Necrotizing soft tissue infections of the head and neck: case reports and literature review

A small but nevertheless important part of a surgeon's experience comprises necrotizing soft tissue infections of the head and neck. The purpose of this report is to heighten awareness of necrotizing soft tissue infections in any patient with an infection of the head and neck. The article also outlines an appropriate management strategy for use in the treatment of patients with this potentially fatal condition. Prompt diagnosis and early radical surgical debridement are significant factors in avoiding a fatal outcome in these patients. This article reviews the literature on necrotizing soft tissue infections of the head and neck and presents cases from our recent experience.     

Current thinking on the management of abnormal retropharyngeal nodes in patients with oral,oropharyngeal, and nasopharyngeal squamous cell carcinoma: a structured review

The management of enlarged retropharyngeal lymph nodes (RLN) in patients with confirmed oral, oropharyngeal, or nasopharyngeal squamous cell carcinoma (SCC) has prognostic relevance and is a challenge for the clinical teams. There is, however, no consensus regarding their clinical management or radiographic evaluation. The aim of this review therefore was to present the current thinking on management to help improve outcomes. We searched several online databases using the key terms “retropharyngeal node”, “oral cancer”, “head and neck cancer”, “oropharyngeal cancer”, “nasopharyngeal cancer”, “nasopharynx”, “oral cavity”, “oropharynx”, “TORS”, and “radiotherapy”. A total of 1024 papers were screened, of which 32 were eligible. There was no consensus about the management of RLN. There is a lack of randomised studies and a lack of consistency in the presentation of results. Management should be tailored in patients with nasopharyngeal carcinoma (NPC), and prophylactic irradiation is warranted as these nodes are at high risk of metastasis. In patients with non-NPC tumours, we prefer to resect them during primary operations when there is radiological uncertainty or evidence that they are affected, as the combination of radiological and histological outcomes will further our understanding. In both NPC and non-NPC tumours, sampling may also help to standardise the radiological criteria for the diagnosis of RLN by contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) CT.     

The impact of COVID-19 on cervicofacial infection of dental aetiology

Cervicofacial infections of dental aetiology can be life-threatening and with the closure of dental practices following the onset of the COVID-19, it would be anticipated that their prevalence presenting to maxillofacial surgery would increase and services may be overwhelmed, with patients presenting later with a potential subsequent increase in morbidity. A retrospective analysis of patients with cervicofacial infection of dental aetiology referred to maxillofacial surgery during the initial six weeks of COVID-19 lockdown in 2020 was carried out and compared with the equivalent period in the two preceding years. Unexpectedly, during COVID-19 lockdown, there was a reduction in patients seen with cervicofacial infection of dental aetiology. This may have resulted from patient adherence to government guidelines “Stay at home”, successful triaging of patients in primary care and emergency treatment provided by urgent dental care centres. Proportionally more patients who presented to hospital had received prior antibiotic therapy and required in-patient admission. All patients admitted received incision and drainage, with an increase extraoral drainage and an associated reduction in length of stay. During COVID-19 lockdown, maxillofacial managed a reduced number of patients with cervicofacial infection, likely resulting from primary and secondary dental care working together. The rate of incision and drainage of patients not admitted increased under local anaesthesia with increase of extraoral drainage and reduced length of stay for those admitted.     

Management of sinus graft infection—a systematic review

Sinus graft infections are rare but serious complications, as they are associated with significant morbidity and sinus graft loss. The aim of this study was to systematically review the management of sinus graft infection in order to define which protocols should be implemented. The terms searched in each database were “sinus graft infection management”, “maxillary sinus lift infection”, “maxillary sinus graft infection”, “maxillary sinus elevation infection”, and “maxillary sinus augmentation infection”. The management of the sinus graft infection was assessed. The outcomes evaluated were maxillary sinus health and dental implantation results. The initial search yielded 1190 results. Eighteen articles were included, reporting a total of 3319 patients and 217 sinus graft infections. Drainage was performed with an intraoral approach in 13 studies, an endoscopic approach in two studies, and a combined approach in three studies. In every study, a disease-free sinus was finally obtained in all patients, but the outcomes of the graft and the dental implant were more varied. It is not possible to define the best treatment protocol for sinus graft infections based on the published data, since the level of evidence is poor. Management is very heterogeneous. This review highlights the necessity of surgical treatment associated with antibiotic therapy.     

Cervicofacial necrotizing fasciitis following periodontal abscess

Soft tissue infections are characterized by acute inflammation, diffuse edema, and suppuration, and are often associated with symptoms such as malaise, fever, tachycardia, and chills. Necrotizing fasciitis is a destructive bacterial infection affecting subcutaneous tissue and superficial fascia and is associated with high rates of mortality. It usually involves the abdomen and extremities, but it also can occur in the head and neck. Early diagnosis is critical and the most commonly accepted treatment includes radical surgical intervention and administration of broad-spectrum antibiotics. This article reports and discusses the case of a patient with odontogenic cervicofacial necrotizing fasciitis, and emphasizes the importance of early and effective treatment.     

Thoracic pain associated with an odontogenic infection: An unusual Lemierre's syndrome

Lemierre's syndrome is characterized by thrombophlebitis in the internal jugular vein after an infection in the area of the head or neck, mostly in the form of pharyngitis and/or tonsillitis. It may also result from less common conditions, such as odontogenic infections, but this condition has not often been reported in the dental literature. The syndrome's main etiological agent is Fusobacterium necrophorum, and it most commonly occurs in young adults. This study reports the clinical case of a 34‐year‐old female patient of poor socioeconomic status with a history of pericoronitis, who reported having a chest pain that radiated to the upper limbs, along with dyspnea. The computed tomography of her neck provided evidence of an acute thrombus in the right internal jugular vein. The treatment comprised antibiotic and anticoagulant therapy in addition to the extraction of her third molar and some residual roots. This report highlights the perils of systemic complications through dental infection, including the risk of death.     

Cervicofacial necrotizing fasciitis: report of three cases and literature review

Three cases of cervicofacial necrotizing fasciitis have been reported, two of dental etiology, and one the result of blunt and abrasive facial trauma. All cases responded well to aggressive surgical intervention in combination with broad spectrum antibiotic coverage and supportive medical therapy. The presence of increased vascularity in the head and neck region probably minimizes the amount of overlying soft tissue that must be excised during surgical management (in comparison to extremity and trunk necrotizing fasciitis cases). The key to successful management of such infections is early diagnosis of the disease process with prompt surgical and medical intervention.     

Metastasis of squamous cell carcinoma of the head and neck to the thyroid: a single institution’s experience with a review of relevant publications

The thyroid gland is a rare site of metastasis, and in particular of those of squamous cell carcinoma (SCC) from the head and neck region. We have reviewed the aetiology, pathogenesis, clinical characteristics, radiological features, immunohistochemical profile, prognosis, and management of metastatic SCC from the head and neck region to the thyroid, and searched current publications on the Medline, Embase, and Cochrane databases using the following keywords: “SCC of thyroid”, “secondary SCC of thyroid”, and “metastasis to the thyroid”, for papers published during the last 33 years (April 1984 to October 2017).We found a total of 19 papers that reported a total of 32 cases that were relevant. Four further cases were discovered as an incidental finding on follow-up positron emission tomographic/computed tomographic scans with magnetic resonance imaging of the head and neck at our hospital, which were confirmed with an ultrasound-guided core needle biopsy followed by immunohistochemical examination. For patients who are doing well, whose disease is controlled at the primary site, and who have no evidence of distant metastatic disease, total thyroidectomy could be considered followed by adjuvant radiation or chemoradiotherapy, depending on the presence of intermediate or high-risk features on pathological examination and previous history of radiation. This may help to control the disease and avoid local morbidity.     

Atypical fulminating dental nfections

Dental surgeons are faced with treating dental infections on a daily basis and the cases discussed in this paper highlight the potential outcome of such infections, especially in immunocompromised patients. Fulminating infection in the head and neck may present as a rapidly progressive, potentially fatal condition characterized by extensive necrosis of the subcutaneous tissues. One form of such infection is necrotizing fasciitis. Although first described in 1793 by Pouteau, the term necrotizing fasciitis was first coined in 1952 by Wilson who noted that facial necrosis was the most consistent feature of this disease. When necrotizing fasciitis occurs in the head and neck region it is usually odontogenic in origin. This paper reviews the cases of four patients presenting with atypical fulminating dental infection who presented to the oral and maxillofacial department at Guy's and St Thomas's Hospital, London, resulting in cellulitis and necrotizing fasciitis. Aggressive management is critical for patient survival and time wasted is tissue lost. CLINICAL RELEVANCE: Early diagnosis and aggressive treatment of dental infections, especially in patients with altered immune status, is critical. There should be a high index of suspicion in patients with dental infections not responding to treatment and maxillary dental infections with sinus symptoms.     

Dentoalveolar infections

Dentoalveolar infections represent a wide spectrum of conditions, from simple localized abscesses to deep neck space infections. The initial assessment of the patient with a dentoalveolar infection requires considerable clinical skill and experience, and determines the need for further airway management or emergent surgical therapy. Knowledge of head and neck fascial space anatomy is essential in diagnosing, understanding spread, and surgically managing these infections. Oral and maxillofacial surgeons must make use of their wide spectrum of clinical skill and knowledge to effectively evaluate and treat patients with dentoalveolar infections.     

Treatment of Cervicofacial Actinomycosis: A report of 19 cases and review of literature

Objectives: Actinomycosis is a chronic suppurative granulomatous infection caused by the Actinomyces genus. Orocervicofacial actinomycosis is the most common form of the disease, seen in up to 55% of cases. All forms of actinomycosis are treated with high doses of intravenous penicillin G over two to six weeks, followed by oral penicillin V. Large studies on cervicofacial actinomycosis are lacking. Therefore proper guidelines for treatment and treatment duration are difficult to establish. The aim of this study is to establish effective treatment and treatment duration for orocervicofacial actinomycosis. Study design: A Pubmed and Embase search was performed with the focus on treatment and treatment duration for cervicofacial actinomycosis. The hospital records of all patients presenting to our department with head and neck infection from January 2000 to December 2010 were reviewed, retrospectively. The following data were collected: age, gender, clinical presentation, aetiology, duration of symptoms, microbiological findings, treatment, and duration of treatment. The treatment and treatment duration is subsequently compared to the literature. Results: The literature search provided 12 studies meeting the inclusion criteria. All studies were retrospective in nature. Penicillin or amoxicillin/clavulanic acid are the preferred antibiotic regimens found in the literature. Most of our patients were treated with a combination of penicillin G 12 million units/day and metronidazol 500 mg 3/day, most commonly for a duration of 1 – 4 weeks, being shorter than the 3 – 52 weeks reported in the literature. Conclusion: When actinomycosis is suspected, our review has shown that a surgical approach in combination with intravenous penicillin and metronidazol until clinical improvement is seen, followed by oral antibiotics for 2 – 4 weeks is generally efficient. Key words:Actinomycosis, actinomyces, actinomycosis treatment, cervicofacial infection, actinomycosis diagnosis, head and neck infection.     

Advantages of not using the intensive care unit after operations for oropharyngeal cancer: an audit at Worcester Royal Hospital

We reviewed 68 cases of oral and oropharyngeal cancer that were managed without the routine use of intensive care units (ICU), to establish success rates for flaps, complications including nosocomial infections, cancellations, and length of stay. More than 98% of flaps survived and over half the patients had no complications. Low rates of perioperative infection were recorded with a median length of stay of 12 days (range 2-63), and there were no cancellations. We conclude that the routine use of a specialist head and neck ward is more appropriate than ICU for selected cases; it fulfils current guidelines for cancer services, and is an effective use of resources.     

Elongated Styloid Process: Diagnostic Problems Related to Symptomatology

A certain number of patients with elongated styloid process may not have the classic cervicofacial complaints which were originally described by W. Eagle in 1937. Some of those cases who have radiologic evidence of elongated styloid process are symptom free and can be accepted as normal anatomical variants. On the other hand, some of those symptomatic cases may present uncommon neurologic signs and can be misdiagnosed as neurologic or infectious disease. Sometimes, the radiologic presence of an elongated process may cause the clinician to miss another pathology. Therefore, it is essential for the clinician to be aware of the clinical variants with different symptomatology or to particularly seek the origin of the pain in the head and neck before reaching a conclusion, since the only effective treatment in symptomatic cases is the surgical shortening of the process. We report five patients with elongated processes. Problems related to an elongated styloid process with different symptomatology are discussed and the associated literature is reviewed.     

The Effect of the PostureJac on Deep Cervical Flexor Endurance: Implications in the Management of Cervicogenic Headache and Mechanical Neck Pain

Abstract

The convergence of cervical and trigeminal afferents on second-order neurons in the trigeminocervical nucleus may refer pain from the upper cervical spine into the head and face. Furthermore, “bi-directional interactions” between trigeminal and upper cervical afferents may also explain neck symptoms of trigeminal origin (e.g., migraine). It is known that cervicogenic headache sufferers present with several musculoskeletal changes including poor endurance of the deep cervical flexor muscles. These intrinsic muscles of the neck contribute to stabilization and protection of the cervical spine and are critical for the control of both intervertebral motion and the cervical lordosis. The purpose of this study was to determine whether the use of the PostureJac (SomatoCentric Systems, Inc., Toronto, Ontario, Canada), a posture support and exercise jacket, was effective in enhancing deep cervical muscle endurance. Forty-five (45) female subjects, between the ages of 18 and 40 years, were randomly assigned to three groups consisting of the no-treatment control, the treatment-control (table stabilization), and the experimental (PostureJac) group. The outcome measure of deep cervical flexor muscle endurance was based on the Flexor Endurance Test and was recorded in seconds. The results indicated that the PostureJac group was superior to the no-treatment control (p=.001) and the treatmentcontrol (p=.004) groups in terms of increasing endurance of the deep cervical flexors. Consequently, the PostureJac may be a useful therapeutic tool in the management of cervicogenic headache and mechanical neck pain.     

Cutaneous Sinuses of Cervicofacial Region: A Clinical Study of 200 Cases

Purpose

To evaluate the sinuses in the cervicofacial region and to identify the focus of infection. It is also to help the clinician in differentiating the sinuses’ of odontogenic and nonodontogenic focus of infection.

Materials and Methods

The study has been conducted in 200 patients, aged between 11 and 77 years for a period of 6 and a half years at Narayana Dental College and Hospital, Nellore. History of present illness, clinical, radiological and laboratory examinations were carried out on all the patients.

Results

Majority of the cervical sinuses are of odontogenic origin (80%) and non-odontogenic being (20%) of the cases.

Conclusion

The literature reveals that many cases have been misdiagnosed and inappropriately treated by many specialties of Medicine and Surgery wherein the odontogenic foci of infection is the main etiological factor for cervicofacial sinuses. A proper diagnosis is important and forms a key to the successful management of these sinuses in the head and neck region.     

Lymphomas of the head and neck 1: Nasofacial T-cell lymphoma

Nasofacial T-cell lymphoma includes diseases otherwise called “lethal midline granuloma” and “necrosis with atypical cells”. It is characterised by relentless destruction of nose and palate in particular but the lymphoma remains localised to the head and neck. The age of onset ranges from 10 to 87 and the survival ranges from a few months to several years. The histological appearances are of a polymorphic infiltrate but including atypical T cells in a background of macrophages. There is a strong association with Epstein-Barr virus infection.     

A patient of severe cervicofacial subcutaneous emphysema associated with Munchausen's syndrome

Subcutaneous cervicofacial emphysema is an entity with the presence of air within the fascial planes of the head and neck, which results from various causes. A case of severe subcutaneous cervicofacial emphysema associated with Munchausen's syndrome is presented. Detailed diagnostic investigations to find out the organic cause of the condition were failed. Episodes of facial swelling were prevented by psychiatric support. Munchausen's syndrome should be kept in mind among the etiological factors of subcutaneous cervicofacial emphysema cases, in whom no organic causes can be found out.     

Early experience of a nurse-led clinic in a tertiary centre

A busy head and neck or oral and maxillofacial (OMFS) National Health Service (NHS) clinic treats patients with many different conditions. A large proportion will have cancer of the head and neck, and they will be at different stages of their treatment. Their clinical needs may be different from a larger group of patients who have been referred through the “two-week wait” referral pathway, and who are present in the same clinic for their biopsy results. We present our early experience of “fast-track” referrals and their potential effect on the overall volume of work. They are only a small number of the patients who are typically seen in a nurse-led clinic.     

口腔颌面部淋巴管畸形的治疗

根据ISSVA、Waner和Suen的分类,过去所称的淋巴管瘤现统称为淋巴管畸形,包括微囊型和大囊型2类,以头颈部最多见。其发病原因不清,治疗方法多样。本文复习新近文献,论述了淋巴管畸形的手术治疗、硬化治疗、激光治疗的适应证、优缺点等,并介绍了其分子生物学研究和治疗前景。认为淋巴管畸形虽属良性病损。但极少自然消退,常与头颈部重要结构毗邻且具有局部浸润性而引起严重并发症和高复发率,给临床治疗带来了很大困难。虽然目前可用的治疗方法很多,但均有优点与不足,应根据患者病情和技术条件,制定个体化治疗方案。采用综合治疗．以期获得最佳疗效。对黏膜表面的微囊型淋巴管畸形、面颈部大囊型淋巴管畸形,平阳霉素、OK-432等病变内注射可获得良好的效果。黏膜表面的微囊型淋巴管畸形,也适于激光治疗。组织深部的微囊型淋巴管畸形的治疗。仍然是临床上面临的难题。目前不主张毫无指征地对任何类型的淋巴管畸形进行手术切除,手术适用于局限的、黏膜表面的微囊型淋巴管畸形和面颈部大囊型淋巴管畸形的治疗。手术中应注意重要结构的辨别和保护。对于复杂病例,提倡采用综合序列治疗。     

The use of steroids in cervicofacial infections in UK OMFS departments: a Maxillofacial Surgery Trainees Research Collaborative (MTReC) study

Oral and Maxillofacial Surgery - Defining current inpatient management of cervicofacial infections is key to identifying strategies to optimise care. Steroid use is beneficial in peritonsillar and...