Streptococcus milleri: an organism for head and neck infections and abscess

BACKGROUND: Streptococcus milleri, a commensal organism, has the potential to cause significant morbidity. There is a paucity of published data regarding this organism in the head and neck. OBJECTIVES: To identify and assess the presentation, treatment, and outcomes of pediatric patients affected by this pathogen. STUDY DESIGN: Review of the Department of Pathology database at Children's Hospital of Wisconsin, Milwaukee, between 1997 and 1999 identified 26 patients with cultures positive for S milleri group (SMG) bacteria. Retrospective chart analysis examined the demographic data, site of origin of infection, additional organisms cultured, symptoms, treatments, and complications. RESULTS: Sixteen patients had SMG infections involving the head and neck region. Sites of origin included the paranasal sinuses, dental, facial soft tissues, deep neck spaces, peritonsillar region, and a tracheostomy site. The paranasal sinuses were the most common site in 37% (6/16). Streptococcus milleri was the only isolate in 69% (11) of the infections. Significant local extension occurred in 56% (9/16) of the patients and included the orbit, skull base, cranium, and deep neck spaces. All patients had surgical drainage and 15 also received intravenous antibiotic treatment. One complication of osteomyelitis of the frontal bone occurred with resolution after surgical debridement and intravenous antibiotic treatment. CONCLUSIONS: Streptococcus milleri can be an aggressive pathogen in the head and neck with a propensity for abscess formation and local extension of the infection in a pediatric population. Surgical drainage with antibiotics is generally successful in management of the condition. However, emerging penicillin resistance and the ability for local extension require suspicion of incomplete treatment if clinical symptoms persist.     

Clinical and bacteriological significance of the Streptococcus milleri group in deep neck abscesses

Streptococcus constellatus, S. intermedius, and S. anginosus, the three species of the S. milleri group, form part of the normal flora most commonly found in the mouth, throat, gastrointenstinal tract, and genital tract. The S. milleri group has become known as an important pathogen in abscess disease, but little attention has been paid to their role in deep neck abscesses. We have treated 9 patients with deep neck abscesses relating to the S. milleri group since 1991, and regarded this group as an important pathogen also in these abscesses. We studied the frequency of the S. milleri group isolated from deep neck abscesses in our cases and from the literature and discuss clinical significance and bacteriological pathogenesis. Cases numbered 27 treated at our facility since 1991 and 200 cases reported in the Japanese literature since 1990. Of our 9 cases, 4 originated from acute pharyngitis, 3 from peritonsillar abscesses, and 2 from odontogenic infection. Serious complications such as mediastinitis, cervical necrotizing fasciitis, sepsis accompanied by disseminated intravascular coagulation, and spondylitis of the cervical vertebrae were seen in 4 cases. Among organisms isolated, the S. milleri group appeared to be a pathogen contributing to abscess formation and to serious complications. The genus Streptococcus was most frequently isolated both in our 27 cases (66.7%) and the 200 in the literature (45.5%). Among species of the genus Streptococcus, the S. milleri group numbered the highest in our cases at 33.3% but only 8.5% in the literature. Cases in the literature, however, contained many unknown species of Streptococci--31.5% vs. 18.5% in our cases. alpha-streptococcus was frequently reported in the literature among unknown species of Streptococci--36 of 63. Culture-negative cases were also numbered more in the literature than in our case--29.0% vs. 18.5%. Special conditions and procedures are required to suitably isolate and detect the S. milleri group. Since not all facilities use identical techniques in routine bacteriological examination, a considerable number of the S. milleri group could be missed in unknown species of Streptococci or alpha-streptococcus and culture-negative cases. The detailed pathogenesis of the S. milleri group remains to be clarified. Infection by normal flora on mucosa is thought to occur due to an imbalance between organisms and host defense in deep neck abscesses. Some strains of the S. milleri group have been reported to produce many tissue-destroying enzymes such as collagenase and hyaluronidase. The co-existence of the S. milleri group with some anaerobe strains has also been suggested to accelerate inflammation. We discuss the mechanism inducing the massive release of cytokines through T cell response to certain exotoxins produced by S. milleri group, as reported in toxic shock-like syndrome due to the group A beta-streptococcus and in alpha-streptococcal shock syndrome due to viridans streptococci (alpha-streptococci).     

Clinical relevance of the Streptococcus milleri group in head and neck infections

Streptococcus constellatus, S. intermedius, and S. anginosus, the 3 species of the S. milleri group, form part of the normal flora commonly found in the mouth, throat, and gastrointestinal and genital tracts. This group has become known as an important pathogen in infections and abscesses, but data on the anatomical distribution of these species is lacking in relation to clinical significance. We obtained 275 strains of the S. milleri group from different departments at our hospital over the last 3 years, including 54 strains from dental surgery, 47 from internal medicine, 44 from otolaryngology (head and neck), 43 from surgery, 32 from gynecology, 17 from urology, 16 from dermatology, 11 from brain surgery, 6 from pediatrics, 3 from orthopedics, and 2 from opthalmology. The 44 strains from head and neck were found in 42 patients,--23 with primary infection and 19 with secondary infection induced by cancer treatments. The primary infection group included 4 deep neck abscesses, 1 peritonsillar abscess, 5 tonsillitis, 4 paranasal sinusitis, 3 congenital aural fistula infections, 2 dental infections, 2 paranasal sinus cysts, 1 supprative parotitis, and 1 postoperative wound infection. The secondary infection group included 7 postoperative wound infections, 3 postoperative pulmonary infections, 3 laryngitis and pharyngitis, 3 terminal pneumonias, and 3 infections of the local recurrence site. The S. milleri group was the only isolated organism in 13 cases (56.5%) of primary infection and in 5 (26.3%) of secondary infection. Among other organisms from the primary infection group, no so-called major pathogens were found. Antimicrobial susceptibility tests of the S. milleri group showed that 50% were resistant to CCL and 33% to CTM. ABPC, CPDX, and CFDN were also found to be less sensitive, although no resistant strains were detected. To adequately culture the S. milleri group, incubation in air containing carbon dioxide or in an anaerobic atmosphere is required, and differentiation of the 3 requires biochemical reactivity tests. Since not all facilities use identical techniques in routine bacteriological examination, a considerable number of the S. milleri group could be missed in unknown species of alpha-,beta-, and gamma-streptococci and culture-negative cases. With antibiotics now being used widely, normal flora such as the S. milleri group may have become an important pathogen in head and neck infections due to an imbalance between organisms and host defense.     

Clinical significance of the Streptococcus milleri group in peritonsillar abscesses

Few researchers have microbiologically studied peritonsillar abscesses in detail, and their results have been conflicting. Although Streptococcus pyogenes (Group A beta-streptococcus) is commonly considered an important pathogen in this infection, recent studies have demonstrated the recovery of many other streptococci mainly consisting of alpha-streptococci. Few studies have identified these streptococci at the species level, however. We studied details of bacteriology in 31 cases of peritonsillar abscess treated between 1991 and 2000. The Streptococcus milleri group was most frequently isolated (25.8%), followed by Eikenella corrodens (9.7%), Staphylococcus aureus (6.5%), and S. pyogenes (3.2%). The S. milleri group, consisting of 3 species of Streptococcus constellatus, S. intermedius, and S. anginosus, forms part of the normal flora most commonly found in the mouth, throat, gastrointestinal tract, and genital tract. These species have become known as an important pathogen in abscess disease but little attention has been paid to their role in peritonsillar abscesses. To adequately culture the S. milleri group, incubation in air containing carbon dioxide or in an anaerobic condition is required, and then the differentiation of the 3 species requires the biochemical reactivity tests. Since hemolytic patterns of the S. milleri group vary, we studied the population of alpha-, beta-, and gamma-hemolytic strains among 36 strains of this group. We found 32 (88.8%) to be alpha-hemolytic. Although not all alpha-hemolytic strains belong to the S. milleri group, a considerable number of this group could be missed among alpha-streptococci isolated from the peritonsillar abscess. As antibiotics began being used widely, normal flora such as the S. milleri group may have become an important pathogen in peritonsillar abscesses due to an imbalance between organisms and host defense.     

Malignant fibrous histiocytoma of the head and neck: a case series

Purpose

The study objective is to evaluate the clinical features and outcomes of patients treated for head and neck malignant fibrous histiocytoma at a tertiary care medical facility.

Materials and methods

This is a retrospective case series of 17 adult subjects with malignant fibrous histiocytoma of the head and neck who were treated between January 1, 1965, and December 31, 2010. This study was conducted using patient charts at a tertiary medical center. Subject selection was conducted using Current Procedural Terminology numbers; International Classification of Diseases, Ninth Revision, codes; and a search of the tumor registry.

Results

Chart review of the 17 identified subjects revealed an overwhelming male predominance (88%) with an overall mean age of 69 years(52–87 years). Thirteen patients (78%) underwent some form of surgical resection, 6 patients (35%) received radiation therapy, and 6 (35%) were given chemotherapy over the course of treatment. Nine tumors (53%) had a cutaneous origin, whereas 8 lesions (47.1%) were found in the soft tissue of the head and neck region. The local recurrence rate following a single resection was 46%. Overall median survival following diagnosis was found to be 65 months, with a 5-year survival rate of 52%. Median disease-free survival was 20 months, with a 5-year disease-free survival rate of 37%. Overall median and 5-year survival rates were found to increase with clear surgical margins, as was 5-year survival.

Conclusions

Aggressive surgical management to achieve clear margins is central to the effective treatment of malignant fibrous histiocytoma of the head and neck. Metastatic disease portends a dismal prognosis.     

Methicillin-resistant Staphylococcus aureus as a pathogen in deep neck abscesses: a pediatric case series

OBJECTIVES: Pediatric deep neck space abscesses are frequently treated by the otolaryngologist. We report four children with deep neck abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA), including the first described case of descending mediastinitis caused by MRSA in a child. METHODS: Records from March 2001 to April 2002 were reviewed. RESULTS: Four patients presented with neck swelling, and three of these also had leukocytosis. All abscess cultures were positive for MRSA. Abscess drainage with antibiotic therapy successfully treated three cases without complication. The fourth case developed descending mediastinitis but survived after additional surgical treatment and prolonged antibiotic therapy. CONCLUSIONS: MRSA should be considered as a potential pathogen in deep neck space abscesses. A high index of suspicion is needed as well as aggressive treatment including incision and drainage along with culture-directed medical therapy. Surgical drainage may be the most important aspect of therapy.     

Neuroendocrine carcinoma of the head and neck: a 20-year case series

Neuroendocrine carcinoma (NEC) can be an aggressive disease with locoregional and distant metastasis. We present this article (1) to highlight the typical presentation of NEC in head and neck primary sites such as the parotid gland, paranasal sinuses, and supraglottis and (2) to discuss the prognosis of these tumors based on their histologic subtype and stage. We base our comments on the findings of our retrospective review of the cases of 16 adults-10 men and 6 women, aged 43 to 88 years (mean: 65.8)-who had been diagnosed with pathologically confirmed NEC of the head and neck. Analysis of subtypes revealed that 11 of these patients (68.8%) had presented with poorly differentiated NEC, 4 (25.0%) with moderately differentiated NEC, and 1 (6.3%) with well-differentiated NEC. The most common primary sites were the salivary glands (n = 5; 31.3%), paranasal sinuses (n = 4, 25.0%), and larynx (n = 4). There was no statistically significant difference in survival at 24 months between the patients with moderately differentiated NEC and those with poorly differentiated NEC (37.5 vs. 35.4%; p = 0.86); at the end of the study period, the patient with well-differentiated NEC was still living, 129 months after diagnosis. Taken together, patients with stage I, II, and III disease had a combined survival of 77.8% at 12 months, which was significantly higher (p = 0.023) than the 57.1% survival at 12 months for patients with stage IV disease.     

Aneurysmal bone cysts of the head and neck in pediatric patients: a case series

OBJECTIVES: To characterize aneurysmal bone cysts (ABCs) of the head and neck as seen at a tertiary care center. DESIGN: A case series. METHODS: A retrospective chart review of pediatric patients with aneurysmal bone cyst of the head and neck treated at the Hospital for Sick Children during the years 1994-2006 was carried out. RESULTS: Nine patients with ABC were treated. The average age at diagnosis was 9.3 years (range: 5 months-15 years), six males and three females. Four cysts originated in the paranasal sinuses, two in the mandible, one in the zygoma, one in the mastoid and one in the parietal bone. Two cases were associated with a previous localized trauma (mandible, zygoma). 5/9 presented with pain, 4/9 presented as an asymptomatic mass, 2/9 were associated with proptosis and nasal obstruction, 2/9 with nasal obstruction and 1/9 presented with an aural polyp. Seven cysts were successfully excised while one (in the pterygomaxillary fossa) is being followed conservatively. In one case the ABC was found to be secondary to an extensive osteoblastoma and this child continuous to be problematic. Follow-up time ranged from 2 years and 6 months to 10 years. CONCLUSIONS: ABC of the head and neck may vary in presentation and severity. Surgical removal is the treatment of choice at our institution and may provide a satisfying outcome. ABC may be secondary to an underlying bone pathology (e.g., osteoblastoma) which may make it refractory to treatment.     

Head and neck infections caused by Streptococcus milleri group: an analysis of 17 cases

BACKGROUNDS: Streptococcus milleri group (SMG) is a common inhabitant of the mouth and gastrointestinal tract, and can be an aggressive pathogen causing abscess formation at various sites in the body. However, it has rarely been listed as a cause of head and neck infections. OBJECTIVES: The present study was performed to evaluate the clinical significance of SMG by reviewing the microbiology and clinical records of patients with SMG in head and neck infections retrospectively. STUDY DESIGN: A retrospective review of all patients diagnosed as having SMG bacterial infections at Onomichi General Hospital, Hiroshima, between the years 2001 and 2002 was performed; 17 patients developed head and neck infections with SMG. Here, we describe the clinical features and management of SMG in head and neck infection. RESULTS: The patient population consisted of 12 males and 5 females with a median age of 62 years (age range, 8-78 years). The sites of infection were as follows: maxillary sinus (n=6), peritonsillar region (n=4), subcutaneous (n=3), submandibular space-retropharyngeal space (n=1), deep neck-mediastinum (n=1), parapharyngeal space (n=1), submandibular space (n=1), tonsil (n=1), parotid gland (n=1), and masseter muscle (n=1). Ten cases (59%) were of suppurative diseases. Six cases (35%) had mixed SMG with anaerobe infection. Three cases showed deteriorating clinical courses, and all three of these cases were culture-positive for SMG with anaerobes. In addition, one deteriorating case showed gas gangrene regardless of repeated surgical debridement and intravenous antibiotic therapy; hyperbaric oxygen therapy improved this patient's condition. CONCLUSION: It is important to recognize SMG as a pathogen in head and neck infection. In addition, the care should be taken with infectious diseases caused by SMG with anaerobes as the patient's clinical course can deteriorate rapidly.     

Pediatric head and neck extramedullary hematopoietic disease: case series and review of the literature

We review 3 pediatric cases of extramedullary hematopoietic disease occurring in the orbit, ethmoid sinuses, and parotid gland, and present a review of the literature. Each of the 3 patients was taken to the operating room, and the biopsy specimens obtained were successful in establishing the diagnosis in every case. Head and neck manifestations of extramedullary hematopoietic disease are rare, indeed. However, these cases demonstrate that it is important for otolaryngologists, pediatricians, primary-care physicians, radiologists, and pathologists to maintain a high index of suspicion for extramedullary presentations of hematopoietic disease in the head and neck. A coordinated multidisciplinary approach, including the appropriate surgical approach for biopsy, will facilitate determination of the diagnosis and treatment plan.     

Microbiology of abscesses of the head and neck in children

Specimens from 36 children with abscesses of the neck and 31 children with abscesses of the head were cultured for aerobic and anaerobic bacteria. Antimicrobial therapy was administered to 51 of the 67 patients (76%) prior to sample collection. In specimens obtained from neck infections, aerobic bacteria only were recovered in 24 (67%), anaerobic bacteria only in seven (19%), and mixed aerobic and anaerobic bacteria in five (14%). In abscesses of the head, aerobic bacteria only were recovered in 11 (35%), anaerobic bacteria only in eight (26%), and mixed aerobic and anaerobic bacteria in 12 (39%). Of a total of 52 isolates recovered from neck abscesses (1.4 per specimen), 34 were aerobes (0.9 per specimen), and 18 were anaerobes (0.5 per specimen). Of a total of 62 isolates recovered from head abscesses (2.0 per specimen), 20 were aerobes (0.6 per specimen), and 42 were anaerobes (1.4 per specimen). The most frequently recovered organism in neck infection was Staphylococcus aureus (20 isolates), and the most frequently recovered organism in head infection was Bacteroides sp (19 isolates). beta-Lactamase activity was detected in 36 isolates recovered in 21 abscesses (46%). Correlation between the predisposing conditions and the bacteria recovered showed a higher recovery of anaerobes in patients with dental infection or manipulation, tonsillitis, and fetal monitoring. Staphylococcus aureus was associated with trauma. This study demonstrated the importance of anaerobic bacteria in abscesses in the head and neck, especially in infections originating from sites where these organisms are the predominant flora.     

Head and neck teratomas in children: a case series

Teratomas of the head and neck due to their obscure origin, bizarre microscopic appearance, unpredictable behaviour and often dramatic clinical presentation are a clinical surprise. This article focuses on pediatric head and neck teratomas and on their diversity and rarity and also reviews the recent terminology of this group of tumours.     

Microbiology and antibiotic treatment of head and neck abscesses in children

The clinical data, microbiological results and antibiotic treatment of 65 children who have required incision and drainage of suppurative head and neck abscesses was retrospectively investigated with the aim of developing a more effective clinical protocol of treatment, improving speed of resolution and rationalizing the need for surgical intervention. A positive culture grew in 78% of children and of these 45% were Staphylococcus aureus, 9% Streptococcus pyogenes, and 8% atypical mycobacteria. Only 3% of the samples grew anaerobes. All isolates of S. aureus were sensitive to Flucloxacillin and all isolates of S. pyogenes were sensitive to penicillin. All anaerobes were Metronidazole sensitive. In 40% of the children there were no localizing symptoms which could guide the treatment, therefore we recommend Flucloxacillin and Metronidazole as the antibiotic regimen of choice in acute suppurative lymphadenitis. The increasing incidence of atypical mycobacterial lymphadenitis is noteworthy.     

Papillary squamous cell carcinoma of the head and neck: a clinicopathologic series

Purpose

Papillary squamous cell carcinoma (PSCC) is a rare malignancy that has been associated with human papillomavirus. We present all cases of this disease at a single academic teaching hospital over the last 30 years.

Materials and Methods

A retrospective chart review was performed for all patients with a diagnosis of PSCC. Of 65 patients identified, 52 were included after meeting established diagnostic criteria. Chart reviews were performed for patient demographics, overall survival, and disease-free survival.

Results

Mean age at diagnosis was 65 years, with a male to female ratio of 2.3:1. The majority of lesions (n = 34, 65.4%) arose in areas commonly affected by benign squamous papillomas, with the laryngopharynx the most commonly affected (n = 19, 36.5%), followed by the oral cavity (n = 18, 34.6%), sinonasal tract (n = 8, 15.4%), and oropharynx (n = 7, 13.5%). Two- and 5-year disease-free survival rate was 68% and 46%, respectively. Overall survival rate was 90% and 72% at 2 and 5 years, respectively.

Conclusions

Papillary squamous cell carcinoma of the head and neck is a distinct variant of conventional squamous cell carcinoma with a good prognosis despite high locoregional recurrence rates. Histology and subsite localization corroborate existing evidence that human papillomavirus may be involved.     

Granulocytic sarcoma of the head and neck: a case report

A rare case of granulocytic sarcoma of the head and neck region is presented to highlight its unusual clinical presentation and the difficulties encountered in its diagnosis. The risk factors, pathological findings, and treatment modalities are discussed to make head and neck surgeons aware of this condition, which can have a fatal outcome as happened in our case.     

Deep neck space abscesses of dental origin: the impact of Streptococcus group Milleri

In recent years, there has been rising interest in Streptococcus group Milleri (SM) because high mortality rates have been related to it. In case of deep neck infections (DNI), whatever the origin, mortality rates as high as 26 % were reported. But there are no data available for DNI with SM of purely dental origin. The aim of our article was to describe and analyse DNI of purely dental origin involving on one hand SM and on the other hand infections without presence of SM. We compared these two groups and statistically investigated if there were differences in clinical presentation (age, mouth opening, length of hospital stay, laboratory parameters) or clinical behaviour (re-operation, re-hospitalisation, secondary osteomyelitis, stay at intensive care, length of antibiotic treatment, presence of resistances against antibiotics, incapacity to work). For this, we retrospectively searched medical records of our institution for all purulent DNI treated from 2004 till 2012. We found 81 patients meeting all inclusion criteria. Thirty-four patients had involvement of SM, 47 did not. The only statistically significant difference between the SM group and the non-SM group was the length of incapacity to work. All other parameters were non-significant. Furthermore, there were no fatalities. In conclusion, the clinical importance of this article is that patients with deep neck abscesses of purely dental origin involving SM do not need more or different care when compared to all other DNI of dental origin.     

Reducing mortality in mucormycosis of the head and neck in diabetic patients: A CARE case series

IntroductionRhinocerebral mucormycosis is extremely fatal, with mortality rates ranging from 85-93% despite the best treatment in immunocompromised patients. We emphasize the importance of early diagnosis, repeated debridement, and aggressive antifungal treatment to reduce mortality.Case summaryWe report six cases (five male and one female), with a mean age of 51 years who were diagnosed to have mucormycosis from 2017 to 2019. All patients were diabetic. Intracranial involvement and orbital involvement were found in four cases. Facial nerve palsy was seen in two cases, one without any apparent otological involvement. Aggressive serial debridement and amphotericin B was started. Posaconazole was added subsequently to the treatment in two cases. One patient succumbed to the disease five months after discharge. The other five patients are on regular follow-up for a mean duration of 14 months at the end of which two had residual disease which was under control.DiscussionRepeated surgical debridement with an early aggressive and combination antifungal therapy can result in good outcomes even in advanced mucormycosis. Concurrent management of the underlying pathology, monitoring of liver and kidney functions, and therapeutic drug monitoring are useful to ensure smooth and effective treatment.