Current management of upper respiratory tract and head and neck infections

The objective of this study is to present the antimicrobial management modalities of treating upper respiratory tract (URT) and head and neck infections. This article discusses the current antimicrobial treatment strategies of URT and head and neck infections. The increasing antimicrobial resistance of many bacterial pathogens has made the treatment of URT and head and neck infections more difficult. This review summarizes the aerobic and anaerobic microbiology and antimicrobials therapy of acute and chronic URT and head and neck infections. These infections include dental (gingivitis, periodontitis, necrotizing ulcerative gingivitis, and periodontal abscess), acute and chronic otitis media, mastoiditis and sinusitis, pharyngo-tonsillitis, peritonsillar, retropharyngeal and parapharyngeal abscesses, suppurative thyroiditis, cervical lymphadenitis, parotitis, siliadenitis, and deep neck infections including Lemierre syndrome. In conclusion, the proper management of these infections requires an accurate clinical and bacteriological diagnosis.     

The role of biofilms in otolaryngologic infections: update 2007

PURPOSE OF REVIEW: Biofilms have been shown to play a role in otitis media, sinusitis, cholesteatoma, tonsillitis, adenoiditis, and device infections. This article is written to review recent advances in the field. RECENT FINDINGS: The role of biofilms in the persistence of chronic, mucosal-based ENT-related infections was first recognized in otitis media. Definitive proof was lacking until the demonstration of bacterial biofilms on the middle-ear mucosa of children, not only with chronic otitis media with effusion, but also with recurrent otitis media. Strains of Pseudomonas aeruginosa isolated from cholesteatoma are avid biofilm formers. Biofilms have been reported in the adenoids of children with chronic rhinosinusitis, helping to explain the clinical observation that adenoidectomy can be beneficial to children with chronic otitis or chronic rhinosinusiti. Additional studies have confirmed the presence of biofilms in chronic tonsillitis. Biofilms have also been shown to be involved in infected cochlear implants and tracheotomy tubes. SUMMARY: The recognition that chronic otolaryngologic bacterial infections are biofilm related has been the impetus for the development of new technologies for the study of biofilms and their prevention and treatment. Understanding that chronic bacterial infections are biofilm related is fundamental to developing rationale strategies for treatment and prevention.     

Emergence and persistence of beta-lactamase-producing bacteria in the oropharynx following penicillin treatment

The emergence and persistence of aerobic and anaerobic beta-lactamase-producing bacteria (BLPB) were investigated in 26 children treated with penicillin for otitis media or pharyngitis and in 28 nontreated control children. beta-Lactamase-producers were isolated in three (12%) of the treated children before therapy, in 12 (46%) seven to ten days after completion of therapy, in nine (35%) 40 to 45 days after therapy, and in seven (27%) 85 to 90 days after therapy. These organisms were present in three (11%) of the nontreated children, and the number of patients harboring BLPB stayed constant throughout the three-month follow-up. The predominant BLPB were Bacteroides species (Bacteroides melaninogenicus group, Bacteroides oralis, and Bacteroides oris-buccae), Staphylococcus aureus, Haemophilus influenzae, and Branhamella catarrhalis. The emergence and persistence of BLPB after penicillin therapy may have important implications for the antimicrobial management of infections of the upper respiratory tract.     

Deep neck infections

Deep neck infection is relatively rare but potentially life threatening complication of common oropharyngeal infections. This retrospective study was aimed at analyzing the occurrence of complications, diagnostic methods and proper management of deep neck infection. A review was conducted in 32 cases who were diagnosed as having deep neck infection from 1995 to 2005. The causes of deep neck infections were tonsillitis (16 cases), tooth diseases (6 cases), paratonsillar abscess (4 cases), parotitis (1 case), pussy lymphonodes after tonsillectomy (2 cases), pussy congenital neck cyst (1 case), chronic otitis media (1 case), parotitis (1 case), foreign body of the esophagus (1 case). All the puss bacterial cultivation were positive. All the patients were treated by different ways of chirurgical drainage and use of large dosage of antibiotics. Deep neck infection should be suspected in patients with long lasting fever and painful swelling of the neck and treatment should begin quick as possible.     

Pseudomonas cervical osteomyelitis with retropharyngeal abscess: an unusual complication of otitis media

We present the unusual case of a 54-year-old diabetic man with chronic suppurative otitis media, presenting with cervical osteomyelitis and retropharyngeal abscess. This was treated with decompression, debridement and fusion from C2 to C4 with external halo-frame stabilization. Pseudomonas aeruginosa was cultured from the ear and the osteomyelitis specimen. Exploration of the left ear showed evidence of mucosal disease, with granulations in the middle ear and oedematous mucosa in the mastoid antrum, but no evidence of dural-plate dehiscence. Haematogenous spread probably led to cervical osteomyelitis and retropharyngeal abscess formation. Cervical osteomyelitis may develop as a rare complication and present as a cause of severe neck pain in patients with otitis media.     

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.     

Parapharyngeal and retropharyngeal space abscess: an unusual complication of chronic suppurative otitis media

Parapharyngeal and retropharyngeal abscess as a complication of cholesteatoma is an uncommon entity. We present the unusual case of a 32-year-old man with chronic suppurative otitis media, presenting with parapharyngeal and retropharyngeal abscess. This was treated with incision and drainage of the abscess followed by modified radical mastoidectomy for chronic suppurative otitis media.     

Acute non-tuberculous retropharyngeal abscess in adults (case reports of three patients)

Acute non-tuberculous retropharyngeal abscess in adults usually occurs after trauma to the pharynx and oesophagus. However, it may present secondarily to head and neck infection and should be borne in mind when dealing with patients who complain of cervical pain. The probable route of spread is via the lymphatics to a persistent retropharyngeal lymph node. Rarely, the abscess may occur spontaneously. The abscess can be drained safely via a transoral route, as in children, or by an external route.     

The role of biofilms in otolaryngologic infections

PURPOSE OF REVIEW: Bacterial biofilms have recently been shown to be important in diseases of the head and neck. Because the concept of biofilms is novel to most practitioners, it is important to gain a basic understanding of biofilms and to recognize that strategies developed to treat planktonic bacteria are ineffective against bacteria in a biofilm. RECENT FINDINGS: Bacteria preferentially exist in complex, surface-attached organizations known as biofilms. Bacteria in biofilms express a different set of genes than their planktonic counterparts and have markedly different phenotypes. Biofilm bacteria communicate with each other, and have mechanisms to diffuse nutrients and dispose of waste. Biofilms provide bacteria with distinct advantages, including antimicrobial resistance and protection from host defenses. Thus, bacteria exist in a far more complex fashion than previously thought and can best be thought of as "self-assembling multicellular communities." Although a focus on the planktonic form of bacteria has been useful in understanding acute infections, chronic infections are much better understood as biofilm illnesses. Biofilms have been shown to be involved in chronic otitis media, chronic tonsillitis, cholesteatoma, and device-associated infections. SUMMARY: Now that basic research has demonstrated that the vast majority of bacteria exist in biofilms, the biofilm concept of disease is beginning to spread throughout the clinical world. Understanding that many of the infections that affect structures of the head and neck are actually biofilm related is fundamental to developing rational strategies for treatment and prevention.     

Detection of bacterial biofilms in different types of chronic otitis media

Biofilms are organized bacterial communities that may be homogeneous or heterogeneous. They play a significant role in the pathogenesis of chronic nasal sinusitis, chronic tonsillitis, cholesteatomas, and device-related infections. Despite this, few studies have been done that examine the presence of bacterial biofilms in tissues from patients with different types of COM or middle ear cholesteatomas. In the current study, we examined the presence of biofilms in surgical tissue specimens from humans with chronic ear infections using scanning electron microscopy (SEM). We hypothesize that bacterial biofilms present differently in patients with different types of chronic otitis media. Our results provide new insights regarding treatment of chronic otitis media. A prospective study was conducted in which middle ear tissues were obtained from 38 patients who underwent tympanoplasty and/or tympanomastoid surgery due to chronic ear infections. A total of 50 middle and mastoid tissue samples were processed for SEM analysis. In addition, 38 middle ear secretion specimens were obtained for routine bacterial culture analysis. Bacterial biofilms were present in 85 % (11 of 13) of patients with middle ear cholesteatoma, 92 % (12/13) of patients with chronic otitis suppurative media (CSOM), and 16 % of patients (2/12) with tympanic membrane perforation (TMP). Fungal biofilms were found in two cases of cholesteatoma. The positive coincidence rate between bacterial biofilms visualized by SEM and bacteria detected by culture was 82 %. Our findings suggest that bacterial biofilms are very common in CSOM and middle ear cholesteatomas. Positive bacterial cultures imply the presence of biofilm formation in CSOM and cholesteatomas. As such, our results provide new insights regarding treatment of chronic otitis media.     

Medical treatment of non-streptococcal recurrent tonsillitis

Forty patients with a history of recurrent non-beta-hemolytic streptococcal tonsillitis (RNST) participated in a prospective randomized study comparing penicillin and clindamycin in the treatment of acute non-group A streptococcal infection. The efficiency of each antibiotic was evaluated according to its ability to alleviate acute infection and prevent recurrence. Surface tonsillar cultures were obtained both before and ten days after the termination of therapy, and specimens were processed for aerobic and anaerobic bacteria. Beta-lactamase-producing bacteria (BLPB) were present in 36 (90%) tonsillar cultures. Thirty-one BLPB were isolated in 17 patients before penicillin therapy and 42 BLPB were recovered from 19 after such treatment. Thirty-three BLPB were recovered in 19 patients before clindamycin therapy, after which four BLPB were isolated in three patients (P less than .05). From the second day posttherapy onward, significantly fewer patients who received clindamycin had fever, pharyngeal injection, and sore throat. In a 1-year follow-up period, recurrent tonsillitis was noted in 13 of the patients who received penicillin and in two treated with clindamycin (P less than .001). The data clearly demonstrate the superiority of clindamycin therapy over penicillin in patients with RNST.     

Retropharyngeal abscess: An unusual presentation of Kawasaki disease. Case report and review of the literature

We report the case of a patient with Kawasaki disease whose initial presentation mimicked a retropharyngeal abscess and review the literature of this topic (16 cases reported). Fever and deep neck infection like symptoms were the only clinical findings at admission in 87.5% children. All children had a neck CT scan performed showing findings suggestive of retropharyngeal abscess. All children were started antibiotic therapy without clinical improvement and 31% of patients underwent unproductive surgical drainage of the retropharyngeal space. Otolaryngologist should be aware of atypical presentation of Kawasaki disease presentation mimicking retropharyngeal abscess. Early diagnosis is pivotal for preventing cardiac complications and avoiding the risk associated to unnecessary surgical intervention.     

Retropharyngeal and parapharyngeal infections in children: the Toronto experience

OBJECTIVE: To review the Hospital of Sick Children, Toronto's experience of the diagnosis and management of retropharyngeal and parapharyngeal infections with particular emphasis on the role of computed tomography (CT) imaging in diagnosing the presence of an abscess. METHODS: A retrospective analysis of all patients diagnosed with retropharyngeal and parapharyngeal infections from 1987 to 1999 was performed. Demographic data, presenting symptoms, season of presentation, management and complications were reviewed. The CT scans of 27 patients who underwent surgical treatment were retrospectively examined by two neuroradiologists who were blinded to the patient's history and outcome. The sensitivity, specificity and predictive values for the specific features and overall assessment were calculated. RESULTS: Fifty-four children were identified. There were 46 retropharyngeal infections, 6 parapharyngeal infections and 2 patients had both retropharyngeal and parapharyngeal infections. All patients were treated with parenteral antibiotics. Thirty-seven patients underwent surgical drainage and in 27 there was a positive finding of pus. The retrospectively assessed CT scans of the 21 patients who underwent surgery were found to have a sensitivity of 81% in detecting an abscess by CT scan but the specificity was 57%. There were four complications including mediastinitis, aspiration pneumonia, internal jugular vein thrombosis and common carotid artery aneurysm. All patients recovered but abscess recurred in five patients. CONCLUSION: Not all patients with retropharyngeal and parapharyngeal abscesses require surgery. Whilst CT scans are helpful in diagnosing and assessing the extent of these infections they are not always accurate in detecting an abscess. A decision to drain an abscess should therefore not be made based solely on the CT findings.     

Deep Neck Infections in Children: A New Approach to Diagnosis and Treatment

Forty-seven children presented with the diagnosis of a deep neck infection-either cellulitis or abscess-between January 1991 and July 1996. Forty-four (94%) had contrast-enhanced computed tomography (CT) imaging consistent with this diagnosis. Three patients with no CT scan had confirmation of an abscess at surgical drainage. Parenteral antibiotics alone were effective in the treatment of 24 of 47 infections (51%): seven parapharyngeal, one retropharyngeal, and 16 combined. By CT scan these infections represented cellulitis in 17 of 24 (71%), an abscess in three of 24 (13%), and incomplete abscess in four of 24 (17%). The average duration of hospitalization for this group was 4.8 days, with symptomatic improvement usually seen within 24 hours. Surgical drainage was performed on 23 of 47 infections (49%): three parapharyngeal, 17 combined, and three of unknown specific location. In 22 of these 23 children (96%), transoral drainage of the abscess was used as the primary surgical approach. In 21 of these 22 (95%) there was complete resolution without complications or recurrence; one abscess required a subsequent external approach. CT scanning with contrast revealed that all deep neck infections were located medial (usually anteromedial) to the great vessels. Abscesses with volumes estimated to be greater than 2000 mm³ were more likely to undergo surgery, but these differences were not statistically significant. The use of contrast-enhanced CT scanning provides information regarding abscess size, location, and relative position of the great vessels for safe and successful transoral drainage. Thus we recommend CT-assisted transoral drainage for combined retropharyngeal/parapharyngeal abscesses and selected isolated parapharyngeal abscesses that do not respond to parenteral antibiotics.     

Correlation between immunohistochemical indices of adenoid vegetations and health of ailing children

We studied correlations between clinical characteristics of ailing children and their immunohistochemical parameters. Clinical status was assessed by the degree of adenoid vegetations, duration of the disease, the presence of chronic tonsillitis or its combination with adenoiditis. We used the following immunohistochemical parameters: the level of CD3+ in histological slices and the presence or absence of IgA-producing cells. Correlation was found between the presence or absence of IgA-producing cells and the degree of adenoid vegetations as well as the presence only of chronic tonsillitis or chronic tonsillitis plus adenoiditis. We found also important but statistically insignificant differences: in a group of patients with the disease duration up to 2 years CD3+ cells were absent, while in children with the disease duration more than 5 years these cells were present. Thus, immunohistochemical parameters are rather informative in interpretation of a clinical picture in ailing children.     

Severe combined immunodeficiency: otolaryngological presentation and management

In order to increase the awareness of otolaryngologists of severe combined immunodeficiency syndrome (SCIDS) so they may contribute to an earlier diagnosis of this disorder, we performed a retrospective chart review of a multicenter series from 2 children's hospital medical centers. Eighteen cases were identified, and 14 had an otolaryngological presentation. The average age of presentation was 3.3 months, and 72% were males. Most cases were inherited in an X-linked fashion. Five patients had thrush; 4 had recurrent otitis media. Other otolaryngological presentations included cough, mouth ulcers, pharyngitis, mastoiditis, and bilateral neck abscess. The most severe form of immunodeficiency, SCIDS is a rare condition that involves a disorder in both T and B cell functions. The manifestations involving the head and neck include recurrent upper respiratory tract infections, otitis media, thrush, oral ulcers, and abscesses. It is important that SCIDS be considered in any infant with recurrences of these common infections.     

A case of spinal epidural abscess associated with retropharyngeal abscess

Spinal epidural abscesses are known to occur associated with retropharyngeal abscess, but such cases are few in the literature. We treated a 72-year-old woman who reported pain in the back of the neck. Computed tomography (CT) showed a retropharyngeal abscess extending to the upper neck through the carotid space on the left side and an magnetic resonance imaging (MRI) showed a spinal epidural abscess without cervical vertebral osteomyelitis. The abscess was assumed to reach the epidural space along the nerve root through the intervertebral foramen. Since tonsillitis appeared to cause the retropharyngeal abscess, we performed tonsillectomy, and then drained pus through the superior constrictor muscle, effecting a subsequent cure. Staphylococcus aureus was recovered from both the pus and tonsil, and Streptococcus constellatus, a member of the Streptococcus milleri group, from the tonsil. Based on a review of the literature, clinical courses of spinal epidural abscess associated with retropharyngeal abscess are not always simple, as 4 of the 7 cases found demonstrated poor prognosis. Spinal epidural abscess should be considered a critical complication of retropharyngeal abscess.     

Peritonsillar abscesses in children

A follow-up retrospective study was performed on 41 children who presented with peritonsillar abscesses from 1970–1980. The ages ranged from 3 to 16 years, with the mean age of 10 years. There were 26 females and 15 males. The abscesses were predominantly left-sided (28 vs. 13 right-sided) and the mean duration of symptoms was 3 days. Of the patients, 39% had been treated with antibiotics prior to the abscess development. Only 15% of the patients had a documented past history of exudative tonsillitis. Of the 41, 1 patient was lost to follow-up, and 11 underwent tonsillectomy for the abscess. Thus, 29 patients were reviewed who received no surgical therapy for their peritonsillar abscess other than incision and drainage. These patients were contacted for an interval history with a period of follow-up ranging from 6 months to 10 years. Only 2 of the 29 patients (7%) had recurrent abscesses. Two other patients (7%) had further recurrent bouts of exudative tonsillitis but not abscesses. These 4 children were in an initial group of 6 who had a prior history of documented tonsillitis. The incidence of recurrent peritonsillar abscesses reported in the literature has ranged from 7.6 to 16% in series which were comprised mainly of adults. The low incidence of recurrent abscesses (7%) in this series would indicate a need to reevaluate the indication for tonsillectomy for peritonsillar abscess in the pediatric age group. The authors recommend that tonsillectomy be performed in those children who present with a pervious history of documented tonsillitis or suffer a complication at the time of the first abscess (neck abscess or airway compromise).     

Effect of antimicrobial therapy with amoxicillin and cefprozil on bacterial interference and beta-lactamase production in the adenoids

To compare the effects on the bacterial flora of the adenoids of antimicrobial therapy with amoxicillin or cefprozil, we enrolled in a prospective randomized study 60 children scheduled for elective adenoidectomy because of recurrent otitis media. They were randomized before surgery into 3 groups of 20 patients each: a no-therapy group, and groups with 10 days of either amoxicillin or cefprozil therapy. Core adenoid materials were quantitatively cultured for aerobic and facultative bacteria. The in vitro ability of alpha-hemolytic streptococci (AHS) to inhibit the growth of non-type B Haemophilus influenzae and Streptococcus pneumoniae was determined. The number of organisms in adenoids obtained from patients treated with either antibiotic was reduced as compared to that in adenoids from controls. However, in patients treated with amoxicillin, a significant decline in the number of AHS, and an increase (in Staphylococcus aureus) or no change in the number of other beta-lactamase-producing bacteria (BLPB) was noted. In contrast, in those treated with cefprozil, no change was noted in the frequency of recovery of AHS, and the number of BLPB decreased. Interfering AHS were more often recovered in patients treated with cefprozil. We conclude that the adenoids contain more interfering AHS after therapy with a second-generation oral cephalosporin (cefprozil) than after amoxicillin therapy. This study suggests a potential beneficial effect of using an antimicrobial that selectively spares interfering AHS while inhibiting BLPB.