Microbiologic investigations for head and neck infections

Fusobacterium necrophorum an Underrecognized Cause of Petrous Apicitis Presenting with Gradenigo Syndrome: A Case Report

BACKGROUND With the advent of antibiotics, petrous apicitis (PA), inflammation of the petrous temporal bone, has become a rare complication of otitis media. Even more uncommon is Gradenigo syndrome (GS), a result of PA, characterized by a triad of otitis media or purulent otorrhea, pain within the regions innervated by the first and second division of the trigeminal nerve, and ipsilateral abducens nerve palsy. Recent literature has demonstrated increasing reports of Fusobacterium necrophorum isolated in cases of GS. CASE REPORT A 21-year-old man presented with otalgia, reduced hearing, and severe headache. Examination revealed right-sided purulent otorrhea, anesthesia within the trigeminal nerve distribution, and an ipsilateral abducens nerve palsy. F. necrophorum was isolated from an ear swab and a blood culture. Computed tomography and magnetic resonance imaging (MRI) demonstrated otomastoiditis, PA, cavernous sinus thrombosis, and severe stenosis of the petrous internal carotid artery. He was treated with intravenous benzylpenicillin, underwent a mastoidectomy and insertion of a ventilation tube, and was started on a 3-month course of dabigatran. Interval MRI showed improved internal carotid artery caliber, persistent petrous apex inflammation, and normal appearance of both cavernous sinuses. Follow-up clinical review noted persistent abducens and trigeminal nerve dysfunction. CONCLUSIONS We identified 190 cases of PA; of these, 80 presented with the classic Gradenigo triad. Fusobacterium sp. were cultured in 10% of GS cases, making them the most frequent isolates. Due to the fastidious nature of F. necrophorum, it may be underrepresented in the historical literature, and we recommend that empiric antibiotics cover anaerobic organisms.

Upper Eyelid Necrosis Secondary to Hordeolum: A Case Report

We reported a case of upper eyelid necrosis initially misdiagnosed as a preseptal cellulitis following a hordeolum externum resulting in great damage to the upper eyelid (anterior lamella). The infection was successfully treated with surgical cleansing, drainage, and endovenous antibiotics. Early treatment may avoid severe complications such as eyelid deformity, systemic involvement, and blindness.

Deep Neck Space Infections: A Case Series and Review of the Literature

Deep neck spaces are regions of loose connective tissue filling areas between the 3 layers of deep cervical fascia, namely, superficial, middle, and deep layers. The superficial layer is the investing layer, The pretracheal layer is the intermediate layer and the prevertebral layer is the deepest layer. Deep neck space infection (DNI) is defined as an infection in the potential spaces and actual fascial planes of the neck. Once the natural resistance of fascial planes is overcome, spread of infection occurs along communicating fascial boundaries. More recent trends include the increasing prevalence of resistant bacterial strains, a decline in DNIs caused by pharyngitis or tonsillitis, and a relative increase in DNIs of odontogenic origin. Most DNIs are polymicrobial. Only 5% are purely aerobic and 25% with isolated anaerobes. The epidemiology of DNIs needs to be monitored for changing trends and the impact of underlying host immunity and developing microbial multidrug resistance is established. Surveillance at laboratory level should include mandatory susceptibility testing of all empiric antibiotics against microbes commonly identified in adult DNI microscopy, culture, and sensitivity (MC&S) specimens. The role of susceptibility testing of microbes not commonly identified in adult DNI MC&S specimens needs further review, on a clinical case-by-case basis.

Deep neck abscesses: study of 101 cases

INTRODUCTION

Although the incidence of Deep Cervical Abscess (DCA) has decreased mainly for the availability of antibiotics, this infection still occurs with considerable frequency and can be associated with high morbidity and mortality.

OBJECTIVE

This study aimed to present our clinical-surgical experience with deep neck abscesses.

METHODS

A retrospective study analyzed 101 patients diagnosed with deep neck abscesses caused by multiple etiologies, assisted at a medical school hospital during 6 years. One hundred one patients were included and 27 (26.7%) were younger than 18 years old (the children group), 74 patients (73.3%) were older than 18 years old (the adults group). The following clinical features were analyzed and compared: age, gender, clinical symptoms, leukocyte count, the affected cervical area, lifestyle habits, antibiotic therapy, comorbidities, etiology, bacterial culture, time of hospitalization, the need of tracheostomy and complications.

RESULTS

There was predominance in the male gender (55.5%) and young people (mean age 28.1 years). All of the 51 patients with associated disease comorbidity were adults. The most frequent etiologies were bacterial tonsillitis (31.68%) and odontogenic infections (23.7%). The most common cervical areas affected were the peritonsillar (26.7%), submandibular/mouth floor (22.7%) and parapharyngeal spaces (18.8%). In children group, the site most commonly involved was the peritonsillar space (10 patients, 37%). In adults group, the site most commonly involved was multispace (31 patients, 41.8%). Streptococcus pyogenes (23.3%) was the most common microorganism present. Amoxicillin associated with clavulanate (82.1%) was the more used antibiotic. The main complications of abscesses were septic shock (16.8%), pneumonia (10.8%) and mediastinitis (1.98%). Tracheostomy was necessary in 16.8% of patients. The mortality rate was 1.98%.

CONCLUSION

The clinical features and severity of DCA varied according to different age groups, perhaps due to the location of the infection and a higher incidence of comorbidity in adults. Thus, DCA in adults is more facile to have multispace involvement and lead to complications and seems to be more serious than that in children.