deep neck spaces of 14 patients undergoing surgical drainage. Scanning electron microscopy revealed that 12 of the 14 tissue samples contained biofilm imbedded with rod- and cocci-shaped bacteria.[16]
Obtain a detailed history from patients in whom deep neck space infection is suspected. Eliciting a history of the following is important:
Recent dental procedures
Upper respiratory tract infections (URTIs)
Neck or oral cavity trauma
Respiratory difficulties
Immunosuppression or immunocompromised status
Rate of onset
Duration of symptoms
The aforementioned study by Shimizu et al found that in patients with deep neck infection, lymphadenitis was the most common preceding illness in children (73%), while in adults, it was the least common antecedent disease (7%).[14]
Physical examination should focus on determining the location of the infection, the deep neck spaces involved, and any potential functional compromise or complications that may be developing. A comprehensive head and neck examination should be performed, including examination of the dentition and tonsils. The most consistent signs of a deep neck space infection are fever, elevated WBC count, and tenderness. Other signs and symptoms largely depend on the particular spaces involved and include the following:
Asymmetry of the neck and associated neck masses or lymphadenopathy, which is present in almost 70% of pediatric retropharyngeal abscesses according to a study by Thompson and colleagues
Medial displacement of the lateral pharyngeal wall and tonsil caused by parapharyngeal space involvement
Trismus caused by inflammation of the pterygoid muscles
Torticollis and decreased range of motion of the neck caused by inflammation of the paraspinal muscles
Fluctuance that may not be palpable because of the deep location and the extensive overlying soft tissue and muscles (eg, sternocleidomastoid muscle)
Possible neural deficits, particularly of the cranial nerves (eg, hoarseness from true vocal cord paralysis with carotid sheath and vagal involvement), and Horner syndrome from involvement of the cervical sympathetic chain
Regularly spiking fevers (may suggest internal jugular vein thrombophlebitis and septic embolization)
Tachypnea and shortness of breath (may suggest pulmonary complications and warn of impending airway obstruction)
Relevant Anatomy
A detailed anatomic description of the major facial and deep neck spaces is beyond the scope of this article. However, a thorough knowledge of this anatomy is necessary for accurate diagnosis and treatment of these infections. The deep neck spaces are formed by fascial planes, which divide the neck into real and potential spaces.
Fascial planes
Two main fascial divisions exist, the superficial cervical fascia and the deep cervical fascia.
Superficial cervical fascia: The superficial fascia, which lies just deep to the dermis, surrounds the muscles of facial expression. It includes the superficial musculoaponeurotic system (SMAS) and extends from the epicranium to the axillae and chest. The space deep to this layer contains fat, neurovascular bundles, and lymphatics. It does not constitute part of the deep neck space system.
Deep cervical fascia: The deep cervical fascia encloses the deep neck spaces and is further divided into 3 layers, the superficial, middle, and deep layers of the deep cervical fascia.
The superficial layer of the deep cervical fascia is an investing fascia that surrounds the neck. It encompasses the sternocleidomastoid muscle, trapezius, muscles of mastication, and submandibular and parotid glands. It is limited superiorly by the nuchal ridge, mandible, zygoma, mastoid, and hyoid bones. Inferiorly, it is bounded by the clavicles, sternum, scapula, hyoid, and acromion. It contributes to the fascia covering the digastric muscle and to the lateral aspect of the carotid sheath. In its course from the hyoid bone to the medial table of the ramus of the mandible, it envelops the anterior belly of the digastric muscle and forms the floor of the submandibular space. Laterally, this fascia helps to define the parotid and masticator spaces.
The middle layer of the deep cervical fascia has 2 divisions, muscular and visceral. The muscular division surrounds the strap muscles (ie, sternohyoid, sternothyroid, thyrohyoid, omohyoid) and the adventitia of the great vessels. The visceral division surrounds the constrictor muscles of the pharynx and esophagus to create the buccopharyngeal fascia and the anterior wall of the retropharyngeal space. Both the muscular and visceral divisions contribute to the formation of the carotid sheath. The middle layer also envelops the larynx, trachea, and thyroid gland. It attaches to the base of the skull superiorly and extends inferiorly as low as the pericardium via the carotid sheath.
The deep layer of the deep cervical fascia is also subdivided into 2 divisions, prevertebral and alar. The prevertebral division adheres to the anterior aspect of the vertebral body and extends laterally to the transverse processes of the vertebrae. The alar division lies between the prevertebral division and the visceral division of the middle layer and defines the posterior border of the retropharyngeal space. It surrounds the deep neck muscles and contributes to the carotid sheath. Posteriorly, the muscular division of the middle layer of the deep cervical fascia fuses with the alar division of the deep layer of the deep cervical fascia at the level of thoracic vertebrae 1-2 (T1-T2).
Deep neck spaces
Within the deep neck are 11 spaces created by planes of greater and lesser resistance between the fascial layers. These spaces may be real or potential and may expand when pus separates layers of fascia. The deep neck spaces communicate with each other, forming avenues by which infections may spread. These spaces are described briefly.
Parapharyngeal space
The parapharyngeal space (ie, lateral pharyngeal space, pharyngomaxillary space, pterygomaxillary space, pterygopharyngeal space) occupies an inverted pyramidal area bounded by multiple components of the fascial system. The inferior limitation of this space is the lesser cornua of the hyoid bone; the entire space is situated superiorly with respect to the hyoid. The superior margin of the space is the skull base. Its medial boundary is the visceral division of the middle layer of deep cervical fascia around the pharyngeal constrictor and the fascia of the tensor and levator muscles of the velum palatini and the styloglossus. Laterally, the space is defined by the superficial layer of the deep cervical fascia that overlies the mandible, medial pterygoids, and parotid.
The posterior border is formed by the prevertebral division of the deep layer and by the posterior aspect of the carotid sheath at the posterolateral corner. The anterior boundary is the interpterygoid fascia and the pterygomandibular raphe. The parapharyngeal space can be subdivided into compartments by a line extending from the medial aspect of the medial pterygoid plate to the styloid process.
The internal maxillary artery, inferior alveolar nerve, lingual nerve, and auriculotemporal nerve comprise the anterior (ie, prestyloid) compartment. Infections in this compartment often give significant trismus.
The posterior (ie, poststyloid) compartment contains the carotid sheath (ie, carotid artery, internal jugular vein, vagus nerve) and the glossopharyngeal and hypoglossal nerves, sympathetic chain, and lymphatics. It also contains the accessory nerve, which is somewhat protected from pathologic processes in this region by its position behind the sternocleidomastoid muscle.
The parapharyngeal space connects posteromedially with the retropharyngeal space and inferiorly with the submandibular space. Laterally, it connects with the masticator space. The carotid sheath courses through this space into the chest. This space provides a central connection for all other deep neck spaces. It is directly involved by lateral extension of peritonsillar abscesses and was the most commonly affected space before the advent of modern antibiotics.
Infections can arise from the tonsils, pharynx, dentition, salivary glands, nasal infections, or Bezold abscess (ie, mastoid abscess).
Medial displacement of the lateral pharyngeal wall and tonsil is a hallmark of a parapharyngeal space infection. Trismus, drooling, dysphagia, and odynophagia are also commonly observed.
Retropharyngeal space
The retropharyngeal space is sometimes considered a third medial compartment within the parapharyngeal space because the 2 communicate laterally. This space lies between the visceral division of the middle layer of the deep cervical fascia around the pharyngeal constrictors and the alar division of the deep layer of deep cervical fascia posteriorly. It extends from the skull base to the tracheal bifurcation around T2 where the visceral and alar divisions fuse. It primarily contains retropharyngeal lymphatics.
Infection may enter this space directly, as with traumatic perforations of the posterior pharyngeal wall or esophagus, or indirectly, from the parapharyngeal space. More than 60% of retropharyngeal abscesses in children are caused by upper respiratory tract infections, whereas most infections in adults in this region are caused by trauma and foreign bodies. Other common sources of infection in the retropharyngeal space are the nose, adenoids, nasopharynx, and sinuses.
Infections of this space may drain into the prevertebral space and follow that space into the chest. Mediastinitis and empyema ensue. Abscess in this space may push forward, occluding the airway at the level of the pharynx. It may appear as anterior displacement of one or both sides of the posterior pharyngeal wall because of involvement of lymph nodes, which are distributed lateral to the midline fascial raphe.
Retropharyngeal lymph nodes tend to regress by about age 5 years, making infection in this space much more common in children than adults.
Prevertebral space
The prevertebral space is located anterior to the vertebral bodies and posterior to the prevertebral division of the deep layer of the deep cervical fascia. It lies just posterior to the danger space (see below). Laterally, it is bounded by the fusion of the prevertebral fascia with the transverse processes of the vertebral bodies. It extends from the skull base to the coccyx.
The most common etiology of prevertebral abscesses (other than extension from other sites) is trauma, particularly iatrogenic instrumentation. Involvement of the vertebrae can lead to osteomyelitis and spinal instability.
Danger space
The danger space is immediately posterior to the retropharyngeal space and immediately anterior to the prevertebral space, between the alar and prevertebral divisions of the deep layer of the deep cervical fascia. It extends from the skull base to the posterior mediastinum and diaphragm. Laterally, it is limited by the fusion of the alar and prevertebral division with the transverse processes of the vertebrae. Some authors consider the danger space a component of the prevertebral space.
Infections in this region may be extensions of retropharyngeal, parapharyngeal, or prevertebral infections.
Spread within the danger space tends to occur rapidly because of the loose areolar tissue that occupies this region. This spread can lead to mediastinitis, empyema, and sepsis.
Masticator space
The masticator space is situated laterally to the medial pterygoid fascia and medially to the masseter muscle. It is bounded by the sphenoid bone, the posterior aspect of the mandible, and the zygomatic arch. It lies inferiorly to the temporal space and is anterolateral to the parapharyngeal space. It contains the masseter, pterygoids, ramus and body of the mandible, temporalis tendon, and the inferior alveolar vessels and nerve.
Infection in the masticator space may spread to the parapharyngeal, parotid, or temporal space.
Infections here may be a result of dental infections, particularly of the third mandibular molars, and have reportedly occurred from removal of suspension wires following reduction and fixation of facial fractures.
Trismus is commonly seen in the initial presentation and may be a long-term sequela.
Submandibular space
The submandibular space is bounded inferiorly by the superficial layer of the deep cervical fascia extending from the hyoid to the mandible, laterally by the body of the mandible, and superiorly by the mucosa of the floor of mouth.
It is considered to have 2 subdivisions, the sublingual and submaxillary spaces, which are divided by the mylohyoid muscle. The sublingual space contains the sublingual gland, hypoglossal nerve, and Wharton duct. It is in continuity with the submaxillary space via the posterior margin of the mylohyoid muscle, around which pus can readily tract. The submaxillary division is further subdivided by the anterior belly of the digastric into a central submental compartment and a lateral submaxillary space.
Infection in the submandibular space may be secondary to oral trauma, submaxillary or sublingual sialadenitis, or dental abscess of mandibular teeth.
The term Ludwig angina describes inflammation and cellulitis of the submandibular space, usually starting in the submaxillary space and spreading to the sublingual space via the fascial planes, not the lymphatics. As the submandibular space is expanded by cellulitis or abscess, the floor of the mouth becomes indurated, and the tongue is forced upward and backward, causing airway obstruction. Ludwig angina does not require the presence of a focal abscess. It typically includes bilateral involvement and manifests with drooling, trismus, pain, dysphagia, submandibular mass, and dyspnea or airway compromise caused by displacement of the tongue. This is a life-threatening condition that requires tracheostomy for airway control. Before antibiotics, the mortality rate of Ludwig angina was 50%. With modern antimicrobial and surgical therapies, the mortality rate is less than 5%.
Submandibular space infections may spread to the parapharyngeal space or retropharyngeal space.
Carotid space
The carotid (ie, visceral vascular) space is a potential space within the carotid sheath containing the carotid artery, internal jugular vein, vagus nerve, and sympathetic postganglionic fibers.
This space may be affected indirectly from spread of infection from the surrounding parapharyngeal space or directly by injection of drugs in those who abuse IV drugs. The resulting jugular vein thrombophlebitis sends septic emboli to the heart and lungs. The carotid artery may thrombose, form an aneurysm, or erode and rupture. Horner syndrome may occur because of involvement of the cervical sympathetics in this space.
Treatment may include anticoagulation and possibly the ligation of involved vessels.
Pretracheal space
The pretracheal (ie, anterior visceral) space is enclosed by the visceral division of the middle layer of the deep cervical fascia and lies immediately anterior to the trachea. It extends from the thyroid cartilage to the superior mediastinum.
Infections here are most commonly caused by perforation of the anterior esophageal wall by endoscopic instrumentation, foreign bodies, or trauma.
Infections cause dysphagia and odynophagia, pain, fever, and possible hoarseness and airway obstruction.
Peritonsillar space
This space is bounded by the tonsil medially and the superior constrictor laterally. The anterior and posterior tonsillar pillars form the remaining borders of this space.
Peritonsillar abscesses are the most common deep neck space abscess and represent a sequela of tonsillar infections.
Individuals with peritonsillar abscesses typically exhibit trismus, pain, odynophagia, drooling, a "hot potato" voice, and fever. They demonstrate uvular deviation, palatal asymmetry, and displacement of the tonsil medially. Note that the tonsillar erythema and exudates may be mild despite the presence of an abscess.
Patients who have had their tonsils removed effectively lose this space, but they can still develop peritonsillar pathology.
Peritonsillar abscesses are most commonly managed by incision and drainage or by needle aspiration. Most commonly, interval tonsillectomy is performed 4-12 weeks after resolution of the infection.
Peritonsillar abscesses may spread to the parapharyngeal space if not addressed promptly.
Parotid space
The parotid space is enclosed by the superficial layer of the deep cervical fascia. This is an incomplete enclosure because the superomedial aspect of the gland is not covered. This discontinuity allows communication between the parapharyngeal space and the parotid space.
The parotid space is crossed by the external carotid artery, the posterior facial vein, and the facial nerve.
Infections in the parotid space often occur in dehydrated, debilitated patients with poor oral hygiene who develop salivary duct obstruction.
Pain, edema, and erythema in the region of the parotid are typically observed with fever. Trismus is a later finding.
Temporal space
The temporal space lies between the temporalis fascia and the periosteum of the temporal bone, and it contains the internal maxillary artery and the inferior alveolar artery and nerve. The temporalis muscle effectively divides the space into a deep and superficial compartment.
Abscesses in this region are characterized by pain and trismus and may exhibit deviation of the mandible.
Incision and drainage may be accomplished by an approach 3 cm lateral to the lateral canthus or by a horizontal brow incision.
No absolute contraindications to surgical drainage of deep neck space infections exist. However, for patients experiencing airway compromise from the infection, the need to establish a safe airway takes priority and should be addressed before initiating any other surgical procedures. Once the airway has been secured, the surgical drainage procedure can be performed.
A high index of suspicion is important when diagnosing a deep neck space infection. A careful history and physical examination (see Clinical) are critical to the workup. In addition, tests, including the following, may be useful in the workup of a patient in whom a deep neck space infection is suspected:
Blood chemistries
Complete blood cell count
Clotting profile (particularly important in patients who require surgical drainage)
Blood cultures (may be indicated in septic patients)
Abscess cultures with Gram stains (critical to direct antimicrobial therapy)
Lateral neck radiography
These tests may reveal soft tissue swelling in the prevertebral region. Lateral neck radiographs can also demonstrate radiopaque foreign bodies, subcutaneous air, air fluid levels, and erosion of the vertebral bodies.
Prevertebral soft tissue thickening greater than 7 mm over C2 or greater than 14 mm in children and 22 mm in adults over C6 is highly suggestive of a retropharyngeal process.
Mandible series
When a dental source of the infection is suggested, a Panorex can help evaluate the patient for a dental abscess.
Particular attention should be given to the second and third mandibular molars because the apices of these teeth extend below the mylohyoid line, giving them access to the submandibular space.
Chest radiography: To evaluate the mediastinum, check for subcutaneous air or pneumomediastinum, displacement of the air stripe, or concurrent pneumonia suggesting aspiration.
CT scans with contrast are the gold standard in evaluation of deep neck infections. The importance of CT scanning is highlighted in a study by Crespo et al, who found that clinical examination alone underestimated the extent of deep neck space infections in 70% of patients. CT scans indicate the location, boundaries, and relation of infection to surrounding neurovascular structures. Abscesses are seen as low-density lesions with rim enhancement, occasional air fluid levels, and loculations (see the images below). A study by Kirse and Roberson also notes the association between irregularity of the abscess wall on CT as predictive of pus within the cavity.[17] CT scans are fast, relatively inexpensive, and fairly widely available today. CT scanning of the chest may be helpful if extension into the mediastinum is suspected.
Right lateral pharyngeal (parapharyngeal) abscess as seen on CT scan. Note the medial extension in the retropharyngeal area.
Same patient as in the previous image. Lower cut CT scan showing the abscess cavity. The rim enhancement and partial loculation are well demonstrated.
A prospective, blinded study of the effectiveness of CT scanning in diagnosing deep neck infections in adults over the age of 18 showed that CT scan with contrast is 95% sensitive and 53% specific for distinguishing a drainable fluid collection. When CT findings were combined with clinical exam findings, the sensitivity remained about 95%, but the specificity increased to about 80%. The data regarding the utility of CT scans in diagnosing deep neck infections in children are not as clear as in adults.
MRI: Because of the increased time and expense involved in obtaining an MRI result, MRI is not the initial modality of choice. However, when obtained, MRI scans can give excellent soft tissue resolution to help localize the region of involvement.
Ultrasound: Ultrasounds do not reveal anatomic details but can help distinguish between phlegmon and abscess, give information about the condition of surrounding vessels, and guide fine-needle aspiration (FNA) attempts.
Arteriography: This may be helpful when carotid, jugular, or innominate involvement is suggested.
The airway is the first priority of treatment.[18] Addressing the airway may involve observation, endotracheal or nasotracheal intubation, tracheostomy, or cricothyroidotomy for emergent situations.[19]
Even in experienced hands, attempted oral or nasal endotracheal intubation in a patient with a deep neck space infection or abscess may be extremely difficult. The larynx and vocal cords may be difficult to visualize because of swollen pharyngeal walls and laryngeal displacement. Instrumentation can cause additional swelling. The potential exists for abscess rupture with intubation leading to aspiration, acute airway obstruction, or death. Other factors (eg, tracheal deviation, external airway compression, trismus, cervical spine rigidity) can produce difficulty with intubation.
Patients presenting with impending respiratory distress should undergo a tracheostomy while under local anesthesia to secure a safe airway. A tracheostomy is safer, more conservative, and preferable to the development of respiratory compromise. Tracheostomy should be performed before any attempts at surgical drainage in these patients.
Obtain cultures whenever possible to help direct antimicrobial therapy.
This may involve cultures of the neck, abscess fluid, and blood.
Volume and metabolic resuscitation
Initiate these procedures in all patients with deep neck infection.
Identify and address metabolic derangements during resuscitation.
Address attention to other concurrent medical problems (eg, diabetes) early in the course of treatment.
Intravenous antibiotics
Choose parenteral antibiotics to cover the most likely organisms.
Initiate empiric regimens before culture results are obtained based on the local resistance patterns and most common etiologies.
Cover gram-positive and gram-negative organisms and aerobic and anaerobic bacteria, including beta-lactamase producing organisms.[20]
Modify antibiotics according to culture and sensitivity results.
A review of deep neck infections by Broughton indicated that 50% of deep neck infections can be managed nonsurgically in patients with small fluid collections and no respiratory compromise. Other studies by Plaza and McClay support the option of primary nonsurgical management for selected deep neck space abscesses, reserving surgical drainage for patients who do not improve within 48 hours of initiation of broad-spectrum intravenous antibiotics.[21, 22] Most of these studies focus on retropharyngeal and parapharyngeal space abscesses.
A review of current practices by Lalakea and Messner indicated that 60% of pediatric otolaryngologists recommend a trial of IV antibiotics before incision and drainage in selected pediatric patients with retropharyngeal abscesses.[23] According to this review, clindamycin, ampicillin/sulbactam, and cefuroxime are currently the most commonly used antibiotics.
IV antibiotics are administered until the patient is clinically improving and has been afebrile for at least 48 hours. After completion of an IV course of antibiotics, oral antibiotics are given.
Incision and drainage
Incision and drainage is the cornerstone of therapy for the treatment of deep neck space abscesses. Establish a secure airway before initiating any surgical procedure.
Perform incision and drainage for any frank abscess in patients with impending complications because of abscess formation and in patients with no improvement after 48-72 hours of IV antibiotics.
Most deep neck spaces require a transcervical approach to facilitate adequate exposure of the abscess and for protection of the surrounding neurovascular structures.[24] A study by Cable et al describes the successful use of image-guided surgical drainage of medial parapharyngeal space abscesses in the pediatric population to help localize infections in areas that are otherwise difficult to reach.[25] A study by Dabirmoghaddam et al indicated that ultrasonographically guided drainage of deep neck space abscesses leads to shorter hospital stays than does incision and drainage, with the mean hospital stay for the ultrasonography patients in the study being 5.47 days, compared with 9.70 days for those who were treated with incision and drainage.[26]
Approach retropharyngeal abscesses by a transoral route when the abscess is small and focal. This approach requires attention to the airway to prevent aspiration of pus once the abscess cavity is entered.
Quinsy tonsillectomy or tonsillectomy performed with infection in the peritonsillar space is controversial treatment for peritonsillar abscesses. Historically, tonsillectomy during acute infection was avoided because of concern about increased risk of postoperative hemorrhage. Several recent studies, such as those by Ungkanont et al and Dodds and Maniglia, suggest no increased morbidity from this procedure.[11, 27]
Many approaches are possible to the deep neck spaces. Description of the surgical incisions and technique of drainage is beyond the scope of this article. Every approach used must ensure adequate exposure and access to allow drainage without compromising surrounding structures. Abscess cavities should be copiously irrigated, débrided, and left open with a drain or packing to prevent reaccumulation. Once an abscess has been entered, cultures should be obtained to help direct antimicrobial therapy.
Needle aspiration
FNA may be used in patients with small easily reachable abscesses or in patients who are too unstable to undergo general anesthesia. This procedure may require the assistance of CT scanning or ultrasound guidance. It may provide preliminary culture specimens before formal incision and drainage.
Preoperative Details
The most important preoperative considerations are stabilization of the airway, volume and metabolic resuscitation, and initiation of antibiotics.
Intraoperative Details
Many possible surgical approaches to the deep neck spaces can be used. The approach used depends on the precise location of the abscess, the size of the collection, and its relation to the great vessels and other important anatomic structures of the neck.
Postoperative Details
Postoperatively, closely observe the patient for signs of a response to therapy. Reaccumulation of fluid must be recognized and treated with appropriate drainage procedures. Cultures and sensitivities must be monitored, and antibiotics must be tailored appropriately. The patient's airway must also be monitored closely for signs of obstruction. Finally, the patient must be monitored for signs of impending complications (see Complications).
Follow-up care for patients who have had a deep neck space infection consists of monitoring the complete resolution of the infection. Surgical sites must be monitored for complete healing and to ensure that reaccumulation of an abscess does not occur. Any question of redevelopment of an infection warrants re-imaging and possible reexploration.
Deep neck infections have many severe life-threatening potential complications. Deep neck infections that are not treated or are inadequately treated, those that extend to other deep neck spaces, and those that are complicated by a delay in diagnosis and treatment are at particular risk of complications, including the following:
Airway obstruction from compression of the trachea
This is particularly due to perforation of a retropharyngeal abscess with drainage of pus into the airway.
Aspiration may occur spontaneously or during endotracheal intubation.
Vascular complications (ie, thrombosis of the internal jugular vein, carotid artery erosion and rupture)
Mediastinitis from inferior spread along fascial lines
Neurologic deficits: Cranial nerve dysfunction or dysfunction of the autonomic nerves in the neck can lead to problems such as hoarseness from involvement of the vagus in the carotid sheath or Horner syndrome from involvement of the sympathetic chain.
Septic emboli: These emboli can lead to pulmonary, brain, or joint seeding and resultant abscesses.
Septic shock
Necrotizing cervical fasciitis: This is a fulminant infection involving necrosis of the connective tissue that spreads via fascial planes. It has particularly high morbidity and mortality rates.
Osteomyelitis due to local spread to bones of the spine, mandible, or skull base
Grisel syndrome (ie, inflammatory torticollis causing cervical vertebral subluxation)
Several studies have looked at factors that may cause an increase in the risk of complications from deep neck space infections.[28] One study by Wang et al found a higher risk of complications in females, patients with neck swelling, and patients with associated respiratory symptoms. Another study by Huang et al suggests that diabetes and the presence of other underlying systemic diseases significantly increases the risk of complications.[29] This finding was supported in a study by Chen et al, who found that not only did diabetes correlate with a higher complication rate but that it was also associated with a more severe clinical course involving more than one deep neck space and a longer hospitalization.[30]
Using multivariate statistical analysis of 282 cases of deep neck infection, Staffieri et al concluded that in patients with such infections, the involvement of more than 1 neck space was the only significant independent prognostic factor for related complications. According to the study, the following factors were associated with long hospital stays[31] :
Presence of comorbidities
Nonodontogenic sites of origin
Leukocyte counts above 11.0 cells × 109/L at presentation
Need for both medical and surgical treatments
Outcome and Prognosis
Patients treated for deep neck infections can be expected to fully recover as long as the infection is treated properly and in a timely manner. Patients whose treatment is delayed can expect a greater number of complications and a prolonged course of recovery. Once a deep neck infection has fully resolved, no particular predisposition exists for recurrence.
Future and Controversies
The greatest controversy regarding deep neck infections concerns whether all deep neck abscesses require surgical treatment or whether some abscesses can be treated medically. As previously discussed, articles by Broughton and Lalakea and Messner suggest that in selected cases involving patients with no signs of respiratory distress or other impending complications, some small deep neck abscesses can be treated with a trial of IV antibiotics alone, particularly in children.[23, 32] Surgical therapy can be reserved for patients whose symptoms do not respond within 48 hours. However, this issue is still being debated in the literature, and clinical judgment must be used with each individual patient.
Why is the diagnosis and treatment of deep neck infections challenging?
Which medical advancements have led to reduced mortality and morbidity of deep neck infections?
Which factors contribute to the complexity of deep neck infections?
What is the prevalence of deep neck infections?
What causes deep neck infections?
What is the pathophysiology of deep neck infections?
What are the pathophysiologic causes of the signs and symptoms of deep neck infections?
What are the most prevalent pathogens in deep neck infections?
What is the focus of clinical history in suspected deep neck infections?
Which physical findings are characteristic of deep neck infections?
What is the anatomy of the major facial and deep neck spaces relative to deep neck infections?
What is the anatomy of the fascial planes relevant to deep neck infections?
What is the anatomy of the parapharyngeal space relevant to deep neck infections?
What is the anatomy of the retropharyngeal space relevant to deep neck infections?
What is the anatomy of the prevertebral space relevant to deep neck infections?
What is the anatomy of the danger space relevant to deep neck infections?
What is the anatomy of the masticator space relevant to deep neck infections?
What is the anatomy of the submandibular space relevant to deep neck infections?
What is the anatomy of the carotid space relevant to deep neck infections?
What is the anatomy of the pretracheal space relevant to deep neck infections?
What is the anatomy of the peritonsillar space relevant to deep neck infections?
What is the anatomy of the parotid space relevant to deep neck infections?
What is the anatomy of the temporal space relevant to deep neck infections?
What are the contraindications to surgical drainage of deep neck infections?
Which lab tests are performed in the workup of deep neck infections?
What is the role of radiography in the workup of deep neck infections?
What is the role of CT scanning in the workup of deep neck infections?
What is the role of MRI in the workup of deep neck infections?
What is the role of ultrasonography in the workup of deep neck infections?
What is the role of arteriography in the workup of deep neck infections?
What is included in airway management of patients with deep neck infections?
What is the role of cultures in the management of deep neck infections?
What is the role of volume and metabolic resuscitation in the treatment of deep neck infections?
What is the role of antibiotics in the treatment of deep neck infections?
What is the role of incision and drainage in the treatment of deep neck infections?
What is the role of fine needle aspiration (FNA) in the treatment of deep neck infections?
What is included in preoperative care of patients with deep neck infections?
How is the surgical approach selected for the treatment of deep neck infections?
What is included in the postoperative care of patients with deep neck infections?
What is included in the long-term monitoring of deep neck infections?
What are the possible complications of deep neck infections?
Which factors increase the risk of complications from deep neck infections?
What is the prognosis of deep neck infections?
Which deep neck infections may be treated medically?
Alan D Murray, MD Pediatric Otolaryngologist, ENT for Children; Full-Time Staff, Medical City Dallas Children's Hospital; Consulting Staff, Department of Otolaryngology, Children's Medical Center at Dallas, Cook Children's Medical Center; Full-Time Staff, Texas Pediatric Surgery Center, Cook Children's Pediatric Surgery Center Plano
Alan D Murray, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, American Academy of Pediatrics, American College of Surgeons, Texas Medical Association
Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children's Hospital, Montreal General Hospital, and Royal Victoria Hospital
Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology, Canadian Society of Otolaryngology-Head & Neck Surgery
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-Scale;mCharts<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; .
Michelle C Marcincuk, MD Clinical Assistant Professor of Otolaryngology, University of Texas Southwestern Medical Center; Consulting Staff, Department of Surgery, Division of Otolaryngology, Texas Health Care, PLLC
Michelle C Marcincuk, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Texas Medical Association, and Triological Society
Celakovsky P, Kalfert D, Tucek L, et al. Deep neck infections: risk factors for mediastinal extension. Eur Arch Otorhinolaryngol. 2014 Jun. 271 (6):1679-83. [Medline].
Adil E, Tarshish Y, Roberson D, Jang J, Licameli G, Kenna M. The Public Health Impact of Pediatric Deep Neck Space Infections. Otolaryngol Head Neck Surg. 2015 Dec. 153 (6):1036-41. [Medline].
Conrad DE, Parikh SR. Deep Neck Infections. Infect Disord Drug Targets. 2012 Feb 17. [Medline].
Chang L, Chi H, Chiu NC, Huang FY, Lee KS. Deep neck infections in different age groups of children. J Microbiol Immunol Infect. 2010 Feb. 43(1):47-52. [Medline].
Wang LF, Tai CF, Kuo WR, Chien CY. Predisposing factors of complicated deep neck infections: 12-year experience at a single institution. J Otolaryngol Head Neck Surg. 2010 Aug. 39(4):335-41. [Medline].
Poeschl PW, Spusta L, Russmueller G, Seemann R, Hirschl A, Poeschl E, et al. Antibiotic susceptibility and resistance of the odontogenic microbiological spectrum and its clinical impact on severe deep space head and neck infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Aug. 110(2):151-6. [Medline].
Adovica A, Veidere L, Ronis M, Sumeraga G. Deep neck infections: review of 263 cases. Otolaryngol Pol. 2017 Oct 30. 71 (5):37-42. [Medline]. [Full Text].
Favaretto N, Fasanaro E, Staffieri A, et al. Deep neck infections originating from the major salivary glands. Am J Otolaryngol. 2015 Jul-Aug. 36 (4):559-64. [Medline].
Daramola OO, Flanagan CE, Maisel RH, Odland RM. Diagnosis and treatment of deep neck space abscesses. Otolaryngol Head Neck Surg. 2009 Jul. 141(1):123-30. [Medline].
Alotaibi N, Cloutier L, Khaldoun E, Bois E, Chirat M, Salvan D. Criteria for admission of odontogenic infections at high risk of deep neck space infection. Eur Ann Otorhinolaryngol Head Neck Dis. 2015 Nov. 132 (5):261-4. [Medline].
Ungkanont K, Yellon RF, Weissman JL, et al. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg. 1995 Mar. 112(3):375-82. [Medline].
Celakovsky P, Kalfert D, Smatanova K, et al. Bacteriology of deep neck infections: analysis of 634 patients. Aust Dent J. 2015 Jun. 60 (2):212-5. [Medline]. [Full Text].
Cordesmeyer R, Kauffmann P, Markus T, et al. Bacterial and histopathological findings in deep head and neck infections: a retrospective analysis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017 Feb 20. [Medline].
Shimizu Y, Hidaka H, Ozawa D, et al. Clinical and bacteriological differences of deep neck infection in pediatric and adult patients: Review of 123 cases. Int J Pediatr Otorhinolaryngol. 2017 Aug. 99:95-9. [Medline].
Asmar BI. Bacteriology of retropharyngeal abscess in children. Pediatr Infect Dis J. 1990 Aug. 9(8):595-7. [Medline].
May JG, Shah P, Sachdeva L, et al. Potential role of biofilms in deep cervical abscess. Int J Pediatr Otorhinolaryngol. 2014 Jan. 78(1):10-3. [Medline].
Kirse DJ, Roberson DW. Surgical management of retropharyngeal space infections in children. Laryngoscope. 2001 Aug. 111(8):1413-22. [Medline].
Marioni G, Staffieri A, Parisi S, Marchese-Ragona R, Zuccon A, Staffieri C, et al. Rational diagnostic and therapeutic management of deep neck infections: analysis of 233 consecutive cases. Ann Otol Rhinol Laryngol. 2010 Mar. 119(3):181-7. [Medline].
Tapiovaara L, Back L, Aro K. Comparison of intubation and tracheotomy in patients with deep neck infection. Eur Arch Otorhinolaryngol. 2017 Oct. 274 (10):3767-72. [Medline].
Raffaldi I, Le Serre D, Garazzino S, et al. Diagnosis and management of deep neck infections in children: the experience of an Italian paediatric centre. J Infect Chemother. 2015 Feb. 21 (2):110-3. [Medline].
Plaza Mayor G, Martínez-San Millán J, Martínez-Vidal A. Is conservative treatment of deep neck space infections appropriate?. Head Neck. 2001 Feb. 23(2):126-33. [Medline].
McClay JE, Murray AD, Booth T. Intravenous antibiotic therapy for deep neck abscesses defined by computed tomography. Arch Otolaryngol Head Neck Surg. 2003 Nov. 129(11):1207-12. [Medline].
Lalakea Ml, Messner AH. Retropharyngeal abscess management in children: current practices. Otolaryngol Head Neck Surg. 1999 Oct. 121(4):398-405. [Medline].
Hah YM, Jung AR, Lee YC, Eun YG. Risk factors for transcervical incision and drainage of pediatric deep neck infections. J Pediatr Surg. 2018 Apr. 53 (4):666-70. [Medline].
Cable BB, Brenner P, Bauman NM, Mair EA. Image-guided surgical drainage of medial parapharyngeal abscesses in children: a novel adjuvant to a difficult approach. Ann Otol Rhinol Laryngol. 2004 Feb. 113(2):115-20. [Medline].
Dabirmoghaddam P, Mohseni A, Navvabi Z, Sharifi A, Bastaninezhad S, Safaei A. Is ultrasonography-guided drainage a safe and effective alternative to incision and drainage for deep neck space abscesses?. J Laryngol Otol. 2017 Mar. 131 (3):259-63. [Medline].
Dodds B, Maniglia AJ. Peritonsillar and neck abscesses in the pediatric age group. Laryngoscope. 1988 Sep. 98(9):956-9. [Medline].
Kauffmann P, Cordesmeyer R, Troltzsch M, Sommer C, Laskawi R. Deep neck infections: A single-center analysis of 63 cases. Med Oral Patol Oral Cir Bucal. 2017 Sep 1. 22 (5):e536-41. [Medline]. [Full Text].
Huang TT, Liu TC, Chen PR. Deep neck infection: analysis of 185 cases. Head Neck. 2004 Oct. 26(10):854-60. [Medline].
Chen MK, Wen YS, Chang CC. Deep neck infections in diabetic patients. Am J Otolaryngol. 2000 May-Jun. 21(3):169-73. [Medline].
Staffieri C, Fasanaro E, Favaretto N, et al. Multivariate approach to investigating prognostic factors in deep neck infections. Eur Arch Otorhinolaryngol. 2014 Feb 13. [Medline].
Broughton RA. Nonsurgical management of deep neck infections in children. Pediatr Infect Dis J. 1992 Jan. 11(1):14-8. [Medline].
Chi TH, Tsao YH, Yuan CH. Influences of patient age on deep neck infection: clinical etiology and treatment outcome. Otolaryngol Head Neck Surg. 2014 Oct. 151 (4):586-90. [Medline].
Hidaka H, Yamaguchi T, Hasegawa J, et al. Clinical and bacteriological influence of diabetes mellitus on deep neck infection: Systematic review and meta-analysis. Head Neck. 2015 Oct. 37 (10):1536-46. [Medline].


Sea Salted Fluffernutter Filled Oatmeal Cookies | Tasty Kitchen: A Happy Recipe Community!
Sea salted oatmeal cookies filled with ooey gooey peanut butter and Marshmallow Fluff.
Put the butter into a skillet. Over medium/low heat melt your butter until it starts to brown slightly and starts to smell nutty. Be careful not to burn. Remove from heat and set aside to cool slightly.
In the bowl of your electric mixer cream your eggs and sugars. Add in vanilla and mix to combine. Slowly pour in your browned butter as you mix.
Once combined, mix in your flour, oats, salt, baking powder, cinnamon, nutmeg and ginger.
Refrigerate dough for 1 hour. Preheat oven to 350 F towards the end of this time.
Roll dough into 24 small balls no larger than a tablespoon. Press your thumb in the center of each ball.
Fill half of the dough balls with a little bit of peanut butter and Marshmallow Fluff.
Press a second flattened cookie dough ball onto the tops of the filled cookies. Press sides together and form one ball. Place dough onto a parchment paper lined baking sheet, leaving about an inch between each.
Sprinkle sea salt on the tops of each cookie.
So so delicious, the sea salt just really completes these. And what a versatile cookie, I can imagine so many combinations of fillings! Thanks for the recipe.


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David Oyelowo Takes Kate Mara Hostage in the First Trailer & Poster for 'Captive'
By Jake Berlin on June 21, 2015 • ( Leave a comment )
Faith, redemption, and survival. Based on true events, Captive tells the story of a single mother and recovering drug addict who is taken hostage by a murdering prison escapee. She then turns to her personal journey of faith and redemption to survive, while trying to save her capture at the same time. Starring David Oyelowo and Kate Mara, see the first trailer and poster below.
First off, here's the official synopsis:
The true story of Ashley Smith (Mara), a single mother and recovering drug addict who was taken hostage in her own apartment by fugitive, murderer and accused rapist Brian Nichols (Oyelowo). With her back against the wall, Smith turned to the personal spiritual journey of Rick Warren's best-selling book The Purpose Driven Life in an attempt to survive and help Brian find a better way out.
With names like Oyelowo and Mara leading, this is the kind of trailer you'd expect to see. I didn't LOVE it, but I like what I see for sure. It looks like it can end up being a good, tense, and thrilling film; plus it is always intriguing to see a good redemption story.
Captive hits theaters September 18th, 2015. Directed by Jerry Jameson starring David Oyelowo, Kate Mara, Leonor Varela, Jessica Oyelowo, Mimi Rogers, and Michael K. Williams.
Categories: Trailers
Tagged as: Captive, David Oyelowo, Kate Mara, Paramount Pictures
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This cross is stunning! Composed of black onyx and inset with pearls and 14 karat yellow gold the cross measures approximately 3-1/2 inches in length without the bale. With the bail it measures approximately 4-1/4 inches in length. As stupendous as the cross is, there are a few little chips…I have tried as best I could to get them photographed, but because it was black onyx I'm not sure they are showing up real well. On the front of the clasp at the top of the cross, hidden by the bale there is a small chip…the left side, bottom part of the cross there is a very minuscule chip that is super hard to see from the front. The back side of the cross has a small-medium size chip at the top on the left side. There are a few wear nicks on the back as well. The pearls set in 14 karat yellow gold on the front of the cross are all in very good condition. Circa: 1870's Please note postage includes insurance.


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Was the G20 London Summit a Success?
Augusto Lopez-Claros1
Whether to view the G20 London Summit as a success or as a disappointment is very much a function of one's reference point.2 Viewed against the needs of the moment—a global economic crisis without parallel since the Great Depression—it could be argued that the Summit did not go far enough. The fact is that in the past 30 years the global economy has become both more complex and more interconnected, but the mechanisms and institutions that we have to deal with crises have not kept pace with the tempo of change and what has emerged is a "governance gap". An inability to cope with complex global problems either because the institutions we have are woefully unprepared or, in some cases, because we do not even have an institution with the relevant jurisdiction to address the problem in question (e.g. climate change). Against these challenges the Summit's achievements—a combination of well-meaning declarations and a few hard decisions—were at best a mixed bag.
On the positive side, it is no doubt an achievement of sorts to have brought into the decision making some of the larger emerging markets. The G7, accounting for 11 percent of the world's population, was clearly not a broad enough forum. The G7 was originally created to discuss "major economic and political issues facing their domestic societies and the international community as a whole." In time, it became a good forum for open debate about global problems, but not a particularly effective problem-solving vehicle. In the public imagination, its semi-annual meetings were largely perceived rather as excellent photo opportunities, not as brain-storming sessions focused on particular problems requiring urgent solutions as was, for instance, the 1944 Bretton Woods conference which lasted 22 days, involved over 700 delegates from more than 40 countries, and resulted in the creation of a new world financial system, G7 meetings are actually intended—as noted by a former G7 prime minister—to preserve the status quo. The creation of the G20 in 1999 was seen as recognition of the new economic and political realities, but neither the Swiss nor the Dutch nor the Spanish were particularly happy at being excluded. Switzerland manages a third of the world's private wealth and the Netherlands is the most generous donor and, by far, the country with the most development-friendly policies. Spain, a country whose economy is more than 5 times the size of Argentina's (a member of the G20!), took great exception to being excluded from the November 2008 G20 Summit—only strenuous lobbying delivered a last-minute invitation.
Of course, both the G7 and the G20 remain, in fact, official bodies. Their deliberations bring to the table heads of state and a small coterie of civil servants. There is no representation from the business community, nor do civil society representatives participate. Given the global nature of the problems we face and the increasingly shared perception that solutions to these will require broad-based collaboration across various stakeholder groups, for many, these groups still suffer from a deficit of legitimacy. They are not a fair representation of humanity and, as such, cannot be expected to make any important decisions on its behalf. There are no low income countries among the G20—their voices simply do not count. Despite these flaws, some progress was made in London and I would like to focus on those that pertain to the International Monetary Fund.
During much of the past decade the IMF has found itself in the middle of virtually all major emerging market crises and questions about its effectiveness have been raised; indeed some have argued that the organization is no longer needed in a world of largely floating exchange rates. It is clear, however, that with fully globalized financial markets and in which policy missteps in one country have costly spillover effects on others (as we have seen over the past year), an institution that will have sufficient resources to deal with episodes of financial instability and that will help cushion or prevent the effects of future crises is indispensable.
Like a central bank the IMF can create international liquidity through its lending operations and the occasional allocations to its members of SDRs, its composite currency. The IMF already is, thus, in a limited sense, a small international bank of issue. As seen during much of the past decade and a half, the Fund can also play the role of "lender of last resort" for an economy experiencing debt-servicing difficulties. But the amount of support it can provide has traditionally been limited by the size of the country's membership quota and there is an upper limit on total available resources; as of early-2009 this amounted to about $250 billion, a puny amount when compared with the sorts of sums that are necessary to intervene in industrial countries in distress or even some of the larger emerging markets.
There are a number of ways to deal with these funding shortfalls. One proposal some years back was to create a Financial Stability Fund, to supplement IMF resources. This would be a facility that could be financed by an annual fee on the stock of cross-border investment; a 0.1% tax could generate some $25-30 billion per year, which could then be used over time to create a $300 billion facility. An alternative and more promising proposal would give the Fund the authority to create SDRs as needed, as a national central bank can in theory, to meet calls on it by would-be borrowers. When this idea was first put forward, in the early 1980s, concerns were raised about the possibly inflationary implications of such liquidity injections, but international inflation was a serious problem then in ways that, in the midst of a global recession, it is clearly not one today and measures could be introduced to safeguard against this.
The London Summit went some ways toward strengthening the capacity of the IMF to play a supportive role to emerging markets currently suffering the effects of the international financial crisis. This was achieved mainly by significantly expanding the resources available to the organization under special borrowing arrangements negotiated with a few central banks and by allowing a $250 billion SDR issue. The Summit seems to have been less successful in moving more quickly to update the voting power of its member countries, to better reflect the changes which have taken place in the structure of the global economy during the past quarter century. Slowly and grudgingly, kicking and screaming, EU members finally appear to be coming around to recognize the absurdity of a system where the voting power of the EU currently stands at 32.4 percent, whereas the combined voting power of the United States, China, India, Brazil and Russia, accounting for about half of the world's population is 26.9 percent, though, collectively, these countries account for a much larger share of global GDP. This distribution of power leads to such anomalies as Belgium having a larger quota than India and China having a quota only marginally higher than Italy's and well below that of France, facts which have undermined the institution's credibility. Not surprisingly, Asian countries do not see they have a stake in empowering the IMF, regarding it increasingly as embodying power relationships which no longer reflect contemporary economic and political realities. An IMF without credibility, of course, is of no use to the international community, particularly at a time of global crises. That these so-called "voice reforms" have to wait until 2011 is a good indicator of the enormous inertia which has to be overcome to modernize our sclerotic global institutions, at a time when it is of the utmost urgency to strengthen mechanisms of international cooperation.
Also welcome was the decision to finally break with the convention adhered to ever since the IMF's creation, which establishes that it's managing director (MD) must be an EU citizen.3 Like the veto power in the UN Security Council this practice is an aberration and should have been done away with long ago. It is, in fact, surprising that this practice has persisted for so long given that whereas IMF lending operations have no budgetary implications for members such as the US and the EU (indeed they earn a return on their SDR reserve assets), the salaries of the Fund's MD and of its entire staff as well as all other administrative expenditures are entirely financed by the interest paid by borrowing countries. In other words: the IMF functions thanks to taxpayers in middle and low-income countries, not the rich countries who have run it since it was first founded.
Despite the important symbolism of the G20's decision, efforts will have to be made not to allow the new system to turn into something actually worse. The main risk is that we could now move to the system in place at the UN, where the Secretary General is chosen, on a rotating basis, from different regions of the world. The problem with that system is that it tends to breed mediocrity, with the top job going to someone who is acceptable to all constituencies—a process which then leads to the lowest common denominator.
It remains an open question whether, in retrospect, the London Summit will be seen as a good starting point for a more multilateral approach to global problem solving. In my view the main risk we face at present does not stem from the financial crisis itself. Rather, the risk is that within a year the global economy will have entered a phase of recovery and governments will start feeling complacent again and, as I noted some months ago in a letter to the Financial Times, we will miss a once-in-a-life-time opportunity to address the serious vulnerabilities in the world's financial system which the current crisis has revealed. The next crisis—most likely hitting us from some totally unforeseen corner—would find us with much higher levels of public debt and, therefore, far more constrained in our ability to respond to the emergencies at hand. Crises can be opportunities for urgent reforms, but they can also be wasted through lack of political will and imagination.
1. Augusto Lopez-Claros was IMF resident representative in Russia and chief economist of the World Economic Forum. In 2007 he was co-editor of The International Monetary System, the IMF, and the G-20: A Great Transformation in the Making? published by Palgrave Mcmillan.
2. For the record, the G20, in fact, is the G22 as it also includes Spain and the Netherlands, two countries originally excluded from membership.
3. A similar recommendation applies to the World Bank, whose president has traditionally been an U.S. citizen.
Posted by Augusto Lopez-Claros at 7:41 PM


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Why Do Professional Organizations Have a Code of Ethics?
by Osmond Vitez
Business owners face ethical situations that test their commitment to common business values such as honesty and fairness.
1 Why Is a Code of Conduct Set Up?
2 Code of Conduct for Businesses
3 Decision Making in Business Ethics
4 What are the Sources of an Organization's Code of Ethics?
Business organizations often develop several different policies, rules and guidelines for governing their operations. While home-based or sole proprietorship businesses usually require fewer policies, larger organizations use these guidelines to manage employee behavior. A code of ethics is a common organizational policy used in business organizations. The code of ethics policy usually sets the minimum standards for business owners, managers and employees to follow when completing various business functions.
In a small business, a code of ethics is usually based on the business owner's personal morals or values. As the business grows and expands, the ethical values can be implemented into the business' organizational mission or values statement. This statement helps provide companies with a compass to guide the organization through the business environment. Companies often refer to the mission or values statement when guidance is needed regarding questionable situations.
Improve Business Relationships
A code of ethics can help companies improve business relationships. Ethical values are often designed to provide guidance when working with other companies and the general public. These values dictate how businesses handle contract negotiations, customer questions and feedback or negative business situations.
Prohibit Inappropriate Behavior
Many companies use a code of ethics to prohibit inappropriate employee behavior. Inappropriate behavior can include lying to managers or clients, engaging in fraud or embezzlement, failing to meet specific operational standards or other similar conduct. A code of ethics can help employees understand why these actions are inappropriate and the reasons companies expect better behavioral performance. Companies may also limit their legal liability from poor employee performance by using a code of ethics.
Hold Management Accountable
Owner, director or upper-level management accountability is an important function of a company's code of conduct. These individuals are usually required to exhibit honesty, transparency and integrity in their daily roles. Not only do these actions set the company's ethical tone, it also keeps individual owners and managers accountable for their actions. Allowing an unethical manager free rein in a business capacity can create difficult business situations that overextend the company's resources.
Companies often use refresher seminars to continually educate and inform employees about the importance of ethical behavior. The seminars may also provide information regarding new business policies or past violations of the company's code of ethics. This information ensures that employees have a clear understanding about the importance of ethics and why they should adhere to the company's policy. Companies can use an employee or third-party agency to conduct these refresher seminars or meetings.
US Legal: Code of Ethics Law & Legal Definition
Enterprise Ethics: Benefits
Vitez, Osmond. "Why Do Professional Organizations Have a Code of Ethics?" Small Business - Chron.com, http://smallbusiness.chron.com/professional-organizations-code-ethics-1210.html. Accessed 17 January 2020.
Vitez, Osmond. (n.d.). Why Do Professional Organizations Have a Code of Ethics? Small Business - Chron.com. Retrieved from http://smallbusiness.chron.com/professional-organizations-code-ethics-1210.html
Vitez, Osmond. "Why Do Professional Organizations Have a Code of Ethics?" accessed January 17, 2020. http://smallbusiness.chron.com/professional-organizations-code-ethics-1210.html
About Ethics in Managerial Accounting
Factors That Affect Business Leadership
About Managing Conflict
Three Levels of Ethical Standards in a Business Organization
Organizational Structure Guidelines
How a Manager Controls Unethical Behavior
Correct Poor Professional Boundaries
The Role of the Organization's Policies
What Can Companies Do to Promote a Positive Ethical & Responsible Workforce?
What Are Key Performance Indicators For?
Organizational Structure & Conflict of Interest


If you're following us on Facebook (and if you're not, you're missing out), you may remember that some time ago, in May, we went to a launch party by Grofova Design.
You can check out more pictures from the event on the Czech Center in Stockholm site. As you can see, Pavlina Grofova, the designer behind the brand is an amazingly talented glass bead maker. Using a centuries old lampwork technique, she designs modern, colorful glass jewelry.
We met Grofova Design at one of the markets in Stockholm on a rainy day and it was love at first sight for us. So we got in touch with her and after a few "dates" we managed to get a hold of some of her signature beads for our own use. We chose some red glass frosted beads to play with. (Geeky fun fact: red glass is some of the most expensive glass color you can get because the material that gives it the red color is gold.) Because they were so pretty, it felt as if they were asking to be framed rather than stringed or beaded around. We think the black Tila beads pleasantly encase and make the red glass beads stand out.
We've been told this bracelet resembles lady bugs, mushrooms in the cartoon variety, and even strawberry mochi sweets covered in sugar.