Recurrence of a deep neck infection: a clinical indication of an underlying congenital lesion

OBJECTIVE: To discuss the computed tomographic (CT) and clinical findings of those entities that may present as recurrent deep neck infections. PATIENTS AND METHODS: Twelve patients with recurrent deep neck infections and CT scans were retrospectively identified since 1990. Their CT scans and medical histories were reviewed. The diagnosis was pathologically confirmed in all cases. RESULTS: The CT scans revealed an abscess or a localized infected cyst in the deep soft tissues of the neck, with varying degrees of associated inflammatory change in the adjacent soft tissues. The diagnoses in these cases included 1 first branchial cleft cyst, 3 second branchial cleft cysts, 1 third branchial cleft cyst, 2 fourth branchial cleft cysts, 2 infected lymphangiomas, 2 thyroglossal duct cysts, and 1 cervical thymic cyst. CONCLUSIONS: Most deep neck infections are the result of suppurative adenitis. The location of the primary focus is usually from the mucosa of the upper aerodigestive tract or from an odontogenic source. Less common causes are perforations due to a foreign body, thrombophlebitis of the internal jugular vein, or osteomyelitis of the spine. Recurrences in these situations are unusual. Less commonly, congenital lesions can present as deep neck infections, and recurrences are common. Our cases suggest that the recurrence of a deep neck infection should alert the physician to the possibility of an underlying congenital lesion and that CT is helpful in the early recognition of these lesions.     

Cochleo-vestibular disturbances in diving.

Insidious development of high-tone sensorineural hearing loss may be associated with diving, but the evidence is not certain and further research is needed. 'Internal ear barotrauma' can cause an acute or relatively acute onset of hearing loss and/or vertigo, and it may be that 'alternobaric vertigo' provides a link between the insidious and acute forms of labyrinthine injury in diving. With deep diving, decompression sickness and other syndromes can also affect the cochleo-vestibular system. These aetiologies and effects will be discussed, together with evidence from an audiometric survey of naval divers and of 5 experimental deep divers.     

Cochleo-Vestibular Disturbances in Diving

Insidious development of high-tone sensorineural hearing loss may be associated with diving, but the evidence is not certain and further research is needed. 'Internal ear barotrauma' can cause an acute or relatively acute onset of hearing loss and/or vertigo, and it may be that 'alternobaric vertigo' provides a link between the insidious and acute forms of labyrinthine injury in diving. With deep diving, decompression sickness and other syndromes can also affect the cochleo-vestibular system. These aetiologies and effects will be discussed, together with evidence from an audiometric survey of naval divers and of 5 experimental deep divers     

Thymic cyst: A fourth branchial cleft anomaly

We report a unique case of a fourth branchial cleft cyst found within the thymus of an adult patient. In the literature to date, there have been no reports of such a finding in the adult population. These anomalies can often cause recurrent acute suppurative thyroiditis or recurrent deep neck abscesses. Delay in recognizing the underlying etiology can lead to significant complications. Laryngoscope, 2010     

Intravenous antibiotic therapy for deep neck abscesses defined by computed tomography

OBJECTIVE: To determine the effectiveness of using intravenous antibiotics alone to treat clinically stable children with clearly defined deep neck abscesses diagnosed by contrast-enhanced computed tomography (CT). DESIGN: Retrospective chart and CT scan review. SETTING: Tertiary care children's hospital. PATIENTS: The study comprised clinically stable pediatric patients who presented with signs and symptoms of a deep neck infection and who had CT scans demonstrating an abscess in the parapharyngeal space, retropharyngeal space, or both that included (1) a well-formed ring enhancement around a nonenhancing density consistent with fluid and (2) a size greater than 1 cm in every dimension. MAIN OUTCOME MEASURES: Clinical resolution of the signs and symptoms of the deep neck abscess after treatment with intravenous antibiotics. RESULTS: Over a 22-month period (May 1999 to March 2001), 11 children ranging in age from 4 months to 16(1/2) years who had contrast-enhanced CT evidence of deep neck abscess and no clinical evidence of severe symptoms or significant airway compromise were initially treated with intravenous antibiotics. Ten (91%) of the 11 children responded to intravenous antibiotic therapy as their only treatment. All 10 responders began to improve clinically by 48 hours. The symptoms resolved in 5 children by treatment day 3. Five to 8 days of treatment were required to completely resolve the symptoms in the other 5 patients. The 1 child who did not respond to intravenous antibiotic therapy underwent surgical drainage of her deep neck abscess within 12 hours of admission, with purulence discovered at the time of surgery. CONCLUSION: In a select number of clinically stable children, deep neck abscesses diagnosed on contrast-enhanced CT scans using strict radiographic criteria can be effectively treated with intravenous antibiotics alone.     

Corneal autoimmunity in Cogan's syndrome? Report of two cases.

Autoimmune reactivity against corneal antigens is described in two patients with Cogan's syndrome, a nonsyphilitic deep interstitial keratitis with vestibuloauditory symptoms. In both cases corneal antibodies were found at the beginning or during an exacerbation of the disease. After administration of high doses of corticosteroids the corneal antibodies diminished. Interstitial keratitis can generally be controlled by local or systemic corticosteroids. The effect of corticosteroid therapy on the audiovestibular symptoms is variable. The possibility of an autoimmune pathogenesis of Cogan's syndrome is discussed.     

The pathologic features of keratosis obturans and cholesteatoma of the external auditory canal

The presence of a keratin plug occluding the deep external auditory canal was first noted and documented in the 19th century. It has subsequently been proposed that two different diseases can be responsible for the presence of this type of obstruction within the deep meatus: keratosis obturans and external auditory canal cholesteatoma. Keratosis obturans is characterized by a dense plug of keratin debris located primarily within the deep meatus. There is an associated hyperplasia of the underlying epithelium and evidence of chronic inflammation within the subepithelial tissue. There is no evidence of erosion or necrosis of the underlying bone. In external auditory canal cholesteatoma the significant finding is extensive erosion of the bony external auditory canal by a wide-mouthed sac, lined with stratified squamous keratinizing epithelium, that arises lateral to the tympanic membrane and is located in the inferior portion of the bony external canal. There is frequently evidence of sequestration of the underlying bone.     

Septoplasty without postoperative nasal packing. Mucosal repair of the upper airway with human biologica glue (author's transl)

With the use of human biological adhesives in nasal septal surgery with or without extensive dissection, nasal packing can be avoided or at least its use essentially shortened. As a result, nasal breathing is not interrupted and mucociliary clearance resumes at an earlier stage of healing. In addition, infections of the sinsuses or the deep airway are prevented. The provisional high costs of the adhesive can be justified by the lessened patient morbidity. Similar favorable experiences with the adhesive were also found in various other reconstructive procedures of the head and neck, including tympanoplasty, aural atresia, skin transplantation, etc.     

Diagnostic and treatment of necrotizing cervical fascitis. Clinical course after a Ludwig angina

The Ludwig angina is an infection of the base of the mouth and submandibular region, frecuently after a dental extraction or a piece in bad state. When it surpassees the milohioid muscle it extends dissecting the superficial aponeurotic planes, and can evolve to a necrotisant fascitis. We present the case of a 67 years old man with a painful tumefaction of the mouth base and submandibular region. The CT reflected an heterogenous submaxilar lesion that extended by the deep cervical fascia introducing itself in the thorax. Under antibiotic treatment the pus was drained by cervicotomy, with daily cures during 3 weeks.     

Drenaje percutáneo ecoguiado vs. drenaje quirúrgico en abscesos cervicales profundos de origen odontógeno. Ensayo clínico controlado y aleatorizado

IntroductionThe most common cause of deep neck infections is dental infection. They are diagnosed with physical examination, imaging studies, ultrasound, or computed tomography. Surgical drainage of collections should always be performed early in a classical or percutaneous way, depending on the case. The aim of the study was to compare ultrasound-guided percutaneous drainage techniques vs. surgical drainage in deep cervical abscesses of odontogenic origin in a controlled and randomized trial.MethodsA randomized controlled clinical trial was performed from January 2015 to December 2019. Hospital stay was evaluated as an efficiency variable. Epidemiological and secondary variable data (tumour, trismus, fever, pain), leukocytosis, cosmetic result comparing both techniques were analysed. Statistical analysis was carried out with STATA v 14.0.Results128 patients were analysed, 51 women and 77 men. Average age 27.3 (SD = 10.13). The percutaneous group had a mean hospital stay of 3.03 (SD = 2.86) days and the surgical group 5.46 (SD = 2.96). The p-value was <.001. Cosmetic results showed differences favouring the percutaneous drainage group. None of the other variables showed statistically significant results.DiscussionSurgical treatment (cervicotomy and debridement) should be undertaken early with evidence of extensive collection in deep spaces. Minimally invasive image-guided procedures are an alternative. These can be performed in well-located, unilocular collections, without compromising of the patient's airway. Percutaneous drainage and suction techniques if necessary, serially, or drainage placement may be performed.ConclusionsUltrasound-guided and serially guided percutaneous drainage is the best therapeutic option in patients with mild and/or moderate dental infections.     

The deep oval window

This article presents the results of an analysis of the variable and surgically important relationship between the oval window, the fossular walls and the related posterior tympanic recesses in 50 temporal bones. The visual impressions of superficial and deep oval windows seem to correspond fairly closely to the depth of the inferior wall of the fossula fenestra vestibuli (FFV). The depth of the superior and anterior walls of the FFV by themselves, did not appear to have such a dominating relationship in determining the deep oval window. There does not appear to be a well defined posterior wall in the vast majority of the specimens (86 per cent). In the event of scar tissue forming between the superior, inferior and anterior walls, the gap between the postero-superior part of the promontory and the posterior tympanic wall (posterior communication) could allow aeration of the region of the deep oval window in such an instance. Closure of this gap by a solid shelf of ponticulus or scar tissue could cause a localized malaeration of the fossula in most cases of deep oval windows. This is an entirely new concept of the likely problems of malaeration of a deep oval window which could arise due to anatomical variations and of the possible safety valve mechanism which could prevent such malaeration and its consequences.     

Deep lobe parotidectomy: clinical rationale in the management of primary and metastatic cancer

Deep lobe parotidectomy is an important management approach for highgrade primary parotid cancers that metastasize to the deep lobe nodes and for cancers that metastasizes to the deep parotid from a site outside the parotid. This paper reviews the rationale for deep lobe parotidectomy with facial nerve preservation for these parotid cancers. Deep lobe parotid involvement was reviewed in 27 patients. Twelve patients had primary parotid tumors that metastasized to the deep lobe, and 15 had tumors outside the parotid that metastasized to deep parotid nodes. Deep lobe parotidectomy should be considered in patients with a highgrade primary parotid tumor, a cancer that metastasizes to a superficial intraparotid node, or a primary parotid malignancy that metastasizes to a superficial parotid node or a neck node.     

Internal jugular vein thrombosis and deep neck infection from intravenous drug use: management strategy

OBJECTIVE: Internal jugular vein thrombosis (IJVT) manifests in multiple clinical scenarios including traumatic, neoplastic, and infectious processes. No clear management algorithm exists for IJVT in the setting of deep neck infections. This study examines the cause, diagnosis, and treatment strategy for IJVT in the setting of deep neck infections caused by intravenous drug use (IVDU). STUDY DESIGN: Retrospective chart review. METHODS: The clinical, radiographic, and laboratory data of 11 IVDU patients with deep neck infections and IJVT are reviewed in a retrospective fashion. The patients were seen in a university tertiary care facility. RESULTS: Eleven patients with deep neck infections, recent history of IVDU, and concurrent IJVT were identified. All patients underwent computed tomography (CT) scanning. Antibiotic therapy was instituted in all cases, abscesses were treated invasively with aspiration or incision and drainage, and no veins were ligated or resected. Three patients received anticoagulation. One patient had bilateral IJVT with thrombus extension through the sigmoid sinus to the lateral sinus. This patient received anticoagulation and developed bacteremia. No further IJVT complications have been diagnosed at an average of 14 months postintervention. CONCLUSION: IJVT and deep neck infection caused by IVDU constitute a clinical entity present even in the modern day era of antibiotic therapy. Aggressive antibiotic therapy and surgical intervention for the deep neck infection is recommended. The indications for anticoagulation remain variable. Although anticoagulation is often recommended in the presence of thrombus progression or septic emboli, the very presence of IJVT does not mandate the need for anticoagulation. Ligation or resection of the thrombosed vein may be reserved for selected cases, but was not necessary in our series.     

Surgical approach to the parotid gland

The key to surgical treatment of the parotid gland is adequate exposure and careful identification and protection of the facial nerve. The superficial and deep lobes of the gland can be removed from external approaches with little or no damage to the facial nerve if a careful and thoughtful surgical technique is employed.     

A text-book case of tropical facial elephantiasis

INTRODUCTION: Tropical facial elephantiasis is a nosological entity which can arise from various underlying causes: von Recklinghausen neurofibromatosis, lymphatic and cutaneodermal filarioses, deep mycosis. CASE REPORT: We report an exceptional case of tropical facial elephantiasis caused by onchocercosis and entomophtoromycosis (rhinophycomycosis). The patient's facial morphology was noted "hippopotamus-face" or "dog-face". DISCUSSION: Onchocercosis and entomophtoromycosis are two diseases known to cause facial elephantiasis. We have not however been able to find any case report in the literature of co-morbidity nor any information on factors predictive of concomitant occurrence.     

Akustische Analyse von Schnarchger?uschen

Acoustic analyses of snoring sounds have been performed for 30 years in the diagnostic procedure for sleep disordered breathing and can be categorized according to the frequency spectrum. Snoring with dominant deep frequencies below 500 Hz is predominately caused by velar vibrations without obstruction in simple snoring. High frequency snoring above 500 Hz is caused by partial or complete obstruction of the upper airway in patients with obstructive sleep-apnea syndrome. Combined snoring noises with deep and high frequency components are still a diagnostic challenge. The human hearing is still better in rating threatening characters of snoring noises than any acoustic analysis. New approaches by means of psychoacoustic analysis might contribute to decoding the acoustic fingerprint of snoring. By applying adequate analysis algorithms acoustic screening devices might be able to shed light on the extent of sleep disordered breathing in the future. Moreover an improved topodiagnostic approach in snoring might contribute to a better outcome in the treatment of snoring.     

Pressure equilibration in the penguin middle ear

CONCLUSIONS: King penguins have a venous structure in the form of a corpus cavernosum (CC) in their middle ear (ME) submucosa. The CC may be viewed as a special organelle that can change ME volume for pressure equilibration during deep-sea diving it is a pressure regulating organelle (PRO). A similar CC and muscles also surround the external ear (EE) and may constrict it, isolating the tympanic membrane from the outside. A CC was previously found also in the ME of marine diving mammals and can be expected to exist in other deep diving animals, such as marine turtles. OBJECTIVES: Marine animals require equalization of middle ear (ME) pressure when diving hundreds or thousands of meters to catch prey. We investigated what mechanism enables king penguins to protect their ME when they dive to great depths. MATERIALS AND METHODS: Biopsies and serial sections of the ME and the EE of the deep diving king penguin (Aptenodytes patagonicus) were examined microscopically. RESULTS: It was demonstrated that the penguin ME has an extensive network of small and large submucosal venous sinuses. This venous formation, a corpus cavernosum, can expand and potentially 'flood' the ME almost completely on diving, thus elevating ME pressure and reducing the ME space. The EE has a similar protective mechanism.     

220例颈深间隙感染临床分析

目的 探讨颈深间隙感染患者临床特征、治疗体会和经验教训,提高对颈深间隙感染的诊疗水平。 方法 回顾性分析220例颈深间隙感染患者临床特征、治疗措施、预后资料。 结果 220例患者中,98例颈深间隙蜂窝织炎患者经单纯抗感染和对症支持治疗治愈88例,10例进展为颈深间隙脓肿,并经进一步脓肿穿刺或切开引流治愈。122例颈深间隙脓肿患者经抗感染联合脓肿穿刺或切开引流和对症支持治疗,其中12例结核感染性脓肿联合抗结核治疗,25例因并发严重喉阻塞行气管切开治疗,最终118例治愈,4例因严重并发症死亡。 结论 颈深间隙感染病情危重,有效抗感染联合脓肿穿刺或切开引流是治疗成功的关键,结核等特殊性感染需联合抗结核等药物治疗。及时正确处置合并症与并发症,可减少致死致残率。     

Adenosquamous carcinoma of the larynx associated with necrotizing sialometaplasia—A diagnostic challenge

Necrotizing sialometaplasia is a benign, self-limiting, inflammatory process involving salivary glands, commonly associated with tissue ischemia. Clinically, necrotizing sialometaplasia is most often found in the hard palate as a deep ulcer with raised, indurated edges that can be indolent. This, as well as the histopathologic findings of necrotizing sialometaplasia, can be confused with those of a malignant neoplasm. We report a rare case of necrotizing sialometaplasia in the larynx, probably initiated by an underlying malignant process. We suggest an aggressive diagnostic approach, when necrotizing sialometaplasia involves the larynx and no recent exposure to radiation, surgery or trauma has been recorded. Necrotizing sialometaplasia of the larynx should be regarded as secondary to malignancy until proven otherwise.     

The relationship between dental overbite and eustachian tube dysfunction

OBJECTIVE: The purpose of this study was to investigate the association between deep dental overbite and eustachian tube dysfunction (ETD). DESIGN: Case-control study. SETTING: Tertiary care pediatric otolaryngology outpatient clinic at the Children's Hospital, Boston, Massachusetts. PATIENTS: 105 patients between the ages of 2 and 6 years. STUDY MEASUREMENTS: Dental overbite, overjet, and occlusal relationships were measured by an observer who was unaware of ETD status. ETD was defined as having ventilation tubes in place or having the recommendation for ventilation tube placement by an attending pediatric otolaryngologist. In addition, demographic information and medical and social histories were prospectively recorded. RESULTS: In a multivariate logistic regression model, children with deep bites were 2.8 times more likely to have ETD than those without deep bites (P = .03). Other independent risk factors for ETD identified in this model were family history of otitis media (OM) and age less than 3 years. CONCLUSIONS: Children with deep dental overbites are at a significantly increased risk for developing ETD.