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.     

Atypical presentation of cutaneous tuberculosis and a retropharyngeal neck abscess

A 70-year-old Asian man with noninsulin-dependent diabetes presented with a 4-month history of left-sided otitis externa and right-sided facial palsy. Physical examination of the left ear revealed a punched-out ulcerative lesion on the tragus, an edematous and inflamed external auditory canal, and a purulent nonmucoid discharge. Computed tomography of the brain and neck demonstrated a large retropharyngeal abscess, an abscess in the left parapharyngeal space, and a small collection adjacent to the right carotid sheath at the level of C4; the cervical vertebrae and lungs were normal. Microscopy of drained pus and histology of left ear and neck node biopsies identified tuberculosis. The patient was started on antituberculosis drug therapy, but he died within 2 weeks of treatment. We discuss the characteristics of this unusual presentation of tuberculosis infection.     

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.     

Drainage of retro-parapharyngeal abscess: an additional indication for endoscopic sinus surgery

Deep neck abscesses are life-threatening conditions, in early stages preferably treated by intravenous antibiotic therapy; in advanced stages, surgical drainage is mandatory. We report two cases of retro-parapharyngeal abscess with prevalent retronasopharyngeal extension in two men aged 60 and 82, both of whom underwent transnasal endoscopic drainage. The main surgical steps were incision of the posterior pharyngeal mucosal wall, widening of the incision, drainage of purulent collection and careful dissection and removal of the necrotic tissue. The first patient, with an abscess associated with chronic otitis media and presenting hypoglossal nerve palsy, quickly recovered from pharyngodinia, otalgia and trismus. Twenty-six months after surgery, he is symptom-free, with hemitongue atrophy due to denervation as the only residual sign. The second patient, affected by skull base osteomyelitis secondary to malignant external otitis, after a first successful drainage, underwent a second endoscopic procedure for the reoccurrence of an abscess in the contralateral retroparapharyngeal space. Twelve months after the first surgery, the patient reported an improvement of symptoms, except for persistent dysphonia related to vagal nerve palsy. At follow-up MR, another abscess was detected in the left retro-parapharyngeal space. In selected cases of abscess, transnasal endoscopic drainage may be an effective alternative to external approaches. Minimal morbidity, the absence of cervical or palatal scars and a short hospitalization time can be considered as important advantages in comparison to external approaches. Patients with abscess secondary to skull base osteomyelitis require close imaging surveillance because of the difficulty of definitive control of the disease.     

Primary tuberculous petrositis

Tuberculous osteomyelitis of the temporal bone is a rare and dangerous entity that should be included in the differential diagnosis of infectious processes of the base of the skull. We present the case of an 11-year-old child who presented with diplopia, ear discharge and hearing loss. The radiological and histopathological findings revealed tuberculous otitis with osteomyelitis and an abscess in the petrous apex. The child responded to anti-tuberculous chemotherapy. The diagnosis and management of tuberculous osteomyelitis are discussed and a brief review of the literature is presented.     

Primary tuberculous petrositis

Tuberculous osteomyelitis of the temporal bone is a rare and dangerous entity that should be included in the differential diagnosis of infectious processes of the base of the skull. We present the case of an 11-year-old child who presented with diplopia, ear discharge and hearing loss. The radiological and histopathological findings revealed tuberculous otitis with osteomyelitis and an abscess in the petrous apex. The child responded to anti-tuberculous chemotherapy. The diagnosis and management of tuberculous osteomyelitis are discussed and a brief review of the literature is presented.     

Colour Doppler ultrasonography of retropharyngeal abscess.

OBJECTIVE: This study was conducted to determine the capability of colour Doppler ultrasonography (CDU) in evaluating retropharyngeal abscess in children. MATERIALS AND METHODS: From July 1996 to February 1998, five children with clinical suspicion of retropharyngeal abscess were evaluated by CDU. The distance from internal carotid artery (ICA) to cervical vertebra (CV) (DICA-CV) at the upper cervical level was measured by longitudinal ultrasonography. Fifty healthy children, aged from 1 to 15 years, were recruited in the study to measure DICA-CV as control. Colour Doppler ultrasonography was used to differentiate abscess from other pathology and to detect carotid sheath invasion. Computed tomography was performed to confirm the sonographic diagnosis. Measurements of the DICA-CV at regular intervals were performed to monitor the progression of retropharyngeal abscess. RESULTS: Retropharyngeal abscess was highly suspected in all cases under sonographic studies. A patient was found to have carotid sheath invasion. Computed tomography confirmed the diagnosis of retropharyngeal abscess in all cases. Retropharyngeal abscess can be evaluated by the measured DICA-CV. The DICA-CV decreased as the retropharyngeal abscess gradually resolved. CONCLUSION: Colour Doppler ultrasonography offers a sensitive method to evaluate retropharyngeal abscess in children. It can also be used to monitor the progression of retropharyngeal abscess and avoid unnecessary radiologic examinations.     

A case of calcific retropharyngeal tendinitis suspected to be a retropharyngeal abscess upon the first medical examination

We report a case of calcific retropharyngeal tendonitis that was difficult to distinguish from retropharyngeal abscess. The patient was a 34-year-old woman who complained of severe cervical pain and stiffness for 1 day. She had a fever and moderately elevated WBC. Fine needle aspiration of the swollen region of the retropharyngeal wall could not elucidate the pus characteristics. Enhanced CT scan showed no signs of an abscess, but clearly showed calcifications in front of the C1-2 cervical spine. An emergency drainage operation was avoided, and the patient fully recovered after treatment with NSAIDs and steroids.     

Otitis media and mastoiditis in temporal bones of prehistoric Chilean populations. A paleopathological and paleoepidemiological study

Background: This study evaluates otitis media in prehistoric populations in northern Chile.

Aims/objectives: Determining prevalence of otitis media and diagnostic usefulness of temporal-bone X-rays in skulls.

Materials and methods: 444 skulls belonging to three groups: prehistoric-coastal (400–1000 AD), prehistoric-highland (400–1000 AD) and Pisagua-Regional Developments (1000–1450 AD). Skulls were evaluated visually and with Schuller’s view X-rays. Five skulls diagnosed as having had otitis media, five diagnosed as normal, and one with temporal bone fistula also had a computed tomography (CT).

Results: Changes suggestive of otitis media were present in Prehistoric-coastal 53.57%; Pisagua-Regional Developments 70.73%; prehistoric-highlands 47.90%. Diagnostic effectiveness of Schuller’s view X-rays for assesing middle ear disease was confirmed by CT studies. The case with temporal bone fistula had changes suggestive of mastoiditis and possible post auricular abscess.

Conclusions: There was a high prevalence of otitis media in prehistoric populations in Chile. The higher prevalence in one group was presumably due to racial factors. Temporal-bone X-rays are effective for massive evaluation of ear disease in skulls. A case of mastoiditis with temporal bone fistula and possible post-auricular abscess is documented.

Significance: Documenting racial factors in otitis media. Validating X-rays for massive evaluation of otitis media in skulls.     

Marrow-tympanum connections in fetuses and infants

The connections between hematopoietic bone marrow and the tympanum caused by bony dehiscences in immature middle ear were examined in 58 temporal bones of fetuses and infants. There were no anomalies in any of the cases, and they were divided into two groups: a group with inflammation of middle ear and a group without inflammation. The tympanic cavity was compartmentalized into thirteen portions to investigate the appearance of the connection, and the connections were classified into the mesenchymal type and the direct type dependent on residual mesenchyme in each portion. Marrow-tympanum connections were observed from 20 weeks of gestation until 14 months of age. In most cases the connections were the mesenchymal type. A large amount of mesenchyme remained in the inflammatory group. Some direct-type connections were observed in the non-inflammatory group from 1 month after birth onward and the mesenchyme was completely absorbed in these connections. Both types of the connections were frequently found in the antrum, facial recess and tympanic sinus. These results indicate that a marrow-tympanum connection is usually present in the temporal bone not only anomaly cases but also normal fetuses and infants. In addition, in normal cases without otitis media the connections first appear as mesenchymal type, and progress to direct type due to the absorption of mesenchyme. Presumably marrow-tympanum connections have structural disadvantage to induce osteomyelitis in cases with otitis media. And evoked osteomyelitis may cause complications such as acute mastoiditis and facial paralysis. The results of this study suggest that children under 2 years of age are at higher risk of complications of otitis media owing to marrow-tympanum connections than older children. Further study of the role of mesenchyme in otitis media is needed.     

Detection of fungal DNA in effusion associated with acute and serous otitis media

OBJECTIVES/HYPOTHESIS: Routine bacterial and viral cultures of middle ear fluid are often negative, suggesting that other infectious agents may be involved. Because of the similarities between the paranasal sinuses and middle ear space and the recent recognition of fungi as important pathogens in inflammation of the paranasal sinuses, we investigated the potential role of fungi in acute otitis media and serous otitis media using culture and polymerase chain reaction techniques. STUDY DESIGN: Prospective study. METHODS: Middle ear effusions of 29 patients who underwent myringotomy and pressure equalization tube placement for persistent serous otitis media or recurrent acute otitis media were collected. Fungal culture of the effusion samples was performed on potato flake agar. DNA from the effusion was isolated using standard techniques. Polymerase chain reaction, using radiolabeled universal fungus primer for internal transcribed spacer of 5.8s ribosomal DNA, was performed to detect the presence of any fungal DNA in the samples. RESULTS: Culture of middle ear effusions showed no evidence of fungal growth. Polymerase chain reaction analysis was able to detect the constituent ribosomal DNA of a single fungal genome. Fungal DNA was present in 34% of middle ear effusion samples. CONCLUSIONS: Fungal DNA is present in recurrent acute otitis media and serous otitis media suggesting that it may play an etiological role in serous otitis media and acute otitis media. However, additional studies are necessary to delineate the role of fungi in the pathogenesis of otitis media.     

Skull base osteomyelitis originating in the middle ear or mastoid: a review of 3 cases

Skull base osteomyelitis is a life-threatening condition that sometimes arises as a sequela of otitis media and mastoiditis. We present a retrospective analysis of the clinical course of 3 patients with skull base osteomyelitis that originated in the middle ear or mastoid. All 3 patients were elderly diabetic men who presented with headache. We review the clinical features, radiologic findings, and culture results in all 3 cases, and we describe the treatment regimens that led to a successful response in all 3 patients.     

Pathology and pathogenesis of tympanic membrane retraction

Temporal bones without evidence of otitis media, as well as temporal bones with various types of otitis media, were examined for the presence of retractions of the tympanic membrane and their related histopathologic progression to the formation of cholesteatoma. Retractions were not present in non-otitis media, purulent, or mucoid otitis media. Retractions were observed in 2.1% of temporal bones with serous otitis media and 19.5% of temporal bones with chronic otitis media. All temporal bones with retractions demonstrated evidence of current or previous otitis media. Histopathologic changes of the middle ear cleft were associated with the type and degree of retraction. This study supports the continuum theory according to which otitis media with effusion eventually leads to a variety of sequelae and/or to chronic otitis media. The tympanic membrane appears to follow progressive changes, from simple retraction to retraction pockets and finally to cholesteatoma.     

Vascular events in experimental otitis media models: a comparative study

The vascular leakage and components of middle ear effusion (MEE) were determined and compared in various experimental otitis media models in the rat: purulent otitis media (POM); serous otitis media (SOM); mucoid-like otitis media (MOM); stimulating the external auditory canal with a 14 degrees C airstream and vagotomy. When the Evans blue technique was used, all otitis media models exhibited a significant increase in middle ear vessel permeability. The MEEs contained numerous PMNLs, except for animals stimulated with a 14 degrees C airstream, in which the MEE was free of cells. The IgG/SIgA ratio in MEEs indicated that the MEE components are derived from serum in the early phases of fluid accumulation, in these otitis media models. In POM, MEE components appeared to be derived from local synthesis by the middle ear mucosa as well.     

Transoral approach to drain streptococcus pneumoniae spinal epidural abscess in an HIV-infected adult

Spinal epidural abscess due to Streptococcus pneumoniae is extremely rare in adults. It typically occurs in the thoracic, lumbar or lumbosacral epidural spaces, and less frequently in the cervical epidural space. The principal causative microbial agent is Staphylococcus aureus, representing 70% of cases, while 1.6% of cases are caused by S. pneumoniae. We report the first case of an HIV-infected patient with a cervical spinal epidural abscess. The patient was a 43-year-old male with pneumococcal bacteremia and a metatarsal abscess. He reported cervical pain with muscle spasm during cephalic flexion and extension, fever and a painful tumefaction on the second metatarsal of the left foot. MRI confirmed that the retropharyngeal abscess extended to the cervical spinal epidural space. Antibiotic therapy with cefotaxime plus vancomycin was initiated and a transoral surgical approach was used to achieve retropharyngeal and local debridement of the metatarsal abscess. Blood and pus cultures were positive for S. pneumoniae. After 4 months of follow-up the patient remained asymptomatic, without clinical or MRI evidence of recurrence.     

Transoral approach to drain streptococcus pneumoniae spinal epidural abscess in an HIV-infected adult

Spinal epidural abscess due to Streptococcus pneumoniae is extremely rare in adults. It typically occurs in the thoracic, lumbar or lumbosacral epidural spaces, and less frequently in the cervical epidural space. The principal causative microbial agent is Staphylococcus aureus, representing 70% of cases, while 1.6% of cases are caused by S. pneumoniae. We report the first case of an HIV-infected patient with a cervical spinal epidural abscess. The patient was a 43-year-old male with pneumococcal bacteremia and a metatarsal abscess. He reported cervical pain with muscle spasm during cephalic flexion and extension, fever and a painful tumefaction on the second metatarsal of the left foot. MRI confirmed that the retropharyngeal abscess extended to the cervical spinal epidural space. Antibiotic therapy with cefotaxime plus vancomycin was initiated and a transoral surgical approach was used to achieve retropharyngeal and local debridement of the metatarsal abscess. Blood and pus cultures were positive for S. pneumoniae. After 4 months of follow-up the patient remained asymptomatic, without clinical or MRI evidence of recurrence.     

Beta-lactamase-producing bacteria in head and neck infection

We have summarized our experience in recovery of beta-lactamase-producing bacteria (BLPB) in head and neck infection (HNI). These HNI include conjunctivitis, serous and chronic otitis media, cholesteatoma, chronic mastoiditis, chronic sinusitis, adenoiditis, recurrent tonsillitis in children and adults, peritonsillar abscess, and retropharyngeal abscess. Beta-lactamase-producing bacteria were found in 262 (51%) of 513 patients with HNI; 72% had aerobic BLPB and 57% had anaerobic BLPB. The infections, where these organisms were most frequently recovered, were adenoiditis (85% of patients), tonsillitis in adults (82%) and children (74%), retropharyngeal abscess (71%), and chronic otitis media (57%). The predominant BLPB were Staphylococcus aureus (49% of patients with BLPB), the Bacteroides-melaninogenicus group (28%), the Bacteroides fragilis group (20%), Pseudomonas aeruginosa (13%), Hemophilus influenzae (5%), and Branhamella catarrhalis (3%). The high incidence of recovery of BLPB in head and neck infections may have important implications on the antimicrobial management of these infections.     

中耳胆脂瘤研究进展

中耳胆脂瘤是耳鼻咽喉科较为常见的一种慢性中耳疾病,长期外耳道流脓、鼓膜穿孔、听力下降为其主要特点,它对周围组织具有侵袭性,易引起中耳传音结构的破坏和骨质吸收,进而引起面瘫、迷路炎、耳后骨膜下脓肿及各种颅内外并发症。中耳胆脂瘤的病因及发病机制复杂,治疗方法的疗效争议较多。本文主要将近年来关于中耳胆脂瘤的病因、发病机制及治疗进展进行综述。     

Hyperbaric oxygen therapy: effect on middle ear and eustachian tube function.

Hyperbaric oxygen therapy (HBO) involves intermittent inhalation of 100% oxygen under a pressure greater than 1 atm. It is an important mode of adjuvant therapy for disease processes such as decompression sickness, osteomyelitis, carbon monoxide poisoning, and poorly healing wounds. Patients undergoing this therapy often complain of ear pain and/or fullness which can be transient or long standing. This prospective study objectively measured the changes in eustachian tube function before and after HBO treatment in 33 adult patients by the 9-step inflation-deflation test described by Bluestone. The results show 15 of the 33 patients (45%) had evidence of eustachian tube dysfunction after treatment was initiated. Of these, 15 (100%) developed the sensation of fullness, 13 (87%) developed serous otitis media, and 7 (47%) required tympanostomy tubes. The overall incidence of middle ear problems was 27 patients (82%) experiencing a sensation of fullness, 17 (52%) developing serous otitis media, and 8 (24%) requiring tympanostomy tubes. The middle ear complications reported in this study are much higher than those in previous reports in the literature. Twelve of 33 patients presented with a subjective history of eustachian tube dysfunction, and all 12 (100%) developed fullness in their ears and serous otitis media during the course of the treatment. The findings reveal that patients manifesting eustachian tube dysfunction after their first HBO treatment were at significantly greater risk toward developing symptoms of fullness and serous otitis media, often requiring tympanostomy tube placement. In addition, a history of eustachian tube dysfunction accurately predicted the development of fullness and serous 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.