Extracranial head and neck infections

This article outlines infections in the submandibular, lateral pharyngeal, retropharyngeal, danger, and prevertebral spaces, in conjunction with infections of the sinuses and mediastinum. By understanding the anatomy and pathophysiology, the reader will gain insight into the rationale for various therapeutic options.

[Clinical features and management of pyothorax due to postoperative cervical anastomotic leakage in esophageal cancer surgery]

OBJECTIVE

To investigate the clinical characteristics and managements of pyothorax due to postoperative cervical anastomotic leakage after esophageal cancer surgery.

METHODS

From January 2006 to January 2013, 3342 patients with esophageal carcinoma underwent esophagectomy and cervical esophagogastric anastomosis. Of them, 19 patients developed pyothorax following cervical anastomotic leakage and their clinicopathological data were analyzed retrospectively.

RESULTS

All the patients underwent a cervical anastomosis via a three-incisional approach (right cervicothoracic mid-abdominal incision, RT group, n=1094) or a two-incisional approach (left cervicothoracic incision, LT group, n=2248). The total number of cervical anastomotic leakage cases was 237, of which 152 cases were in LT group (6.8%), and 85 cases in RT group (7.8%), respectively (P=0.287). The incidence of pyothorax was 2.0% (n=3) in LT group, and 18.8% (n=16) in RT group, respectively (P<0.01). Fourteen cases develop pyothorax within 3 days after operation. The main symptoms were high fever, dyspnea and chest pain. All the pyothorax patients received conservative treatments, including thoracic closed drainage, nasogastric tube placement, jejunal stoma, nutritional support, antibiotics and symptomatic treatment. Sixteen cases were cured, while 3 cases were dead.

CONCLUSIONS

The right thoracotomy approach predisposes the cervical anastomotic leakage-associated pyothorax. Sufficient drainage and sufficient nutritional support are critical to the treatment.

[Pulmonary mycobacterium intracellulare infection complicated with pneumothorax and chronic empyema]

A 75-year-old woman who had been treated for pulmonary Mycobacterium intracellulare infection was admitted to a nearby hospital because of hemoptysis, right pneumothorax, and empyema. She had been treated by thoracic drainage and pleural lavage, but was reffered to our hospital because of refractory empyema. Her chest radiograph and chest computed tomography( CT) showed right chronic empyema of which pleural aspirate was smear positive for acid-fast bacilli and positive for the polymerase chain reaction method(PCR)-Mycobacterium intracellulare. Serum levels of white blood cell and C-reactive protein(CRP) were found to be slightly elevated. She was treated with combined use of ethambutol, rifampicin, clarithromycin, and kanamycin and with pleural curettage by thoracoscopic surgery. After surgery additional treatment was done using urokinase which was administered into the thoracic cavity via an thoracic tube. Chronic empyema gradually improved with the treatment and the pleural effusion became bacterial free, enabling the patient to discharge from hospital without thoracic drainage.

[Refractory methicillin-resistant Staphylococcus aureus empyema invasion from a cervical abscess: report of a case]

The patient was a 68-year-old male. At the previous hospital, continuous hemodiafiltration (CHDF)was performed through internal jugular vein for diabetic nephropathy. Long term catheterisation caused the abscess of the sternoclavicular joint, which induced methicillin-resistant Staphylococcus aureus( MRSA) empyema. Endoscopic thoracic debridement was performed for the empyema, however inadequate drainage for the abscess. Thereafter, the patient transferred to our hospital. We performed adequate drainage for the abscess under general anesthesia at 5 days after hospitalization, and then open decortication for empyema at 26 days. The patient recovered well after operation and was discharged from the hospital at 46 days. This was a successful case of surgical treatment for refractory MRSA empyema, which controls all focus of infection.

Length of nonoperative treatment and risk of pleural empyema in the management of pancreatitis-induced pancreaticopleural fistula

Pancreaticopleural fistula is a very uncommon complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. Initial conservative treatment fails in a significant number of cases. Ascending infection through the fistulous tract results in pleural empyema. The aim of this study is to investigate the relation between lengths of nonoperative management and risk of pleural empyema. The retrospective study includes our own experience as well as all case reports identified by a systematic review of the English literature from 1954 to 2012. Inclusion criteria were acute or chronic pancreatitis, whereas tumorous fistulization or complications of pancreatic surgery were kept out. A total of 113 patients were identified. There were 86 men and 27 women. The mean age was 46.5 years and 78 patients had a history of alcoholism. The mortality rate was 1.8 per cent (two of 113). Nonoperative management including interventional therapy and endoscopic stenting was successful in only 40 cases (36%), whereas 73 patients (64%) finally underwent surgery. The most common procedure was distal pancreatectomy (32 of 73). Pleural empyema occurred in 17 cases. Successful nonoperative management had a mean length of 5.5 weeks, whereas surgery was performed after an average of 10.9 weeks of failed conservative efforts. Initial nonoperative therapy was significantly longer in patients eventually sustaining empyema (17 weeks, P < 0.001) and all needed surgical intervention. Prolonged nonoperative treatment is associated with a noteworthy risk of septic complications such as pleural empyema. Further improvement seems achievable by reducing the time gap between fruitless conservative efforts and surgical intervention.

[Clinical application of a fully covered self-expandable metallic stent in treatment of airway fistula]

OBJECTIVE

To assess the feasibility, safety and efficacy of the use of a fully covered self-expandable stent for the treatment of airway fistula.

METHODS

From August 2005 to November 2011, 9 patients underwent treatment by the introduction of a tracheo-bronchial or bronchial fully covered self-expandable metallic stent. There were 7 males and 2 females, aged from 28-65 years with a mean of 46 years. In this group, 7 cases were diagnosed as bronchopleural fistula, 1 case as tracheopleural fistula, 1 case as broncho-esophageal fistula, 8 cases with thoracic empyema. The fistula orifices were from 3.5-25.0 mm in diameter with a mean 8.4 mm. All patients received topical anesthesia, and L-shaped stent was placed in 6 patients and I-shaped stent in 3 patients under fluoroscopic guidance. After the stent placement, the patients with empyema were treated with continual irrigation of the empyema cavity.

RESULTS

Stent placement in the tracheo-bronchial tree was technically successful in all patients, without procedure-related complications. The operating time was from 5-16 minutes, mean time (10 ± 4) minutes. Except for 1 patient, immediate closure of the airway fistula was achieved in the other patients after the procedure, as shown by the immediate cessation of bubbling in the chest drain system or the contrast examination. In this study, 1 patient coughed the inserted stent out due to irritable cough on the 5th day and had to receive repositioning of a new stent. Among the patients who were with empyema, 1 patient died of septicemia on the 8th day and 1 patient died of brain metastases from lung cancer 6 months after the stent insertion with empyema not cured, the other 6 patients' empyema healed from 2-5 months, mean time 3.7 months. Seven patients were followed from 3 to 36 months with a median of 13.5 months. During follow-up, 1 stent was removed from a patient 8 months after the stent implantation without empyema recurred. The remaining patient presented good tolerability to the existence of stent. The stents remained stable, no migration occurred, no empyema recurred, and the patient with broncho-esophageal fistula fed and drunk well.

CONCLUSION

The use of fully covered self-expandable stents proved to be a safe, effective and fast minimally invasive method to treat airway fistula, especially for patients with a higher surgical risk or other failed treatments.

Surgical treatment for severely damaged lung and pyothorax with bronchopleural fistula 9 years after induction chemoradiotherapy and bilobectomy

Here, we present a 54-year old man 9 years after induction chemoradiotherapy and subsequent lower bilobectomy for Stage IIIA lung cancer suffering late complications of pyothorax and bronchopleural fistula in a severely damaged lung. Open-window thoracostomy and subsequent completion pneumonectomy via median sternotomy and anterior thoracotomy were performed. Although sternal wound infection required steel wire removal and debridement, with wound dressing at home, the patient could return to work. Late complications from infected treatment-damaged lungs need to be taken into consideration after induction chemoradiotherapy and subsequent surgery.

Free deep inferior epigastric perforator flap used for management of post-pneumonectomy space empyema

Various solutions exist for management of post-pneumonectomy space empyema. We describe the use of a free deep inferior epigastric perforator (DIEP) flap to fill the space and close a pleural window. Previously, flaps involving abdominal muscle or omentum have been used for this purpose. Abdominal surgery to harvest such flaps can impair ventilatory mechanics. The DIEP flap--harvested from the abdomen, and composed primarily of skin and muscle avoids this problem, thus is a desirable technique in patients with impaired lung function. We believe this is the first report of the DIEP flap to close a postpneumonectomy empyema space.

Empyema and psoas abscess in a previously undiagnosed diabetic patient

A 48-year-old man presented with a 2-month history of polyuria, polydypsia, chest pain, fever, cough and extreme weight loss. He was diagnosed with diabetic ketoacidosis and investigations revealed widespread infection with an empyema complicated by bronchopleural fistula, and iliopsoas, suprapubic and periarticular abscesses. Streptococcus milleri was cultured from all sites. A multidisciplinary medical and surgical approach was required for treatment. This case highlights the immunosuppression, and life-threatening complications arising from undiagnosed diabetes mellitus.

Thoracic empyema in patients with liver cirrhosis: clinical characteristics and outcome analysis of thoracoscopic management

OBJECTIVE

Thoracic empyema in cirrhotic patients is a challenging situation, and the clinical characteristics are rarely reported. The objective of this study was to report the clinical characteristics among this group and to evaluate whether thoracoscopic intervention would affect clinical outcomes.

METHODS

Between 2001 and 2010, we retrospectively reviewed the clinical characteristics, bacteriologic studies, and treatment outcomes of 63 cirrhotic patients with thoracic empyema. A propensity-score based process, matched on age, sex, diabetes mellitus, malignancy, cause, and Child-Pugh classification (A, B, or C), was performed to equalize potential prognostic factors in thoracoscopy and nonthoracoscopy groups. The Kaplan-Meier curve and log-rank test were applied to compare the survival to discharge between the 2 matched groups.

RESULTS

The median patient age was 61 years. Thirty-two patients (51%) underwent thoracoscopic management, and the remaining patients underwent thoracocentesis or tube thoracostomy. The median hospital stay was 28 days, and 19 patients (30%) had in-hospital mortality. Multivariate analysis showed that Child-Pugh C disease and positive blood cultures were risk factors for in-hospital mortality (P = .016 and .027, respectively), whereas thoracoscopic management may be favorable for survival (P = .041). The propensity score-matched analysis showed a significant reduction in intensive care unit stay (P = .044) in the thoracoscopy group. Kaplan-Meier survival analysis revealed a higher survival to discharge, favoring thoracoscopy over non-thoracoscopy treatment (P = .035).

CONCLUSIONS

Management of thoracic empyema in cirrhotic patients is complicated and associated with a high mortality. With proper patient selection, thoracoscopic management is feasible and may provide a better chance of survival.

Management of thoracic empyema: review of 112 cases

To review our experience in treatment of patients with thoracic empyema at a teaching hospital chart of patients were retrospectively reviewed over a 72-month period. A total of 112 patients (94 men, 18 women, mean age: 39, range: 6-89 years) underwent therapeutic procedures for thoracic empyema between 2001-2006. The causes of empyema included parapneumonic empyema (60.7%), thoracic trauma (20.5%), surgical procedures (7.1%) and seeding from an extra-pulmonary source (11.7%). Multiloculated empyemas were documented in 45 patients (40%). Insertion of chest tube was the first procedure in 103 patients (92%). Nineteen patients (17%) were treated by thoracotomy, ten patients (8.9%) had fibrinolytic therapy, eight patients (7.2%) underwent video assisted thoracic surgery (VATS) and sixteen patients (14.3%) had subsequent radiologic-guided drainage. Thoracotomy-Decortication was successful in 90% of patients undergoing surgery and the least successful intervention was tube thoracostomy alone. Twelve of 112 patients (10.7%) died in the hospital including one patient in the thoracotomy group. Long-term follow-up was available in 67 patients including all of patients requiring surgery and fibrinolytic therapy. Thirty four patients (50%) obtained complete functional recovery. Simple drainage as the first procedure for the treatment of thoracic empyema has a high failure rate. Selection of a therapeutic option should be based on age, underlying disease, stage of the empyema, state of the loculation, local expertise and availability. Surgical procedures such as VATS or thoracotomy are recommended as the first procedure in elderly patients and advanced empyema.

[Videomediastinoscopic transcervical approach of postpneumonectomy left main bronchial fistula]

Bronchopleural fistulas and empyema are the most devastating complications after lung resection. The optimal management remains a major subject of controversy for thoracic surgeons over the wide variety of therapeutic approaches, none suitable for all patients. In 1996 Azorin et al. reported the first successful mediastinoscopic reclosure by stapling of an insufficient bronchial stump after left pneumonectomy using video-assisted mediastinoscopy. The authors report the first national case of left-sided bronchopleural fistula closure using video-assisted mediastinoscopy, describing their experience with this technique. A 40 years old woman presented to our unit with left thorax empyema after having undergone left pneumonectomy for TB destructed lung with aspergillosis in another hospital. Bronchoscopy revealed a 15 mm long bronchial stump with insufficiency. Despite all advances made over the last decades in perioperative management, bronchopleural fistula after pneumonectomy remains a significant problem in thoracic surgery. Video-mediastinoscopy is an alternative to the open methods as it allows approaching the bronchial stump via the mediastinum. The dissection of the trachea through its natural route enables bronchial mobilization. Positive factors influencing our decision were the virgin mediastinum with no surgical dissection and no radiation therapy applied. The mediastinoscopic approach for bronchial stump closure after pneumonectomy is a novel option in highly selected patients. This is our choice for a long (at least 10 mm) bronchial stump because its morbidity is minimal compared with transpericardial sternotomy or a transthoracic approach. It warrants minimal surgical trauma; however, skilled surgeons with experience in mediastinoscopy have to be prepared to convert to an open technique immediately.

[The treatment of pulmonary bleedings and its' complicsations by the blunt thoracic trauma]

The experience of treatment of 224 patients with pulmonary bleeding after the blunt thoracic trauma were analyzed. All patients were diagnosed with lung contusion, of them 134 had traumatic cavities (hematomas) in the lung. The complete regression of contusion foci was observed within 13.7±4.2 days, whereas only 65.4% of patients demonstrated the regression of lung hematomas after 3 months of follow-up. 5.36% of pulmonary bleeding required the urgent thoracotomy on the reason of the continuous bleeding. The thorough analysis of etiology of posttraumatic infectious pulmonary complications after the blunt thoracic trauma is submitted. The drainage of septic foci allowed the fast recovery of the majority of patients. 7,4% of lung abscesses and pleural empyem required thoracotomy.

Pleural empyema secondary to rupture of amoebic liver abscess

Amoebiasis is a worldwide parasitic infection although it is more prevalent in the subtropical and tropical countries. Extraintestinal amoebic infections currently have been reported in increased numbers of male homosexuals and immunocompromised patients. Here, we present an interesting case of a 27-year-old homosexual man with pleural empyema secondary to rupture of amoebic liver abscess. Using chest tube and percutaneous liver abscess drainage, the patient was treated with metronidazole followed by iodoquinol. His general condition improved dramatically. After one-year of follow-up, there was no evidence of relapse on plain chest radiography and abdominal CT scan.

[Optimization of treatment methods of surgical complications in lung cancer]

The present report analyses the immediate and long-term results of treatment of surgical complications in 998 patients with lung cancer. There were complications in 37,5% of the cases, with a fatality rate of 14,7%. The most frequent complications were as follows: postoperative empyema with bronchopleural fistula (41,3%), bleeding (12,0%), pneumonia (9,8%), pulmonary arteries embolism (8,1%) and heart rhythm disorders (8,1%). Adjuvant and neoadjuvant treatment does not increase the rate of surgical complications as compared to just surgery alone (p = 0,1). Postoperative empyema with bronchopleural fistula requires intensive therapy, affects the quality of life of patients but does not decrease survival rates as compared to patients at the same stages of disease with uncomplicated course (p = 0,001). Timely drainage of pleural cavity accompanied by its adequate sanation does not differ (p = 0,1) from usage thoracoplasty (MS 29,9 months to 33,2 months).

[The surgical treatment of the pleural empyem]

The treatment results of the 286 patients with pleural empyem after thoracic injuries (n=107) and closed trauma of the pleural cavity (n=179) were retrospectively analyzed. The frequency of pleural empyem was 1.39% by injuries and 1.34% by the closed thoracic trauma. 15 (14%) patients of the first group developed the bronchopleural fistula, whereas the complication was observed in 32 (17.9%) patients of the second group. The adequate pleural drainage with intrapleural enzyme therapy in acute inflammation period allowed recovery in 78% and 71.9% of patients, respectively. Early videothoracoscopic sanation of the pleural cavity shortened the recovery time in more then 1.5 times. The chronization of the empyem was more often observed after the closed thoracic trauma - 14.5% rather than 6.5% after the open thoracic injury. The lethality rate by pleural empyem was 14% after the open injuries and 15.6% after the closed trauma.

[Complex treatment of pulmonary abscesses and pleural empyema in patients with severe thoracic trauma]

The results of complex treatment of 40 injured persons with severe thoracic trauma, in whom pulmonary abscesses and pleural empyema had occurred postoperatively, were analyzed. Complex treatment of pulmonary abscesses and pleural empyema, using the methods of a local superhighfrequency irradiation of purulent foci have promoted their accelerated regression occurrence and reduction of a systemic inflammatory reactions severity, as well as prophylaxis of secondary purulent-septic complications, permitting to achieve lethality lowering and to escape practically reoperations performance.