Systematic review of the role of corticosteroids in cervicofacial infections

Anti-inflammatories as adjunct treatment for cellulitis: a systematic review and meta-analysis

OBJECTIVES

Existing guideline recommendations suggest considering corticosteroids for adjunct treatment of cellulitis, but this is based on a single trial with low certainty of evidence. The objective was to determine if anti-inflammatory medication (non-steroidal anti-inflammatory drugs [NSAIDs], corticosteroids) as adjunct cellulitis treatment improves clinical response and cure.

METHODS

Systematic review and meta-analysis including randomized controlled trials of patients with cellulitis treated with antibiotics irrespective of age, gender, severity and setting, and an intervention of anti-inflammatories (NSAIDs or corticosteroids) vs. placebo or no intervention. Medline (PubMed), Embase (via Elsevier), and Cochrane CENTRAL were searched from inception to August 1, 2023. Data extraction was conducted independently in pairs. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2. Data were pooled using a random effects model. Primary outcomes are time to clinical response and cure.

RESULTS

Five studies (n = 331) were included, all were adults. Three trials reported time to clinical response. There was a benefit with use of an oral NSAID as adjunct therapy at day 3 (risk ratio 1.81, 95%CI 1.42-2.31, I2 = 0%). There was no difference between groups at day 5 (risk ratio 1.19, 95%CI 0.62-2.26), although heterogeneity was high (I2 = 96%). Clinical cure was reported by three trials, and there was no difference between groups at all timepoints up to 22 days. Statistical heterogeneity was moderate to low. Adverse events (N = 3 trials) were infrequent.

CONCLUSIONS

For patients with cellulitis, the best available data suggest that oral nonsteroidal anti-inflammatory drugs (NSAIDs) as adjunct therapy to antibiotics may lead to improved early clinical response, although this is not sustained beyond 4 days. There is insufficient data to comment on the role of corticosteroids for clinical response. These results must be interpreted with caution due to the small number of included studies.

REGISTRATION

Open Science Framework:   https://osf.io/vkxae?view_only=fb4f8ca438a048cb9ca83c5f47fd4d81 .

The role of adjuvant systemic corticosteroid in pediatric retropharyngeal and parapharyngeal abscess

OBJECTIVES

To evaluate the potential benefits of systemic corticosteroids as an adjuvant treatment for pediatric retropharyngeal abscess (RPA) and parapharyngeal abscess (PPA).

METHODS

We retrospectively reviewed medical records of patients diagnosed with RPA and PPA who were admitted to Shenzhen Children's Hospital between January 2010 and January 2023. Data on demographic characteristics, clinical presentation, physical examination, laboratory data, use of corticosteroids, management, duration of hospital stay, need for surgical drainage, and complications were collected. Patients were divided into two groups: non-corticosteroid group (antibiotic only) and corticosteroid group (corticosteroid and antibiotic).

RESULTS

A total of 111 patients were enrolled. There were 51 cases in non-corticosteroid group and 60 cases in corticosteroid group (10 cases received methylprednisolone and 50 cases received dexamethasone). There was no significant difference in sex, age, location of abscess, size of abscess and laboratory parameters at admission and discharge between the two groups. The surgical drainage rate was significantly lower in the corticosteroid group than in the non-corticosteroid group (p = 0.008). The hospital duration was also shorter in the corticosteroid group than in the non-corticosteroid group (p = 0.026). The hospitalization cost was significantly lower in the corticosteroid group than in the non-corticosteroid group (p = 0.000).

CONCLUSION

The use of systemic corticosteroids along with antibiotics in children with RPA and PPA may reduce the need for surgical drainage, shorten hospital duration, and decrease hospitalization cost. Further studies are needed to confirm these findings and determine the optimal timing, duration, and route of administration of corticosteroids.

Management of cervicofacial infection: a 7-year retrospective study

OBJECTIVE

We aimed to describe and analyze the epidemiologic and clinical variables associated with, treatment for, and development of cervicofacial infection (CFI).

STUDY DESIGN

We retrospectively examined 201 patients older than 14 years who had met the CFI diagnostic criteria and whose treatment required hospitalization and intervention under general anesthesia at our hospital. We performed chi-square tests to compare proportions in categorical variables and either the Student t test or the Wilcoxon signed-rank test to compare quantitative variables. We performed an analysis of variance to compare 3 or more categories and either Pearson or Spearman correlation coefficient analysis to examine the correlations between quantitative variables.

RESULTS

The majority (85.07%) of the CFIs were of odontogenic origin. The mean hospitalization length was 4.58 days. Patients with diabetes who used tobacco and/or alcohol had a significantly longer length of hospitalization and several postoperative complications.The most common symptoms were pain, trismus and toothache. Symptoms of fever and nausea were associated with longer hospitalization. The most affected anatomic spaces were submandibular and pterygomandibular. Buccal and infraorbital, temporal, and parotid spaces were associated with longer hospitalization.

CONCLUSIONS

Most CFIs are of odontogenic origin. Diabetes and tobacco and alcohol use are important risk factors. Treatment should be surgical and target the cause of infection. Timely referrals are important when patients present symptoms compatible with CFI for immediate treatment.

Clinical diagnosis and outcome of cervicofacial cellulitis in pyrexic rabbits: six cases (2014-2021)

OBJECTIVES

To assess the signalment, history, exam findings, diagnostics, treatment and outcome of rabbits diagnosed with pyrexia and concurrent cervicofacial cellulitis.

MATERIALS AND METHODS

Retrospective evaluation of medical records of rabbits diagnosed with cervicofacial cellulitis and pyrexia based on physical exam, contrast-enhanced CT, clinicopathology and microbiology findings.

RESULTS

Six out of 1588 rabbits met the study inclusion criteria. Rabbits presented with a median age of 6 years (range, 8 months to 8 years) with a presenting complaint of anorexia or hyporexia. All rabbits had a rectal temperature >40.2°C (104.4°F). Physical exam and contrast-enhanced CT revealed unilateral submandibular and ipsilateral cervical diffuse soft tissue swelling in five of six rabbits. No antemortem evidence of periodontal or dental disease was found on physical exam or CT. Leucopenia was present in five of six rabbits. A left shift with marked toxic changes was present in all four rabbits, for which blood smears were reviewed. Bacterial cultures of the aspirated subcutaneous soft tissue swelling cultured Escherichia coli, Pasteurella multocida, Granulicatella adiacens, Streptococcus species, Haemophilus species and Bacteroides species. Treatment was pursued in five rabbits, where all rabbits received supportive care and four of five rabbits received systemic antibiotics. One rabbit was euthanased following a diagnosis of cervicofacial cellulitis. Three out of five rabbits continued to decline clinically despite medical management, and thus, euthanasia was pursued within 24 hours of starting treatment. Two rabbits responded to initial treatment and developed subsequent multi-focal abscessation. One rabbit was euthanased due to client cost constraints, and one rabbit died shortly after achieving clinical resolution of cervicofacial cellulitis.

CLINICAL SIGNIFICANCE

Cervicofacial cellulitis should be considered a differential diagnosis in pyrexic rabbits with facial or cervical swelling with medical and surgical management pursued for therapy.

Efficacy/Safety of the Use of Glucocorticoids in Oral and Maxillofacial Surgery

INTRODUCTION

Glucocorticoids, also known as corticosteroids or steroids, are drugs derived from cholesterol. They are synthesized by the adrenal cortex, along with other hormones, such as cortisol and aldosterone. Glucocorticoids are drugs recommended for patients undergoing surgery on the oral cavity, facial skeleton, and related cervical structures due to their high efficacy against inflammatory and immune processes. However, these drugs are restricted due to their multiple and serious adverse effects. The objective of this study was to verify the efficacy of corticosteroids administered in major surgeries of the oral cavity, as well as of the cervical and facial structures, based on the characteristics of the patient so as to select the best therapeutic strategy.

METHODS

Articles in the databases of PubMed, Nature Portfolio, Medline, Cochrane Library, and Google Scholar were thoroughly examined.

RESULTS

A total of 54 articles were selected to address the proposed objectives. The results obtained show that it is effective and safe to use glucocorticoids as pre- or postsurgical therapy in oral and maxillofacial surgery to control the processes of inflammation, pain, lockjaw, and edema. However, when referring to the use of these drugs, one must proceed with caution and pay particular attention when handling them. The concentration of the glucocorticoids used must be individualized, as well as the selection of the route of administration. Various studies show that, although the oral route is the most used route, the most effective route is the intramuscular route due to its easy absorption. However, for patients who have recurrent inflammatory and vesiculobullous ulcerative lesions, the topical route should be chosen to mitigate side effects, considering that recurrent applications must be made to prevent the worsening of the lesion and to avoid having to use medications enterally. In patients with cervicofacial infections, antibiotics continue to be the main drugs used to manage the condition in conjunction with corticosteroids. It is important to know the possible interactions of glucocorticoids with other medicines or food: it has been described that the interaction between Ritonavir, an antiretroviral drug that inhibits human immunodeficiency virus (HIV) proteases, and prednisone causes an increase in the concentration of prednisone, leading to possible toxicity in normally safe doses and, in many cases, iatrogenic Cushing's syndrome. It is also important to know the systemic or topical adverse effects of the chronic or high-dose use of glucocorticoids.

CONCLUSIONS

It can be concluded that by making adequate use of glucocorticoid therapy in oral and maxillofacial surgery to manage clinical manifestations, it is possible to attenuate the morbidities of treatment and intervention.

Granulicatella adiacens Causing a Parapharyngeal Abscess in a 10-Month-Old Infant: A Rare-Case Report and Literature Review of Deep Neck Infections (DNIs) in Children

Granulicatella adiacens is a rare variant of the Streptococcus bacteria. When isolated, G. adiacens has been described in cases of endocarditis and bacteremia, but less commonly seen in isolated pyogenic infections. We report a case of a parapharyngeal abscess caused by G. adiacens in an otherwise healthy 10-month-old infant, which was successfully treated with antibiotics and surgical drainage. To the best of our knowledge, this is the first described case of a pediatric deep soft tissue neck infection caused by G. adiacens with one other report in an adult. Additionally, of all localized infections from this bacteria, this is only the second reported case in the pediatric population. We also include an evidence-based literature review of the clinical presentation, microbiology, imaging modalities, and management approach to deep neck infections (DNIs).

Cavernous sinus and jugular thromboses, base of skull osteomyelitis and cranial nerve palsies: catastrophic complications of sphenoid sinusitis

Sphenoid sinusitis is a clinically important entity as it may be associated with catastrophic complications including cavernous sinus thrombosis (CST), cerebral abscess or infarction, meningitis, base of skull osteomyelitis and cranial nerve palsies. We report a case of occult sphenoid sinusitis presenting as Streptococcus intermedius bacteraemia, bilateral jugular vein and CST, cranial nerve palsy and base of skull osteomyelitis.

Management of Deep Neck Space Infections: A Large Tertiary Center Experience

INTRODUCTION

Deep neck space infections (DNIs) represent serious bacterial infections affecting the deep cervical space and fascial planes of the neck. This study aims to describe our clinical and surgical experience in the management of DNIs, emphasizing the importance of appropriate imaging in the diagnostic setting and the role of the multidisciplinary approach according to the severity of the infection.

METHODS

In this retrospective study, we describe 85 patients affected by DNIs coming to the Otolaryngology department observation from the Emergency Room of San Camillo Forlanini Hospital in Rome from January 2006 to December 2021 and treated both by pharmacological and surgical therapy.

RESULTS

54 patients (64%) were male, and 31 (36%) were female, with a mean age of 50.5 years. The most common cause of DNI was odontogenic, accounting for 70% of all collected cases. In 68 patients (80% of all cases), the surgical approach consisted of an extended unilateral cervicotomy, whereas in 17 patients (20% of all cases), a bilateral cervicotomy was performed. Surgical revision was required in 15 cases (18%). A tracheostomy was necessary in seven cases. The overall survival rate was 96.5%.

CONCLUSIONS

DNI represents a serious and life-threatening condition, remaining a constant challenge for the head and neck surgeon. Contrast-enhanced computed tomography is critical for therapeutic planning, which requires both a surgical approach and antibiotic therapy. Surgical treatment should be performed as soon as possible. In severe cases, the multidisciplinary approach is advisable.

Systemic corticosteroids for orbital complications of pediatric rhinosinusitis: A systematic review

OBJECTIVES

Determine if systemic corticosteroids administration is associated with reduced length of stay, surgical intervention, and abscess formation in pediatric patients with orbital complications of rhinosinusitis.

METHODS

Systematic review and meta-analysis were performed utilizing the PubMed and MEDLINE databases to identify articles published between January 1990 and April 2020. Retrospective cohort study of the same patient population over the same time period at our institution.

RESULTS

Eight studies, 477 individuals, met criteria for inclusion in the systematic review. 144 patients (30.2%) received systemic corticosteroids, while 333 patients (69.8%) did not. Meta-analyses of frequency of surgical intervention and subperiosteal abscess showed no difference between those who did and did not receive systemic steroids ([OR = 1.06; 95% CI: 0.46 to 2.48] and [OR = 1.08; 95% CI: 0.43 to 2.76], respectively). 6 articles evaluated hospital length of stay (LOS). 3 of these reported enough data to perform meta-analysis, which showed patients with orbital complications who received systemic corticosteroids had shorter mean hospital LOS when compared with those who did not receive systemic steroids (SMD = -2.92, 95% CI: 5.65 to -0.19).

CONCLUSION

While available literature was limited, systematic review and meta-analysis suggests systemic corticosteroids decrease length of stay for hospitalized pediatric patients with orbital complications of sinusitis. Further research is needed to more clearly define the role of systemic corticosteroids as an adjunctive treatment.

Risk factors for difficult ventilatory weaning in intensive care patients with cervical cellulitis

PURPOSE

Cervical cellulitis is an infrequent but serious infection. The management of the upper airways is difficult, at the actual time of intubation but also regarding the necessity of maintaining mechanical ventilation. The objective of this study is to identify risk factors on admission to the intensive care unit for difficult ventilatory weaning in patients with cervical cellulitis.

METHODS

Between January 2013 and December 2018, this retrospective observational study was performed in an intensive care unit with 10 beds in a university hospital recognized as a reference center for the management of cellulitis. All intensive care patients receiving mechanical ventilation after surgery for cervical cellulitis were eligible. Difficult ventilatory weaning was defined as mechanical ventilation lasting more than 7 days or failure of extubation as established by the WIND 2017 study.

RESULTS

We included 120 patients with severe cervical cellulitis. The median age was 43 years. Eighteen patients (16%) presented mediastinal extension. The risk factor for difficult ventilatory weaning (n = 49) in multivariate analysis was a high level of procalcitonin on admission (OR at 1.14[1.005-1.29]; p<0.042) and the protective factor was surgery in an expert center (OR at 0.11[0.026-0.47]; p<0.003). Eight patients required a tracheotomy in our study: 3 patients during surgery and at a later time for the other 5 of our 8 patients.

CONCLUSION

No intensive care studies have investigated ventilatory weaning risk factors in patients with cervical cellulitis. Yet simple criteria seem to predict this risk. It is now necessary to confirm them by a multicenter prospective study.

Length of hospital stay among oral and maxillofacial patients: a retrospective study

OBJECTIVES

: Many conditions of the oral and maxillofacial region require hospitalization and in-patient care. The average length of stay (LOS) of these patients varies and is usually affected by multiple confounding variables. However, even with an increasing number of hospital admissions, published evidence on the factors that affect the LOS of oral and maxillofacial patients is lacking. Therefore, this study assessed the LOS of in-patients at the oral and maxillofacial surgery department of a government-funded, multi-specialty hospital in Malaysia, based on their reasons for admission and other factors.

MATERIALS AND METHODS

Our samples were collected retrospectively over a 5-year period and included patients with maxillofacial infections, post-trauma stabilization, facial bone fracture surgery, benign and malignant lesion surgery, dentoalveolar surgery, and other maxillofacial surgeries as reasons for admission. Factors potentially affecting LOS were also recorded, and their significance was determined using multiple logistic regression analyses. A P-value of less than 0.05 was considered to be statistically significant.

RESULTS

A total of 1,380 patients were included in this study. Most (84.5%) of our in-patients were of Malay ethnicity, and males outnumbered females in our sample by 502 subjects. The median LOS of our in-patients was 3 days. Sex, ethnicity, age, reason for admission, and American Society of Anesthesiology (ASA) classification were factors that significantly affected LOS.

CONCLUSION

The median LOS reported in this study was 3 days. LOS was significantly affected by sex, ethnicity, age, reason of admission and ASA classification.

Gender differences in patients with severe dental infections presenting to hospital

Introduction Gender differences have been documented in prevalence and morbidity of caries, gingivitis and oral health, but not previously in cervicofacial infection. Identification and minimisation of gender inequalities is a World Health Organisation priority, and there are physiological, behavioural and cultural reasons to suspect that sex and gender differences may be present.Methods Analysis was carried out of the MTReC National Snapshot audit of cervicofacial infections. This database was created by oral and maxillofacial surgery trainees in 2017 and records over 400 variables in 1,002 individual patients admitted to hospital with severe odontogenic infection.Results Records were available for 1,002 patients with cervicofacial infection (456 females and 546 males). There were significant differences between recorded gender in those presenting with airway compromise (male 7% vs female 2%, p = 0.001), severe inflammatory response syndrome (male 60% vs female 39%, p = 0.007) and requirement for awake fibre-optic intubation on admission (male 4% vs female 1%, p = 0.014).Discussion These results suggest that male patients access healthcare later in their disease than female patients, and with more severe systemic compromise. This may be due to prevalent cultural and behavioural norms. As equality of access is the responsibility of the administrator, we discuss methods which might improve timely presentation in males with cervicofacial infections.

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

INTRODUCTION

Defining current inpatient management of cervicofacial infections is key to identifying strategies to optimise care. Steroid use is beneficial in peritonsillar and orbital abscess, but there are few studies of steroid use in odontogenic cervicofacial infections. Our previous research identified widespread variation in practice, necessitating a national audit to define current practice.

METHODS

A multicentre, trainee-led snapshot audit was carried out across 25 hospitals in the UK. Information recorded included demographic features, presentation, surgical and medical management, and steroid administration.

RESULTS

One thousand two admissions were recorded. Fifty-five percent were male, with mean age 37.3 years (range 0-94 years). Steroids were administered to 357 patients (36%), 159 of whom received steroids on admission, and 254 peri-operatively. Patients who were prescribed steroids had significantly higher white cell count (12.4 vs 11.5), CRP (79.5 vs 57) and heart rate (94 vs 88) on admission. Justifications given for administration included swelling (74), dysphagia (21), and airway compromise (7). Three patients (0.8%) reported steroid-related side effects.

CONCLUSIONS

This study uses the largest recorded cohort of cervicofacial infections to define current inpatient steroid administration. Our results suggest that steroids are targeted towards the most compromised 1/3 of patients. The incidence of steroid-related side effects was low. Defining the characteristics of patients currently receiving steroids will aid in determining whether steroid administration is an effective adjunct in treating odontogenic cervicofacial infection.

Impacts of lockdown during the SARS-CoV-2 pandemic on patients presenting with cervicofacial infection of odontogenic origin: a comparative study

The SARS-CoV-2 pandemic caused unprecedented disruption to primary and secondary healthcare services. Our aim was to explore whether the pandemic had had any impact on patients presenting with cervicofacial infections (CFI) of odontogenic origin to secondary care and management. Comparative analysis was carried out evaluating prospective and retrospective consecutively admitted patients with a diagnosis of CFI of odontogenic origin in the COVID-19 lockdown period from 15 March to 15 June 2020 and pre-COVID-19 during the same period of the previous year. Data included patients' demographics, comorbidities, systemic inflammatory response syndrome (SIRS) status on admission, clinical features, prior treatment in primary care, source of referral, SARS-COV-2 antigen status, treatment received in secondary care, intraoperative findings, and whether escalation of the level of care was required. Across both cohorts there were one hundred and twenty-five (125) patients admitted with CFI of odontogenic origin, with a 33% reduction (n=75 (2019) vs n=50 (2020)) in number of patients admitted during COVID-19 lockdown. There was no difference between the cohorts in terms of age (p=0.192), gender (p=0.609) or major comorbidities (p=0.654). Proportionally more patients in the COVID-19 group presented with SIRS (p=0.004). This group of patients persisted with symptoms for longer before presenting to secondary care (p=0.003), more delay from hospital admission to surgical intervention (p<0.005) and had longer hospital stays (p=0.001). More patients required extraoral surgical drainage during COVID-19 (p=0.056). This study suggests that the COVID-19 lockdown has had adverse effects on the presentation of CFI of odontogenic origin and its management within a Regional Acute Maxillofacial Service. Commissioners and clinicians should endeavour to plan for adequate primary and secondary care provision during any future local lockdowns to ensure that patient care is optimised.

The role of adjuvant systemic steroids in the management of periorbital cellulitis secondary to sinusitis: a systematic review and meta-analysis

PURPOSE

The role of adjuvant systemic corticosteroids in the management of periorbital cellulitis and subperiosteal/orbital abscesses secondary to sinonasal infections is not well understood. Our objective was to systematically review the current evidence on the efficacy and side effects of systemic steroids when used in the management of periorbital cellulitis.

METHODOLOGY

A systematic review of literature was conducted in accordance with PRISMA guidance. A systematic search of MEDLINE, Embase and Cochrane databases, MetaRegister and ISI conference proceedings was conducted. The outcomes of interest were duration of inpatient stay, requirement for surgical intervention, adverse effects and recurrent/residual symptoms.

RESULTS

Four studies were identified involving 118 patients. Of these, 78 underwent treatment with systemic corticosteroids and 40 were controls. Meta-analysis demonstrated that the mean duration of inpatient stay was significantly shorter in the steroid group (WMD - 2.90 days; 95% CI - 3.07, - 2.73; p < 0.00001). There were no significant differences in requirement for surgical intervention (RR 0.93; 95% CI 0.50, 1.75; p = 0.83). Side effects were reported in 6/78 patients (7.7%), with 5 patients showing signs of hyperactivity and 1 patient with insomnia. These were mild except in one case, which required early cessation of corticosteroids. There was one case of recurrence of symptoms in each cohort (steroid vs. non-steroid) following discharge.

CONCLUSIONS

The evidence suggests that systemic corticosteroids may offer some benefit in the management of periorbital cellulitis secondary to sinonasal infections. However, there is significant heterogeneity and risk of bias. A well-designed randomised controlled trial may provide a better insight into the efficacy of systemic steroids for this condition.

Deep neck space infection and Lemierre's syndrome caused by Streptococcus anginosus: A case report

Introduction

Deep neck space infections most commonly arise from a septic focus of the mandibular teeth, tonsils, parotid gland, middle ear or sinuses, usually with a rapid onset and frequently with progression to life-threatening complications. Lemierre’s syndrome is classically defined by an oropharyngeal infection with internal jugular vein thrombosis followed by metastatic infections in other organs.

Case presentation

A 32-year-old female patient, with no significant past medical history, was diagnosed with a dental abscess on her left inferior 3^rd molar. Six days later, the condition complicated with severe upper respiratory distress, odynophagia and trismus, and extension of the inflammatory signs to the anterior cervical region, involving the upper airway. Computed tomography scan confirmed extension to submandibular, parapharyngeal and retrosternal spaces), which required nasotracheal intubation due to compromised airway. Urgent and subsequent surgical drainages were performed, alongside with concomitant antibiotic therapy. Additionally, left internal jugular vein thrombosis was described - with later extension to the brachiocephalic vein, without other complications, consistent with Lemierre's syndrome, although without full features. Streptococcus anginosus was identified in the drained pus specimens. The patient made a satisfactory clinical progress and was discharged after 25 days, still under therapeutic hypocoagulation.

Conclusion

As deep neck space infections can be life-threatening, clinicians must be aware and not underestimate their potential severity. Lemierre's syndrome is a complication difficult to recognize, which requires additional awareness of the many possible presentations, for appropriate diagnostic studies and therapeutic plan.