Neutrophil to Lymphocyte Ratio as a Predictor of Outcomes in Orofacial Infections in Patients Admitted to Kenyatta National Teaching and Referral Hospital in Nairobi, Kenya
Background: Untreated and progressive orofacial infections pose a great health risk due to local and distant spread, which often leads to increased morbidity and mortality. These infections can be of either odontogenic or non-odontogenic origin. Early definitive diagnosis allows for early intervention, thereby ultimately reducing the associated morbidity and mortality. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are the most commonly used markers of severity, prognosis and treatment response of severe orofacial infections in our setup. The neutrophil to lymphocyte ratio (NLR) has been demonstrated to be a useful, inexpensive diagnostic and prognostication tool in infections in other parts of the body. Its utility in orofacial infections remains largely unexplored. Aim: To determine the utility of NLR as an independent predictor of outcomes in orofacial infections. Design: This was a cross-sectional study carried out in patients admitted with orofacial infections to the oral & maxillofacial, otorhinolaryngology and ophthalmology clinics at the Kenyatta National Teaching and Referral Hospital (KNH) in Nairobi, Kenya between November 2023 and July 2024. Methods: Demographic and relevant clinical data were obtained from consenting eligible patients at admission. The values of the absolute counts of neutrophils, lymphocytes and C-reactive proteins were also obtained, and the Neutrophil-Lymphocyte Ratio (NLR) calculated. Length of hospital stay, admission to intensive care unit (ICU) and mortality were recorded. The Mann Whitney U test was used to establish whether there was a significant difference in NLR and CRP among outcomes. Spearman rank order correlation was used to establish the relationship between NLR values and length of stay. Results: Only 80 patients were recruited into the study. The participants ranged form <5 to >60 year with an interquartile range of 33.8 years and a median age of 26.3 years. Most participants were male (71.2%, n = 57). NLR was significantly associated with the length of hospital stay with a p-value of 0.029 before adjustment. Participants with normal NLR had 8.21 times higher odds of disease resolution compared to those with abnormal. Conclusion: NLR had a significant association with mortality and disease severity and was comparable to CRP in ability to predict disease outcomes in orofacial infections. Participants with resolved disease had significantly lower levels of NLR compared to those who were admitted to the ICU. Similarly, participants who
Fang, H., Huang, X.Y., Chien, H., Chang, J.T., Liao, C., Huang, J., et al. (2013) Refining the Role of Preoperative C‐reactive Protein by Neutrophil/Lymphocyte Ratio in Oral Cavity Squamous Cell Carcinoma. TheLaryngoscope, 123, 2690-2699. https://doi.org/10.1002/lary.24105
[3]
Balta, S., Demirkol, S., Unlu, M., Arslan, Z. and Celik, T. (2013) Neutrophil to Lymphocyte Ratio May Be Predict of Mortality in All Conditions. BritishJournalofCancer, 109, 3125-3126. https://doi.org/10.1038/bjc.2013.598
[4]
Özpelit, E., Akdeniz, B., Özpelit, M.E., Tas, S., Bozkurt, S., Tertemiz, K.C., et al. (2015) Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Pulmonary Arterial Hypertension. JournalofInternationalMedicalResearch, 43, 661-671. https://doi.org/10.1177/0300060515589394
[5]
Yang, A., Liu, J., Tao, W. and Li, H. (2020) The Diagnostic and Predictive Role of NLR, D-NLR and PLR in COVID-19 Patients. InternationalImmunopharmacology, 84, Article 106504. https://doi.org/10.1016/j.intimp.2020.106504
[6]
Buonacera, A., Stancanelli, B., Colaci, M. and Malatino, L. (2022) Neutrophil to Lymphocyte Ratio: An Emerging Marker of the Relationships between the Immune System and Diseases. InternationalJournalofMolecularSciences, 23, Article 3636. https://doi.org/10.3390/ijms23073636
[7]
Kawashita, Y., Kitamura, M., Soutome, S., Ukai, T., Umeda, M. and Saito, T. (2021) Association of Neutrophil-to-Lymphocyte Ratio with Severe Radiation-Induced Mucositis in Pharyngeal or Laryngeal Cancer Patients: A Retrospective Study. BMCCancer, 21, Article No. 1064. https://doi.org/10.1186/s12885-021-08793-6
[8]
Forget, P., Khalifa, C., Defour, J., Latinne, D., Van Pel, M. and De Kock, M. (2017) What Is the Normal Value of the Neutrophil-to-Lymphocyte Ratio? BMCResearchNotes, 10, Article No. 12. https://doi.org/10.1186/s13104-016-2335-5
[9]
de Jager, C.P., van Wijk, P.T., Mathoera, R.B., de Jongh-Leuvenink, J., van der Poll, T. and Wever, P.C. (2010) Lymphocytopenia and Neutrophil-Lymphocyte Count Ratio Predict Bacteremia Better than Conventional Infection Markers in an Emergency Care Unit. CriticalCare, 14, R192. https://doi.org/10.1186/cc9309
[10]
Şentürk, M., Azgın, İ., Övet, G., Alataş, N., Ağırgöl, B. and Yılmaz, E. (2016) The Role of the Mean Platelet Volume and Neutrophil-To-Lymphocyte Ratio in Peritonsillar Abscesses. BrazilianJournalofOtorhinolaryngology, 82, 662-667. https://doi.org/10.1016/j.bjorl.2015.11.018
[11]
Omeje, K.U., Amole, I., Efunkoya, A.A., Agbara, R., Adesina, O.A. and Jameel, I. (2017) A Revisit of Oral and Maxillofacial Mortality from Orofacial Infections in a Resource Limited Setting: Is There a Need for a Change in Management Protocol? East African Medical Journal, 94, 499-505.
[12]
Fu, B., McGowan, K., Sun, H. and Batstone, M. (2018) Increasing Use of Intensive Care Unit for Odontogenic Infection over One Decade: Incidence and Predictors. JournalofOralandMaxillofacialSurgery, 76, 2340-2347. https://doi.org/10.1016/j.joms.2018.05.021
[13]
Mathew, G.C., Ranganathan, L.K., Gandhi, S., Jacob, M.E., Singh, I., Solanki, M., et al. (2012) Odontogenic Maxillofacial Space Infections at a Tertiary Care Center in North India: A Five-Year Retrospective Study. InternationalJournalofInfectiousDiseases, 16, e296-e302. https://doi.org/10.1016/j.ijid.2011.12.014
[14]
Lipsky, M.S., Su, S., Crespo, C.J. and Hung, M. (2021) Men and Oral Health: A Review of Sex and Gender Differences. AmericanJournalofMen’sHealth, 15, 1-8. https://doi.org/10.1177/15579883211016361
[15]
Shweta and Prakash, S.K. (2013) Dental Abscess: A Microbiological Review. Dental Research Journal (Isfahan), 10, 585-591.
[16]
Kabak, M., Çil, B. and Hocanlı, I. (2021) Relationship between Leukocyte, Neutrophil, Lymphocyte, Platelet Counts, and Neutrophil to Lymphocyte Ratio and Polymerase Chain Reaction Positivity. InternationalImmunopharmacology, 93, Article 107390. https://doi.org/10.1016/j.intimp.2021.107390
[17]
Sharma, A., Giraddi, G., Krishnan, G. and Shahi, A.K. (2012) Efficacy of Serum Prealbumin and CRP Levels as Monitoring Tools for Patients with Fascial Space Infections of Odontogenic Origin: A Clinicobiochemical Study. JournalofMaxillofacialandOralSurgery, 13, 1-9. https://doi.org/10.1007/s12663-012-0376-4
[18]
Hoerter, J.E. and Malkin, B.D. (2024) Odontogenic Orofacial Space Infections. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK589648/
[19]
Gallagher, N., Collyer, J. and Bowe, C.M. (2021) Neutrophil to Lymphocyte Ratio as a Prognostic Marker of Deep Neck Space Infections Secondary to Odontogenic Infection. BritishJournalofOralandMaxillofacialSurgery, 59, 228-232. https://doi.org/10.1016/j.bjoms.2020.08.075
[20]
Dogruel, F., Gonen, Z., Gunay-Canpolat, D., Zararsiz, G. and Alkan, A. (2017) The Neutrophil-to-Lymphocyte Ratio as a Marker of Recovery Status in Patients with Severe Dental Infection. MedicinaOralPatologíaOralyCirugiaBucal, 22, e440-e445. https://doi.org/10.4317/medoral.21915
[21]
Urechescu, H., Gheran-Vida, E., Cuzic, C., Ancusa, O., Ursoniu, S. and Pricop, M. (2023) Inflammatory Markers as Predictors for Prolonged Duration of Hospitalization in Maxillofacial Infections. JournalofClinicalMedicine, 12, Article 871. https://doi.org/10.3390/jcm12030871
