Peritonsillar and deep neck infections: a review of 330 cases

Introduction

Deep neck infections are defined as suppurative infectious processes of deep visceral spaces of the neck.

Risk factors of postoperative infection in head and neck surgery

Objectives

Patients undergoing head and neck oncological surgery are at great risk of developing complications following surgery. It is important to clarify risk factors contributing to operative wound infections.

Methods

Two hundred and nine cases with head and neck tumor (87 female, and 122 male, averaged 58.6 years old) were studied at Mie University Hospital within a 24-month interval, during 2002 and 2003.

Results

Twenty-one (10.0%) surgical site infections (SSIs) were recorded. Univariate analysis revealed that the following factors were significantly related to SSI: blood loss, previous chemotherapy, clean-contaminated surgery, tracheotomy, malignant tumor, advanced T-stage, flap reconstruction, and long operative time. Multivariate analysis showed that blood loss, previous chemotherapy, and the type of surgery contributed to SSI. Otherwise, the following factors did not show any significant correlations: age, body mass index, smoking, alcohol intake, diabetes, sex, previous radiotherapy, N-stage or ASA score.

Conclusions

In order to minimize postoperative wound infection, clinicians managing the head and neck tumor patients should have a thorough understanding of the risk factors leading to postoperative infections such as blood loss, previous chemotherapy, and clean-contaminated surgery.     

Strategies to prevent biofilm-based tympanostomy tube infections

Objective

To review the potential contributory role of biofilms to post-tympanstomy tube otorrhea and plugging as well as the available interventions currently utilized to prevent biofilm formation on tympanostomy tubes.

Data sources

A literature review was performed utilizing the MEDLINE/Pubmed database from 1980 to 2013.

Review methods

Electronic database was searched with combinations of keywords “biofilm”, “tympanostomy tube”, “ventilation tube”, and “post-tympanostomy tube otorrhea”.

Results

Two of the most common sequelae that occur after tympanostomy tube insertion are otorrhea and tube occlusion. There is an increased evidence supporting a role for biofilms in the pathogenesis of otitis media. In this review, we have shown a multitude of novel approaches for prevention of biofilm associated sequelae of otitis media with effusion. These interventions include (i) changing the inherent composition of the tube itself, (ii) coating the tubes with antibiotics, polymers, plant extracts, or other biofilm-resistant materials, (iii) tubal impregnation with antimicrobial compounds, and (iv) surface alterations of the tube by ion-bombardment or surface ionization.

Conclusion

Currently, there is not one type of tympanostomy tube in which bacteria will not adhere. The challenges of treating chronic post-tympanostomy tube otorrhea and tube occlusion indicate the need for further research in optimization of tympanostomy tube design in addition to development of novel therapies.     

Deep neck space infections: a retrospective review of 173 cases

Purpose

The purpose of this study is to review our recent experience with deep neck infections and emphasize the importance of radiologic evaluation and appropriate treatment selection in those patients.

Materials and Methods

The records of 173 patients treated for deep neck infection at the Department of Otolaryngology and Head and Neck Surgery of Dicle University Hospital during the period from 2003 to 2010 were retrospectively reviewed. Their demography, symptoms, etiology, seasonal distribution, bacteriology, radiology, site of deep neck infection, durations of the hospital admission and hospital stay, treatment, complications, and outcomes were evaluated. The findings were compared to those in the available literature.

Results

Dental infection was the most common cause of deep neck infection (48.6%). Peritonsillar infections (19.7%) and tuberculosis (6.9%) were the other most common cause. Pain, odynophagia, dysphagia, and fever were the most common presenting symptoms. Radiologic evaluation was performed on almost all of the patients (98.3%) to identify the location, extent, and character (cellulitis or abscesses) of the infections. Computed tomography was performed in 85.3% of patients. The most common involved site was the submandibular space (26.1%). In 29.5% of cases, the infection involved more than one space. All the patients were taken to intravenous antibiotic therapy. Surgical intervention was required in 95 patients (59.5%), whereas 78 patients (40.5%) were treated with intravenous antibiotic therapy alone. Life-threatening complications were developed in 13.8% of cases; 170 patients (98.3%) were discharged in stable condition.

Conclusion

Despite the wide use of antibiotics, deep neck space infections are commonly seen. Today, complications of deep neck infections are often life threatening. Although surgical drainage remains the main method of treating deep neck abscesses, conservative medical treatment are effective in selective cases.     

Identification of adenoid biofilms with middle ear pathogens in otitis-prone children utilizing SEM and FISH

Objectives

Biofilms have been implicated in the development of several chronic infections. We sought to demonstrate middle ear pathogens in adenoid biofilms using scanning electron microscopy (SEM) and fluorescent in situ hybridization (FISH) with confocal laser scanning microscopy (CLSM).

Methods

Comparative micro-anatomic investigation of adenoid mucosa using SEM and FISH with confocal scanning laser microscopic (CLSM) imaging from patients with recurrent acute otitis media (RAOM).

Results

All otitis-prone children demonstrated biofilm surface area presence greater than 85% by SEM. FISH accompanied by CLSM imaging also demonstrated patchy biofilms All biofilms contained middle ear pathogens and were frequent in polymicrobial distributions: 4 of 6, 4 of 6 and 3 of 6 samples contained Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis, respectively.

Conclusions

Dense adenoid biofilms may act as a reservoir for reinfection of the tubotympanum. Aspiration of planktonic middle ear pathogens existing in resistant adenoid biofilms during a viral upper respiratory tract infection may be an important event in the development of RAOM.     

Zębopochodne stany zapalne tkanek miękkich twarzy i szyi w materiale Oddziału Otolaryngologii Szpitala Wojewódzkiego im. św. Łukasza w Tarnowie – obserwacja 5-letnia

Introduction

In the ethology of inflammations within the head and neck area, odontogenic ethology still plays an important role. Early recognition, diagnosis and management of odontogenic infections are requisites for avoiding or minimizing the development of potential complications.

The aim of the study

The aim of this study was to retrospectively analyze the clinical presentation, surgical management and cost implications of patients treated for odontogenic inflammations of head and neck area at the Department of Otolaryngology in the Regional Hospital in Tarnów in last 5 years.

Materials and methods

The study was based on medical documentations of 65 patients, 34 males and 31 females between the age of 16–83 years.

Results

Despite common accessibility of wholesome education and dental prevention, a lot of patients disregard their disorders. That's why treatment of odontogenic inflammations is often difficult and prolonged. The authors reveal a cost burden in a public health care as a result of odontogenic inflammations.     

Blastomycosis of the head and neck

Background

Blastomyces dermatitidis infection of head and neck structures is a rare clinical entity. However, the potential for significant morbidity warrants clinical consideration and timely diagnosis.

Objective of review

To describe the clinical presentations, diagnostic challenges, and outcomes of otolaryngologic blastomycosis.

Search strategy

A literature search of the Pubmed and Ovid databases with the terms “blastomycosis AND. . . “ followed by all terms related to anatomical regions of the head and neck.

Evaluation method

All publications which discussed pertinent otolaryngologic involvement from blastomycotic infections were evaluated.

Results and conclusion

The larynx was the most commonly reported site of infection, followed by the oral cavity, neck, ear, nasal cavity/paranasal sinuses, and skull base/orbit/calvarium. Diagnosis of blastomycosis was almost universally delayed due to the resemblance of presentation to more common clinical entities, most notably squamous cell carcinoma. A substantial portion of cases (42%) presented without clinical or radiographic evidence of pulmonary infection. The initial diagnostic confusion often resulted in disease progression and trials of invasive therapies. Most patients experienced complete resolution of symptoms and lesions within months of initiation of proper antifungal medications. Permanent sequelae were relatively uncommon and related to the structures involved in the primary infection.     

Embryonal rhabdomyosarcoma of the head and neck in an adult

Objective

This report describes an exceedingly rare case of adult embryonal rhabdomyosarcoma arising in the head and neck, which was initially diagnosed as a primary unknown cancer.

Method

The patient underwent a radical neck dissection with the total excision of the tumor, which was diagnosed as embryonal rhabdomyosarcoma.

Result

The patient received intensive adjuvant chemotherapy, and is still alive with no signs of recurrence or metastasis.

Conclusion

This case report demonstrates not only the rarity of this neoplasm but the importance of the differential diagnosis for planning the therapeutic strategy.     

Usefulness and pitfall of Narrow band imaging combined with magnifying endoscopy for detecting an unknown head and neck primary site with cervical lymph node metastasis

Objective

Cervical nodal metastasis from clinically undetectable primary squamous cell carcinoma (SCC) accounts for 1–2% of head and neck malignancies. We retrospectively evaluate the ability of Narrow band imaging combined with magnifying endoscopy (NBI-ME) to detect the primary sites of superficial SCC in the head and neck region.

Methods

This was a report of 11 patients. We performed with NBI-ME to detect unknown primary sites in the head and neck.

Results

Among 11 patients, primary sites were detected in eight. Primary sites were detected in the head and neck in 6 (54.5%) of 11 patients on NBI-ME, all 6 primary lesions were a flat lesion. Two patients in whom primary lesions could not be detected on NBI-ME, one had submucosal tumor like lesion, the other featured by a detectable primary lesion 19 months after neck dissection.

Conclusion

NBI-ME can be recommended as an essential procedure for the detection of primary lesions in patients with primary unknown cervical lymph node metastasis.     

Formation of biofilm by Haemophilus influenzae isolated from pediatric intractable otitis media

Objectives

The aims of this study are to evaluate biofilm formation by nontypeable Haemophilus influenzae (NTHi) isolated from children with acute otitis media (AOM) and its relation with clinical outcome of the disease.

Methods

Biofilm formations by NTHi clinical isolates from pediatric AOM patients were evaluated by a crystal violet microtiter plate and a 98 well pin-replicator assay with a confocal laser scanning microscopy (CLSM). Optical density values of clinical isolates were compared with a positive control and the ratio of clinical isolates to a positive control was defined as biofilm formation index (BFI).

Results

84.3% clinical isolates of NTHi were biofilm forming strains (BFI ≥ 0.4). The BFI represented the levels of biofilm formation and adherence on the surface. The identical strains isolated from both middle ear fluids (MEFs) and nasopharynx showed biofilm formation at the same level. The prevalence of biofilm forming isolates was significantly higher among the susceptible strains than resistant strains. The level of biofilm formation of NTHi isolated from AOM cases who was not improved by amoxicillin (AMPC) was significantly higher than that of NTHi isolated from AOM cases who was improved by AMPC.

Conclusion

We clearly showed the biofilm formation of clinical NTHi isolates from AOM children. In addition, the biofilm formed by NTHi would play an important role in persistent or intractable clinical course of AOM as a result of lowered treatment efficacy of antibiotics.     

Chyle leak: A rare complication post-hemithyroidectomy. Case report and review of literature

Background

Thyroidectomy is one of the common neck surgeries. Well recognized complications include postoperative bleeding, hypocalcaemia and recurrent laryngeal nerve injury. Chyle leak post-thyroidectomy is extremely rare. Most of the reported cases have had a complete central compartment neck dissection.

Methods and results

This is a case report of a patient who suffered from chyle leak after a left hemithyroidectomy without a complete central compartment neck dissection. The patient was managed conservatively with low fat diet and observation. A protocol for approaching thyroid patients with chyle leak is proposed based on a comprehensive literature review.

Conclusion

Chyle leak post-thyroidectomy for a benign disease is a very rare complication. Nevertheless, head and neck surgeons should consider it in the differential diagnosis of neck swelling post-thyroidectomy.     

Benefits of ultrasound vs. computed tomography in the diagnosis of pediatric lateral neck abscesses

Objective

There are no studies comparing the accuracy of ultrasound and computed tomography in the same population of pediatric patients with lateral neck abscesses. This case series assesses the accuracy of the two imaging techniques.

Methods

One hundred and forty imaging studies (ultrasound n = 39 or CT n = 101) that were performed from 2005 to 2011 prior to incision and drainage of a lateral neck mass at a tertiary care academic institution were retrospectively reviewed. All children 0–18 years of age with lateral neck abscesses who underwent CT or ultrasound imaging prior to drainage were included. Sensitivity, specificity, and positive and negative predictive values of ultrasound and CT were determined as compared to the gold standard, incision and drainage of the suspected abscess.

Results

In children undergoing incision and drainage, the prevalence of an abscess was 89%. Ultrasound has a high specificity (100%) but a low sensitivity (53%). The positive predictive value (96%) is high while the negative predictive value is low (16%), assuming a positive abscess prevalence of 0.9. In contrast, CT has low specificity (18%) but slightly higher sensitivity (68%) compared to ultrasound. Similar to ultrasound, CT had low negative (6%) and high positive (88%) predictive values.

Conclusions

This study demonstrates that ultrasound may be an equivalently sensitive and more specific diagnostic tool when compared to CT in the work-up of lateral neck abscesses in children. It is safe and effective in diagnosis when there is an undetermined probability of an abscess.     

Use of positron emission tomography scanning in metastatic head and neck cutaneous squamous cell cancer: Does it add to patient management?

Purpose

To evaluate the impact of whole-body positron emission tomography in comparison to staging by conventional methods alone in management of patients with head and neck cutaneous squamous cell cancer (cSCC) with confirmed regional nodal metastasis.

Materials and methods

This is a retrospective case cohort study carried out at a tertiary referral cancer centre. The participants were thirty-one adults with head and neck cSCC and regional nodal metastasis. The original treatment plan based on conventional cross-sectional imaging and clinical examination was compared to the final treatment plan after additional PET staging to evaluate the impact of 18F-FDG PET–CT on patient management.

Results

Addition of 18F-FDG PET–CT did not change the management in 24/31 (77%) of patients. In four cases the 18F-FDG PET–CT failed to pick up biopsy proven metastatic disease. Two patients who had reduced extent of surgery have shown no features of regional failure after one year of follow-up.

Conclusion

Overall the management in majority of head and neck cSCC patients with regional metastasis does not change by addition of 18F-FDG PET–CT over conventional imaging.     

Extraosseous osteosarcoma in the neck

Background

Extraosseous osteosarcoma arising in the head and neck region is an exceptional finding, with a few isolated cases informed in the literature. We report a new case of a large high-grade extraosseous osteosarcoma located in the neck.

Case presentation

: A 74 year-old woman with a tumor on the right side of the neck was treated by complete surgical resection. The histopathological diagnosis was osteoblastic extraosseous osteosarcoma. PET-CT scan disclosed no evidence of disease in other areas. Patient received adjuvant radiotherapy and after 3 months of follow-up tumor activity was detected in the cavernous sinus and the patient died of disease one month later.

Conclusion

Extraosseous osteosarcoma in head and neck region is exceptional, and incisional biopsy is the only method to establish a diagnosis and the one to differentiate it from other bone-producing soft tissue tumors. Surgery is the gold standard for treatment of extraosseous osteosarcoma.     

Stomal recurrence in head and neck cancer patients with temporary tracheostomy

Objective

Stomal recurrence following a temporary tracheostomy in the management of the head and neck squamous cell carcinoma (HNSCC) without laryngectomy is a rare finding. We studied the incidence and prognostic significance of stomal recurrence in patients who had a temporary tracheostomy.

Methods

Data were obtained retrospectively from a database on all patients with a HNSCC tumour diagnosed and treated at our hospital between 1985 and 2012.

Results

Of 491 patients who underwent temporary tracheostomy, six presented tumour recurrence in the stomal scar. The risk of stomal recurrence after a temporary tracheostomy was therefore 1.2% (6/491). Only one of the three patients who received salvage treatment achieved disease control.

Conclusion

Tumour recurrence in the stomal scar after a transitory tracheostomy in patients with head and neck carcinoma has an incidence of around 1% and very poor prognosis.     

Vacuum assisted closure in the management of wound healing disorders in the head and neck: A retrospective analysis of 23 cases

Background

Since the middle of the 1990s vacuum-assisted closure (VAC) has been used in many areas of surgery to manage complex wounds and impaired wound healing. Until recently, little attention has been paid to this treatment modality in the field of head and neck surgery. The evaluation of its efficacy in wound healing disorders of the head and neck was the aim of this study.

Material and methods

Patients with complex wounds and impaired healing treated with VAC therapy between 2008 and 2011 were included into the study. VAC dressings were changed every 3 days and improvements in wound healing were documented.

Results

23 patients were treated with VAC therapy, in 18 cases (78%) closure of the defect could be reached without any further surgical procedure. 5 patients needed subsequent regional flap reconstruction to close the remaining defect. All of these patients had undergone salvage surgery in a previously irradiated neck before.

Conclusion

Vacuum assisted closure is an effective treatment in the management of wound healing disorders and complex wounds in the head and neck. It offers a useful, non-invasive modality to close even large defects in the area. Previous irradiation seems to have a significant negative influence on the outcome of the therapy, but more data are required to assess these effects.     

Burkholderia cepacia complex isolation in non-polypoid chronic rhinosinusitis

Purpose

Burkholderia cepacia complex (Bcc) infections of the head and neck have been infrequently reported in immunocompetent patients, while their association with cystic fibrosis is quite well known. One of the main problems associated with Bcc is their intrinsic resistance to most clinically-available antimicrobials. Bcc has already been isolated in sinonasal polyposis, while here we report for the first time on its isolation in patients with chronic rhinosinusitis (CRS) but no nasal polyposis.

Materials and methods

Thirty-four consecutive surgically-treated CRS patients without cystic fibrosis were recruited.

Results

Bcc was isolated in 4 cases of CRS without polyposis, and in another case in sinonasal polyposis. All tested Bcc strains isolated in non-polypotic CRS were resistant to ciprofloxacin, amikacin, ertapenem, amoxicillin/clavulanate, cefotaxime, and gentamicin.

Conclusions

The novel finding of Bcc species in CRS without polyposis as well suggests that the mechanism by which these bacteria adhere to the epithelium of the upper respiratory tract may be important in the host’s colonization.     

Fourth branchial cleft anomaly: Management strategy in acute presentation

Objectives

Branchial malformations are common congenital head and neck lesions usually diagnosed in childhood during the first decade of life. Acute presentation is usually managed with conservative protocols before a definitive surgical procedure although the risk of life-treating septic complications may influence the physician’s decision. Surgery is the treatment of choice with the removal of the lesion alone, nevertheless more aggressive approaches must be considered in complicated cases. Selective neck dissection including the removal of part of the thyroid lobe with the congenital lesion should be considered as the “ultima ratio” treatment to avoid recurrence.

Methods

We reviewed literature and report our experience concerning two patients with fourth branchial cleft sinus.

Results

A three-year-old child with a clinical history of recurrent neck abscess was referred to our department after several drainages performed in another centre. A three-year-old child referred to our department for a left side lower primary neck abscess. In both cases the diagnosis of a complicated fourth cleft remnant was confirmed by rigid endoscopic visualization of the mucosal orifice of the sinus in the pyriform fossa. Surgical management during acute presentation was challenging; in one patient the early fasciitis required an emergency procedure to remove the infected sinus that were strictly adherent to the deep vascular-nervous axis.

Conclusion

Surgery was the definitive treatment in both cases and at 12 and 25 months follow-up respectively no recurrences were observed.     

Laser tonsil cryptolysis: In-office 500 cases review

Objectives

Tonsilloliths, proven to be tonsillar biofilms cause symptoms of halitosis, foreign body sensation and recurrent sore throats. Laser Tonsil Cryptolysis (LTC) performed in the office may represent an alternative to tonsillectomy in selected cases of persistent tonsilloliths with cryptic infections.

Study Design

A retrospective chart analysis using CPT codes.

Setting

Office and hospital.

Methods

A retrospective complications review consisting of bleeding, the need for an additional procedure, patient satisfaction and conversion rate to complete tonsillectomy was documented.

Results

Five hundred consecutive LTCs performed in the office under local anesthesia with a CO2 or diode laser were identified. Energy delivery was in continuous mode with power settings of 18W and 10W respectively. Bleeding occurred in 6 patients requiring unscheduled return office visit for evaluation. Eighty patients required a second procedure, comprising total of 1.16 procedures per patient. Eighteen (3.6%) patients underwent complete tonsillectomy. Patient satisfaction was high with an overall incidence of 0–2 days of work absence. Follow-up was 1–8 years.

Conclusions

With a small tonsil size, controllable gag reflex and cooperative adult patient LTC allows several advantages compared to conventional tonsillectomy. Benefits of LTC include avoidance of general anesthesia and limited ablation of cryptic pockets, resulting in reduced post-operative pain, bleeding, shorter recovery time and the convenience and cost advantage of an office procedure. With 1.16 sessions required per patient, low conversion rate to standard tonsillectomy and minimal complication rate LTC can be considered an alternative option to a patient suffering from recurrent cryptic tonsillitis with or without tonsilloliths.     

Parapharyngeal and retropharyngeal infections in children: Argument for a trial of medical therapy and intraoral drainage for medical treatment failures

Objective

To review the outcomes of parapharyngeal infections (PPI) and retropharyngeal infections (RPI) in children after medical and surgical management.

Methods

The charts of all children who presented to a tertiary-care pediatric hospital between March 2005 and February 2007 with a diagnosis of parapharyngeal infection or retropharyngeal infection were reviewed. Thirty-two patient records were analyzed.

Results

The mean age of our patients was 4.4 years, 63% of whom were boys. The majority of patients presented during the winter months with some combination of fever, neck stiffness, and neck swelling. Ten patients had surgery less than 1 day after admission (early surgical intervention). Twenty-two patients were given a trial of at least 24 h of intravenous (IV) antibiotics (medical trial group), nine of whom were treated exclusively with IV antibiotics (medical therapy alone). The remaining 13 patients failed medical therapy, and went on to surgical drainage (late surgical intervention). All patients requiring surgical drainage were treated successfully with an intraoral approach. Patients given a trial of IV antibiotics had an average hospital stay of 3.3 days (3.0 days for medical therapy alone and 3.5 days for late surgical intervention). Patients with early surgical intervention stayed 2.7 days. All patients were discharged home with oral antibiotics. There was no statistically significant difference in the length of stay between the medical trial and early intervention groups. Those who failed medical therapy had significantly larger abscesses than those who responded to medical therapy (1.53 versus 5.38 cm²).

Conclusions

A trial of IV antibiotics does not adversely affect outcome and may obviate the need for surgery, particularly for patients with smaller abscesses. When surgery is required, an intraoral procedure is usually adequate.