Principles of Antimicrobial Therapy for Head and Neck Infections

Comparison of preoperative computed tomography and surgical findings in maxillofacial infections

PURPOSE

To examine the accuracy of computed tomography (CT) in predicting the presence of surgically confirmed abscess in patients presenting with deep maxillofacial infections (DMIs).

MATERIALS AND METHODS

The medical records of 36 patients with clinically suspected DMI were reviewed. All patients underwent preoperative CT scan to determine whether abscess or cellulitis was present. The operative reports of all patients were compared with their preoperative CT scan findings.

RESULTS

Of 36 patients, 30 had abscess predicted by preoperative CT scan. The positive predictive value for DMI based on CT findings interpreted by an oral surgeon and confirmed as an abscess at operation was 90%, whereas the negative predictive value was 33%. When findings were interpreted by a radiologist, the positive predictive value was 94.1% whereas the negative predictive value was 26.3%. Thirty patients had abscess predicted by preoperative CT scan when interpreted by an oral surgeon, whereas seventeen had abscess predicted by a radiologist. At operation, 3 of 30 patients had cellulitis whereas 27 had abscess, for a false-positive rate of 60% and false-negative rate of 12.9%. On the basis of preoperative radiography, 1 of 17 patients had cellulitis whereas 16 had abscess, for a false-positive rate of 16.7% and a false-negative rate of 46.7%. The agreement between CT and operative findings in predicting abscess by an oral surgeon was 80.6% and by a radiologist was 58.3%.

CONCLUSION

CT yielded high sensitivity for the detection of DMI abscess but poor specificity, likely because of the paucity of cellulitis.

Efficacy of piperacillin-tazobactam in the treatment of surgical wound infection after clean-contaminated head and neck oncologic surgery

BACKGROUND

Although perioperative antibiotic prophylaxis has significantly reduced surgical wound infection rates, this complication is still a frequent complication of head and neck cancer surgery. Because these infections are typically polymicrobial, our study evaluated the safety and efficacy of piperacillin-tazobactam in the treatment of surgical wound infection after clean-contaminated head and neck oncologic surgery.

METHODS

In this multicenter, prospective clinical trial, 70 patients with surgical wound infection received piperacillin-tazobactam.

RESULTS

Of patients who were evaluable, 92.4% were also clinically cured or improved, and the bacteriologic eradication rate was 80.3%. Of the 70 patients enrolled in the study, six (8.5%) experienced six adverse events: two cases of moderate diarrhea, one allergic skin reaction, and three cases of phlebitis. No deaths were attributable to the study drug.

CONCLUSIONS

Piperacillin-tazobactam is a good choice of treatment as monotherapy for surgical wound infection after clean-contaminated head and neck oncologic surgery.

Prospective application of a protocol for selective nonsurgical management of suspected orbital subperiosteal abscesses in children

Goodwin et al (1982) and Souliere et al (1990) have proposed a protocol for the selective nonsurgical management of suspected orbital subperiosteal abscesses. This protocol has been routinely applied by the Temple Pediatric Otolaryngology and Ophthalmology services since 1990. During this period, children with computed tomography and physical examination findings consistent with orbital subperiosteal abscesses and visual acuity better than 20/60 were treated with intravenous antibiotics rather than immediate surgery. They were followed with frequent ophthalmologic examinations and operated upon if vision deteriorated or they failed to improve clinically within 48 hours. A review of patients admitted to St Christopher's Hospital for Children, the site of Temple University's pediatric activities in the years from 1991 to 1997, revealed 14 patients with clinical evidence of orbital subperiosteal abscesses. Twelve patients were treated in accordance with the Goodwin-Souliere protocol. All recovered completely without surgical intervention and without any adverse sequelae. Selective nonsurgical treatment of clinically diagnosed orbital subperiosteal abscesses in children is relatively safe and effective.

Improvement of bronchial hyperresponsiveness in asthmatic children treated for concomitant sinusitis

BACKGROUND

There appears to be an association between sinusitis and asthma. The effect on bronchial hyperresponsiveness of clinical therapy for sinusitis in children may help to decipher whether sinusitis and asthma are independent manifestations of the same disease.

OBJECTIVE

To evaluate the effect of clinical treatment for sinusitis in patients with rhinitis and/or asthma on symptoms and on bronchial hyperresponsiveness to methacholine.

METHODS

Open label, randomized, non-treatment control in a teaching hospital in São Paulo, Brazil. Forty-six atopic and 20 normal children were studied. The atopic children consisted of 18 with allergic rhinitis (12 without sinusitis and 6 with sinusitis), and 28 children with rhinitis with asthma (13 with normal sinus radiographs and 15 with complete opacification of the maxillary sinuses). Methacholine PC20 was determined before and 30 days after treatment with nasal saline, sulfamethoxazole-trimethoprim, antihistamine/decongestant, and five days of prednisone. Sinus radiographs were also repeated.

RESULTS

The only patients with increase in methacholine PC20 were patients with rhinitis and asthma with opacified maxillary sinuses at entry and who at 30 days had normal sinus radiographs (P < .05).

CONCLUSION

In this study, children with allergic rhinitis and sinusitis with asthma improved their bronchial hyperresponsiveness to methacholine and decreased their symptoms with appropriate response of their sinuses to clinical therapy.

Comparison of computed tomography and surgical findings in deep neck infections

Computed tomography is routinely used in the evaluation of patients suspected to have deep neck infections. This 10-year retrospective study compares preoperative computed tomography scan reports with intraoperative findings in 38 patients who underwent surgical exploration of the parapharyngeal or retropharyngeal space within 48 hours of their radiographic assessment. Overall, intraoperative findings confirmed computed tomography scan interpretation in 76.3% of the patients. The false-positive rate was 13.2%, and the false-negative rate was 10.5%. The sensitivity of computed tomography scan for detection of parapharyngeal space or retropharyngeal space abscess was 87.9%. This study's documentation of false-positive computed tomography scans in the evaluation of deep neck infections emphasizes the importance of correlating radiologic interpretation with clinical examination before surgical intervention.