Diagnosis and treatment of deep neck space abscesses.

OBJECTIVE: To review our experience with deep neck abscesses and identify unique trends in our patient population. STUDY DESIGN: Case series with chart review. SUBJECTS AND METHODS: Evaluation of patients with deep neck space abscesses between 2001 and 2006. Peritonsillar abscess, superficial craniocervical infection, and salivary gland infections were excluded from selection of study population. A total of 106 cases were reviewed. RESULTS: Dental infections were the most common cause of deep neck abscesses (49.1%). Comorbidities included substance abuse (53.7%), psychiatric illness (10.4%), hypertension (9.4%), head and neck cancer (6.6%), and diabetes mellitus (5.7%). All patients received systemic antibiotics, eight patients required tracheotomy, 85 patients underwent surgical drainage in the operating room, and 11 had bedside drainage. Median and lower quartile of time in hospital was 2 and 3 days, respectively, whereas upper quartile was 4 days (range, 1 to 27 days). Patients with comorbidities or concurrent illness tended to stay longer (P<0.05, Mann-Whitney test). There were six complications and no mortality. CONCLUSION: Substance abuse and poor orodental hygiene are important predisposing factors to deep neck abscesses. Appropriate management continues to favor a combination of early surgical drainage and systemic antibiotics.

Surgical debridement and adjunctive hyperbaric oxygen in cervical necrotizing fasciitis.

OBJECTIVE: To review our management of cervical necrotizing fasciitis (CNF) with the use of adjunctive hyperbaric oxygen therapy (HBO). STUDY DESIGN: Case series with chart review. SUBJECTS AND METHODS: Evaluation of ten patients with CNF between 2001 to 2006. RESULTS: There were five male and six female patients. Mean age was 43 +/- 11 years. Eight cases resulted from an odontogenic source. Comorbidities included diabetes mellitus, hypertension, and substance abuse. All patients had computed tomography scans performed, received intravenous antibiotics, and underwent surgical debridement. Eight patients underwent surgery within 24 hours. The average number of debridements was 2.2 +/- 0.8. Hospitalization was twice as long for diabetic patients (15.5 +/- 8.16 days) compared with nondiabetic patients (7.5 +/- 1.6 days, P = 0.029). Nine patients had HBO therapy. Combined data revealed a possible decrease in length of hospitalization with HBO therapy (P < 0.001). No mortality was documented. CONCLUSION: In addition to early and aggressive medical management and surgical debridement, this study suggests that HBO therapy is a beneficial adjunct by potentially decreasing length of hospitalization. Randomized trials are still needed to demonstrate its efficacy.

Complications of otitis media before placement of tympanostomy tubes in children.

OBJECTIVES: To report the incidence of short-term complications from otitis media in children before placement of tympanostomy tubes (TTs) and to compare children treated according to the Agency for Health Care Policy and Research guidelines with those who were treated earlier or later than recommended. DESIGN: Retrospective outcomes review. PATIENTS: Subjects were children aged 10 or younger who had TTs inserted at a tertiary care county hospital from January 1, 1999, to December 31, 2000. Exclusion criteria included prior TT placement, any concurrent head and neck procedure, and craniofacial defects. INTERVENTION: Tympanostomy tube placement. MAIN OUTCOME MEASURES: Any occurrences of otorrhea, tympanic membrane perforation, tinnitus, antibiotic reactions, speech or language delay, febrile seizures, or meningitis before placement of TTs documented in the county hospital records were recorded as complications. Hearing loss was considered separately. RESULTS: Of 147 children who met our criteria, 81 (55.1%) had 1 or more complications from otitis media before placement of TTs. Fifty-five (37.4%) had 2 to 6 complications documented. Adverse reactions to antibiotics were the most common complication, reported in 34 (23.1%). CONCLUSIONS: Most children in this county hospital experienced short-term complications of otitis media before receiving TTs. Even the children treated "on time" according to the guidelines from the Agency for Health Care Policy and Research experienced complications; however, adherence to the guidelines had no significant effect on complications.

The long-term evaluation of tracheostomy in the management of severe obstructive sleep apnea.

OBJECTIVE: To determine the long-term success and morbidity of tracheostomies for patients with severe obstructive sleep apnea. STUDY DESIGN: A retrospective study of patients who have undergone tracheostomy for documented obstructive sleep apnea at Hennepin County Medical Center since 1979. METHODS: Retrospective chart review of all tracheostomy patients operated January 1, 1979, to June 30, 1999, were evaluated. Follow-up data from patient records, death certificates, and DMV. RESULTS: Seventy-nine patients (70 men and 9 women; age range, 25-70 y; mean age, 47 y) received tracheostomies at a regional sleep disorder center. Respiratory distress index ranged from 45 to 146 (mean value, 81). Tracheostomy eliminated obstructive sleep apnea in all cases. Follow-up ranged from 3 months to 20 years (mean period, 8.3 y). In all, 16 patients had decannulation (range, 2 mo to 13 y): 5 of the patients chose continuous positive airway pressure, 3 grew intolerant of their tracheostomy, 3 had obstructive sleep apnea fully resolve after uvulopalatopharyngoplasty, 3 unknown diagnosis for decannulation, 2 had significant weight loss. Morbidity seen within the first year was primarily limited to granulation tissue, infection, and stoma revision. Fourteen deaths were identified. Average age at time of death was 62 years. Five deaths were cardiopulmonary related, four were from cancer, two were from postoperative complications of unrelated surgery, and one was from aspiration. Tracheostomy-related mortality included one postoperative myocardial infarction and one tracheal-innominate fistula. CONCLUSION: Severe obstructive sleep apnea and its comorbid conditions are effectively treated in the long term with tracheostomy. Initial management of more frequent complication is well tolerated. Significant morbidity and mortality are low. Chances of obstructive sleep apnea resolution allowing decannulation remain poor.