Redefining parapharyngeal space infections.

OBJECTIVES: Our intent was to review the clinical signs, computed tomography (CT) scans, treatment, and outcome of parapharyngeal space infections (PPIs), and to define 2 types of infections of the parapharyngeal space (PPS) according to the location of the infectious process. METHODS: We performed a retrospective analysis of patients hospitalized in a tertiary university hospital with a diagnosis of PPI, abscess, or deep neck abscess between 1988 and 2004. Files and CT scans were reviewed after classification into 2 groups: 1) infection located in the posterior part of the PPS (PostPPI); and 2) infection located in the anterior part of the PPS (AntPPI). RESULTS: Twenty-two patients had a PostPPI; their ages ranged from 10 months to 24 years. Five patients underwent surgical drainage, and 17 others were treated solely with intravenous antibiotic therapy. No pus was found during surgery in 2 patients. The average time of hospitalization was 10 days. Only 1 complication (aspiration pneumonia) was observed. Seven patients had an AntPPI; their ages ranged from 1.5 years to 65 years. All patients underwent surgical drainage, and pus was detected in all cases. The average time of hospitalization was 35 days. Complications (septic shock, respiratory arrest, mediastinitis, pleural empyema, pericarditis) were observed in 4 patients. CONCLUSIONS: The term "parapharyngeal abscess" was assigned long before the CT scan era, and was based on physical examination and plain film radiology. In essence, the entity PPS "abscess" or "infection" is composed of 2 different disorders. Infection located in the posterior part of the PPS with no invasion into the parapharyngeal fat and with no extension into other cervical spaces except the adjacent retropharyngeal space may be termed posterior parapharyngeal infection or parapharyngeal lymphadenitis. This is a relatively benign condition, and nonsurgical treatment should be considered. Infection involving the parapharyngeal fat may be termed parapharyngeal abscess or deep neck abscess. Diffusion into the mediastinum and other severe complications are frequent. Urgent surgical drainage is therefore mandatory.

Nonsurgical management of parapharyngeal space infections: a prospective study.

OBJECTIVE/HYPOTHESIS: Parapharyngeal infections, which can potentially cause life-threatening complications, may, in certain cases, be treated conservatively with no need for surgical drainage. A review of the literature reveals that the most recommended treatment of parapharyngeal infection is surgical drainage combined with intravenous antibiotic therapy. Several retrospective reports recommend conservative treatment with no surgical drainage. STUDY DESIGN: Prospective, nonrandomized. METHODS: A prospective study was performed on all patients with an infection limited to the parapharyngeal space. RESULTS: Twelve patients presented with clinical and radiological diagnosis of parapharyngeal infection during a 5-year period. Five patients showed obvious presence of pus in other spaces and therefore were excluded. Seven patients with no gross extension into other spaces and with no respiratory distress or septic shock were treated with intravenous amoxicillinclavulanic acid for 9 to 14 days (average period, 11 days). All patients except one were children. All were cured with conservative management, and no surgical drainage was needed. None had any complications. CONCLUSION: Our results confirm the effectiveness of nonsurgical treatment of infections limited to the parapharyngeal space, at least in the pediatric population.

"Starplasty" prevents tracheotomy complications in infants.

OBJECTIVE: The average age of children undergoing tracheotomy has declined over the years and the indications for tracheotomy have changed from acute airway obstruction due to infection, to treatment of chronically ill children. Tracheotomy-related complication rates are more numerous in younger children and in certain cases have proved to be fatal. A variety of operative techniques have been advocated for reducing the rate of tracheotomy-related morbidity and mortality. This manuscript reports on our experience with a new technique--starplasty tracheotomy (SPT)--and assesses the value of this procedure in preventing tracheotomy-related complications in infants (under 6 months old), in whom complications are more frequent and more dangerous. METHODS: Children less than 6 months old who underwent tracheotomy in the Department of Otolaryngology/Head and Neck Surgery, Hadassah University Hospital, Jerusalem, between the years 1999 and 2003 were studied. They were divided into two groups according to the surgical technique preferred and performed by the senior surgeon on call. Children in group 1 underwent tracheotomy by means of a regular technique and children in group 2 underwent SPT. All events related to the tracheotomy were recorded and a comparison was made between the two groups. RESULTS: Eleven of a total of 26 pediatric tracheotomy patients were less than 6 months old. Five underwent regular tracheotomy (RT) and six underwent SPT. Three complications were encountered in the RT group and none in the SPT group. Accidental decannulation and failure to re-insert the cannula resulted in severe hypoxemic brain damage in one patient with RT. No tracheotomy-related deaths occurred. CONCLUSION: Our experience supports the existing data regarding the superiority of SPT over RT in preventing dangerous tracheotomy-related complications in infants. We, therefore, recommend performing SPT in all infants undergoing tracheotomy, even at the price of having to perform surgical closure of TCF after decannulation in some cases.

Adverse reaction to surgical sutures in thyroid surgery.

BACKGROUND: A mild reaction to surgical sutures after thyroid surgery is common and is characterized by local edema and inflammation around the surgical scar. Severe reaction with microabscesses and granulomatous masses is quite rare. METHODS AND RESULTS: Two cases of severe reaction to silk sutures after thyroid surgery are presented. Meticulous surgical removal of all surgical sutures along with granulomatous masses, granulation tissue, and microabscesses cured both patients. Pathologic examination revealed giant cells and lymphocytes. Intradermal skin tests were positive to silk sutures. The etiology and the treatment options are discussed. CONCLUSIONS: In rare cases, severe reaction to silk sutures may develop after thyroid surgery. Surgical removal of the stitches is the treatment of choice. Intradermal skin test is a good predictor of allergy to sutures.

Predictors of nodal metastasis in salivary gland cancer.

OBJECTIVES: This study was conducted to determine clinical and histologic factors that would predict nodal metastasis in patients with major salivary gland cancer. METHODS: A retrospective study of 40 patients who underwent surgery, including neck dissection, for major salivary gland cancer between 1975 and 1997 was performed. Patient charts were reviewed, and clinical and pathologic data were extracted along with outcome. Predictive factors were identified and survival curves were obtained. RESULTS: Neck dissections were performed in 40 patients, which revealed histologic evidence of tumor in lymph nodes in 15 cases. Histologically proven metastasis was found in 16% of specimens from elective and 73% of specimens from therapeutic neck dissection. Five-year overall and locoregional disease-free survival rates for histologically positive and negative groups were 40% versus 63% (P < 0.05) and 67% versus 69% (P = 0.59), respectively. Univariate analysis of the factors revealed that clinical evidence of nodal metastasis (P < 0.001) and high-grade cancer (P < 0.033) predicted histologic nodal involvement. Multivariate analysis revealed that only a positive neck examination was a significant predictive factor (OR = 31, 95%CI = 2.99-312). CONCLUSIONS: Our results suggest that clinical neck examination is a reliable predictor of regional metastasis in patients with major salivary gland cancer. In view of the low frequency of occult metastases, routine elective treatment of the neck is not recommended.