Infecciones cervicofaciales graves. Nuestra experiencia en el Hospital Universitario Ramón y Cajal de Madrid / Severe cervicofacial infections. Our experience in Ramón y Cajal University Hospital, Madrid

INTRODUCCIÓN: Las infecciones cervicofaciales constituyen un motivo de consulta muy frecuente en los servicios de Urgencias de nuestro país, siendo con frecuencia causa de gran morbilidad y de importantes complicaciones, incluyendo el compromiso de la vía aérea. Por todo ello, un diagnóstico y tratamiento precoces son de vital importancia. El objetivo principal es realizar un estudio observacional retrospectivo sobre los pacientes diagnosticados de infección cervicofacial grave en nuestro centro, analizando múltiples variables demográficas, el tratamiento administrado, la duración del ingreso y las complicaciones observadas. MATERIAL Y MÉTODOS: Estudio observacional descriptivo retrospectivo sobre una muestra de 47 pacientes diagnosticados de infección cervicofacial grave en nuestro centro entre abril de 2016 y marzo de 2018. Se recogen y analizan múltiples variables: sexo, etiología, clínica asociada, aislamiento microbiológico, tratamiento, comorbilidades, duración de ingreso y complicaciones asociadas. RESULTADOS: El 51 % de la muestra fueron pacientes menores de 50 años sin comorbilidades asociadas. Las comorbilidades más frecuentes fueron los hábitos tóxicos (tabaco y alcohol), hipertensión arterial y diabetes. Respecto a la etiología, el 91 % fueron odontogénicas, siendo los cordales inferiores las piezas dentales afectadas con mayor frecuencia (79,06 %). La clínica característica de presentación fue la tríada de tumefacción facial, dolor y trismus (hasta el 60 %). El espacio cervicofacial afectado con mayor frecuencia fue el submandibular (56 %). El aislamiento microbiológico mostró que la mayoría fueron infecciones polimicrobianas mixtas (18 de 38 aislamientos) con predominio de los grupos Streptococo y Prevotella. Las complicaciones encontradas fueron: dos pacientes con obstrucción de vía aérea superior que precisaron traqueostomía previa intubación, un hematoma postquirúrgico, tres reintervenciones por mala evolución clínica y un paciente con mediastinitis. CONCLUSIONES: De los resultados obtenidos podemos concluir que la etiología odontogénica es la más frecuente, siendo el espacio submandibular el más afectado. En el Hospital Ramón y Cajal de Madrid, la mayoría de las infecciones cervicofaciales graves son mixtas con microrganismos aislados aerobios y anaerobios. El tratamiento combinado con cirugía y antibioterapia intravenosa fue de elección. Amoxicilina-Clavulánico fue el antibiótico más utilizado. Las complicaciones evolutivas graves son poco frecuentes con un tratamiento adecuado

INTRODUCTION: Cervical infections are a very common reason for consultation in the emergency services of our country. However, in certain cases, these infections are a cause of a great morbidity and important complications, including the compromise of the upper airway. For all these reasons, early diagnosis and treatment are of a great importance. The main objective is to perform a retrospective study of patients diagnosed with severe cervicofacial infection in our department, analyzing multiple demographic variables, treatment administered, time of hospitalization and complications observed. MATERIAL AND METHODS: Retrospective descriptive observational study based on a sample of 47 patients diagnosed with severe cervicofacial infection in our center between April 2016 and March 2018. Multiple variables were collected, among which are: sex, etiology, associated symptoms, microbiological isolation, treatment established, comorbidities, time of hospital admission and complications. RESULTS: 51 % of the sample were patients under 50 years of age without comorbidities. The most frequent comorbidities were toxic habits (tobacco and alcohol), hypertension and diabetes. Regarding the etiology, 91 % were odontogenic, being the third inferior molars the most frequently affected (79.06 %). The characteristic clinical presentation was the triad of facial swelling, pain and trismus (up to 60 %). The most frequently affected cervicofacial space was the submandibular space (56 %). The microbiological isolation showed that the majority were mixed polymicrobial infections (18 of 38 isolates) with predominance of the Streptococcus and Prevotella groups. The complications that we found were: two upper airway obstructions, a cervical bleeding, three reinterventions for a bad clinical evolution and a patient with mediastinitis. CONCLUSIONS: We can conclude that odontogenic etiology is the most frequent in severe cervicofacial infections, with the submandibular space being the most affected. Most of severe cervicofacial infections in Ramón y Cajal Hospital were polymicrobial and mixed infections. The combined treatment with surgery and intravenous antibiotic therapy was the therapeutic option chosen for all patients. Amoxicillin-Clavulanic was the most used broad-spectrum antibiotic. Complications are uncommon with an adequate treatment

[Malakoplakia of the submandibular gland in a renal transplant patient]. / Malakoplakie de la glande sous-mandibulaire chez un patient transplanté rénal.

INTRODUCTION: Malakoplakia (MP) is a rare granulomatous disease, usually occurring in immunocompromised patients, linked to Escherichia coli infection. The lesions are usually located in the genitourinary tract, but there is a great variability in the topography and the clinical presentation. CASE REPORT: A 70-year-old diabetic kidney transplant patient under immunosuppressive treatment presented with a voluminous submandibular chronic lesion, involving the skin, associated with a burgeoning lesion of the oral mucosa. Histological examination of biopsies concluded to MP and bacteriological samples were positive for E. coli. Antibiotic treatment allowed for the regression of the lesion before surgical removal. Histological examination of resected material confirmed the diagnosis of invasive MP of the submandibular gland. DISCUSSION: The diagnosis of MP relies on histological examination, showing the presence of von Hansemann's cells and Michaelis- Gutmann bodies. The treatment is based on active antibiotics targeted against intracellular bacteria, possibly associated with surgery. We report the first case of MP involving the submandibular gland.

Neonatal suppurative sialadenitis: an important clinical diagnosis.

Neonatal suppurative sialadenitis is a condition causing infection of the salivary glands, most frequently caused by Staphylococcus aureus. The vast majority of cases reported in the literature have been in infants with recognised risk factors. This report presents two cases of neonatal sialadenitis in siblings, neither of whom had any predisposing characteristics. The aetiology, diagnosis and treatment of this condition are discussed. This report will also highlight the need for awareness of this condition and its inclusion in considered differentials for neck swelling in all infants.

Microbiological examination and antibiotic sensitivity of infections in the head and neck. Has anything changed?

Because of the growing concern about antibiotic resistance, we aimed to investigate whether the microbiological picture and antibiotic sensitivity of infections in the head and neck have changed in the last 30-40 years. We retrospectively studied 150 patients admitted for inpatient treatment of infections in the head and neck, and searched published reports from the last 30 - 40 years for comparison. There were 85 male and 65 female patients (mean age 39 years, range 1-95). Most infections originated from the teeth (n = 111) and skin (n = 16), and the submandibular (69%) and buccal (67%) spaces were involved most often. Multiple spaces were involved in 94 patients. Swabs were taken for culture and sensitivity in 102 cases, and microorganisms were isolated in 91 (89%), of which 67 (74%) were aerobic infections and 24 (26%) were anaerobic. Bacteria were isolated in 87 (96%) cultures of which 60 (69%) were Gram-positive. Gram-positive cocci were isolated in 62% of cultures. The most common bacteria isolated were streptococci. Seventy percent of the bacteria were sensitive to amoxicillin and 84% to amoxicillin and metronidazole; 14% (Staphylococcus aureus from infections of the skin) were resistant to penicillin. A comparison of our results with those found in previous reports shows no significant change in the microbiological picture and antibiotic sensitivity of odontogenic infections in the head and neck over the last 30 - 40 years. Amoxicillin still treats these infections effectively.

Unilateral acute dacryocystitis associated with oculoglandular tularemia: a case report.

PURPOSE: To describe an unusual case of oculoglandular tularemia associated with unilateral acute dacryocystitis and purulent conjunctivitis with 18 weeks pregnancy. METHODS: It is difficult to culture francisella tularensis on media so serological tests such as micro-agglutination methods are used to diagnose the infection. PCR test results were weak positive. The serum sample was analyzed for the presence of f. tularensis antibody, which was determined positive with a titer of 1/160. RESULTS: Oral amoksicilin-clavulonic acid treatment was applied to the patient because of the side-effects of other antibiotics on the fetus. Dacryocystitis was surgically drained but relapsed a few weeks later, so it was drained again and a ciprofloksasin-impregnated sponge was placed into the tissue defect that occured after drainage. No relapses were seen after recovery of dacryocystitis. CONCLUSIONS: Oculoglandular tularemia is not only suspected in cases who complain of fever, cervical lymphadenopathy and purulent conjunctivitis, it should also be suspected in cases who are admitted to the hospital with acute dacryocystitis, which is a rare component of oculoglandular syndrome.

Function of blood monocytes among patients with orofacial infections.

Few data are available on the significance of the integrity of the innate immune system among patients with orofacial infections. This was assessed in the present study. Peripheral blood mononuclear cells (PBMCs) were isolated from 23 patients with orofacial infections before surgical debridement and from 12 healthy volunteers. PBMCs were stimulated with bacterial endotoxin (LPS) and with Pam3Cys. Concentrations of interleukin (IL)-1ß, IL-6 and tumor necrosis factor-alpha (TNFα) were estimated in supernatants by an enzyme immunoassay. Concentrations of estimated cytokines released from PBMCs of healthy volunteers and of patients did not differ. Intensity of cytokine release after stimulation was related with the time until complete resolution of the infection (p: 0.046). It is concluded that adequate functions of blood monocytes are associated with favorable outcome after surgery for orofacial abscesses. It seems, however, that impairment of monocyte function predisposes to infection persistence.

[Sphingomonas paucimobilis infection with underlying submandibular sialolithiasis]. / Submandibüler sialolitiazis zemininde Sphingomonas paucimobilis enfeksiyonu.

Sphingomonas paucimobilis (S. paucimobilis), is a gram-negative, aerobic, non-fermentative, oxidase (+) and catalase (+) bacterium. Although S. paucimobilis is isolated very rarely, it can cause both nosocomial and community-acquired infections. A patient admitted to our clinic had a complaint of swelling in the right mandibular region and pain increasing while eating for the previous week. Bimanual palpation revealed a painful swelling of 1x1x1 cm in size inside the right Wharton's duct. Via massage over the right submandibular gland, a purulent drainage came up from the opening of the Wharton's duct and it was cultivated and S. paucimobilis was isolated. There was no ultrasonographic evidence of calculi in the duct or in the gland, but during the right submandibular gland massage, two stones came out through the Wharton's duct. The infection was observed to be eradicated with a 14-day ampicillin-sulbactam treatment. In the control examination after six months, there were no pathological signs or symptoms and the ultrasonogram was normal. As far as we know, this is the first sialadenitis case with underlying sialolithiasis where S. paucimobilis was isolated.

Neonatal suppurative submandibular sialadenitis.

Neonatal sialadenitis of the submandibular gland is a very rare clinical entity. Information about the etiopathogenesis and management of the disease is very limited. Prematurity, prolonged gavage feeding and dehydration are the frequent causes. This report presents a rare case of isolated suppurative submandibular sialadenitis in a full-term newborn without any risk factors. Possible etiology, diagnosis and management of this uncommon disease are discussed.

[Submandibular sialadenitis in a 10 days old newborn].

We report a case of acute submandibular sialadenitis in a ten days old newborn. The disease was diagnosed at an early stage, therefore rapid antibiotic treatment was initiated, and no surgical intervention was needed. In a long term follow-up, a full recovery was observed. The authors reviewed the literature and describe the common etiologies and recommended treatment options for submandibular sialadenitis.

Coexistence of salivary gland cysticercosis with squamous cell carcinoma of the mandible.

Cysticercosis is a parasitic infestation caused by the pork tapeworm larval stage, Cysticercus cellulosae. The majority of the cases present in ocular, cerebral, and subcutaneous locations. We report the presence of cysticercosis inside the submandibular gland in association with squamous cell carcinoma of the inferior alveolar ramus of the mandible. To the best of our knowledge, this is the first case report documenting cysticercosis inside a salivary gland. A 65-year-old male presented with complaints of an ulcerative lesion on the inferior alveolar ramus present for 2 months. Histological examination revealed a keratinizing well-differentiated squamous cell carcinoma involving the alveolar margin and mandible. The histopathological examination of the submandibular gland revealed cysticercosis. This case emphasizes the importance of adequate sampling of all the tissues obtained for associated infectious disorders, more so in immunosuppressed patients, which will help the clinician to manage the case appropriately.

A case of tularemia presenting as a dental abscess: case report.

OBJECTIVE: The purpose of this report is to present a tularemia case accompanied by a neck mass that easily may be confounded with dental abscess. SUMMARY: Francisella tularensis is a potential agent of biologic terrorism. Thirty percent of the symptoms seen in tularemia localize in the head and neck region and are sometimes mistaken for complications of a dental abscess. To our knowledge, reports of the differential diagnostic characteristics of tularemia are lacking in the dental literature and, to date, no dental journal articles have focused on the disease. In this present case, a 51-year-old woman arrived at the public health department with high fever and facial swelling. The findings suggested a dental origin and the patient was directed to dentistry. Radiology and a detailed intraoral and extraoral examination failed to reveal a dental problem. Fortunately, the patient was known to come from a tularemia region; with the suspicion of tularemia the patient was referred to the faculty of medicine. Serologic tests showed that the patient had a Francisella tularensis infection.

Head and neck infections caused by Streptococcus milleri group: an analysis of 17 cases.

BACKGROUND: Streptococcus milleri group (SMG) is a common inhabitant of the mouth and gastrointestinal tract, and can be an aggressive pathogen causing abscess formation at various sites in the body. However, it has rarely been listed as a cause of head and neck infections. OBJECTIVES: The present study was performed to evaluate the clinical significance of SMG by reviewing the microbiology and clinical records of patients with SMG in head and neck infections retrospectively. STUDY DESIGN: A retrospective review of all patients diagnosed as having SMG bacterial infections at Onomichi General Hospital, Hiroshima, between the years 2001 and 2002 was performed; 17 patients developed head and neck infections with SMG. Here, we describe the clinical features and management of SMG in head and neck infection. RESULTS: The patient population consisted of 12 males and 5 females with a median age of 62 years (age range, 8-78 years). The sites of infection were as follows: maxillary sinus (n=6), peritonsillar region (n=4), subcutaneous (n=3), submandibular space-retropharyngeal space (n=1), deep neck-mediastinum (n=1), parapharyngeal space (n=1), submandibular space (n=1), tonsil (n=1), parotid gland (n=1), and masseter muscle (n=1). Ten cases (59%) were of suppurative diseases. Six cases (35%) had mixed SMG with anaerobe infection. Three cases showed deteriorating clinical courses, and all three of these cases were culture-positive for SMG with anaerobes. In addition, one deteriorating case showed gas gangrene regardless of repeated surgical debridement and intravenous antibiotic therapy; hyperbaric oxygen therapy improved this patient's condition. CONCLUSION: It is important to recognize SMG as a pathogen in head and neck infection. In addition, the care should be taken with infectious diseases caused by SMG with anaerobes as the patient's clinical course can deteriorate rapidly.