Bechara Y. Ghorayeb

Contemporary management of deep neck space infections

Deep neck infections continue to be seen despite the wide use of antibiotics. These infections follow along fascial planes to create deep neck space abscesses. The clinical presentation often points to the space involved. Understanding the regional anatomy gives the surgeon the ability to treat these grave infections. The records of 24 patients with a diagnosis of deep neck space abscess admitted to Hermann Hospital between 1988 and 1993 were reviewed. Fifty percent of the patients had received antibiotics for an infection of the ear, nose, or throat before the development of a neck space abscess. Ten patients had parapharyngeal abscesses, seven had retropharyngeal abscesses, six had submandibular space abscesses, and one had parotid space abscess. Thirty-five organisms were isolated in 18 cases (1.9 isolates per patient). The most common organism cultured was Streptococcus (13 of 18), followed by Staphylococcus (6 of 18), Bacteroides (5 of 18), Micrococcus (2 of 18), and Neisseria (2 of 18). One case each of Candida, Enterobacter, Enterococcus, Peptostreptococcus, Proteus, Proprionobacter, and Pseudomonas was cultured. Six patients had no growth on culture but did have organisms found on Grams stain. The operative techniques and antibiotics used are discussed. The main complications of jugular vein thrombosis, carotid artery rupture, and mediastinitis are described, as well as an unusual case of meningitis from a large retropharyngeal-parapharyngeal abscess.

Temporal bone fractures : longitudinal or oblique ? The case for oblique temporal bone fractures

Classical descriptions and illustrations of temporal bone fractures are misleading. Both oblique and longitudinal fractures produce a similar fracture line in the middle cranial fossa; however, externally, they are different. Oblique fractures cross the petrotympanic fissure while longitudinal fractures run within it. In a study of 150 temporal bone fractures, the majority were oblique. An array of fracture planes accounts for most of the fractures observed. Depending on the direction of trauma, fracture planes rotate around an anteroposterior axis. When they approach the horizontal (axial) plane, they result in oblique fractures. True longitudinal fractures are rare. They are vertical and perpendicular to the oblique planes.

Subcochlear Approach for Cholesterol Granulomas of the Inferior Petrous Apex

Cholesterol granulomas of the petrous apex are drained through two major extra-labyrinthine routes: One, along the posterosuperior chain of air cells, and two, along the anteroinferior chain. Procedures that use the posterosuperior chain approach the apex from the sinodural angle, the base of the zygomatic arch, the attic, or through the arch of the superior semicircular canal. Operations that use the anteroinferior chain reach the apex along the internal carotid canal (Ramadlers operation) or by a posterior infralabyrinthine approach between the descending facial nerve and jugular bulb. Inferior petrous apex cholesterol granulomas may be unreachable by any of these routes, and hence the subcochlear route is proposed as an alternative. The subcochlear approach starts in a triangle bounded superiorly by the cochlea, anteriorly by the internal carotid canal and posteriorly by the deep jugular vein. This operation requires lowering the inferior bony canal wall to the level of the “crutch.” It provides access to an inferiorly situated cholesterol granuloma, yet preserves hearing. It allows enough room for the placement of a tube drain from the petrous apex to the mastoid. It is particularly useful when a high jugular bulb precludes the use of the posterior infralabyrinthine route.

Pediatric temporal bone fractures

Twenty‐seven temporal bone fractures in 25 pediatric patients were evaluated over a 6‐year period. The diagnosis was confirmed with otoscopy and high‐resolution computed tomography scans (HRCT). Three‐dimensional reconstruction of high‐resolution computed tomography scans were used to aid in the diagnosis. The most common fracture was an oblique fracture which is oriented in an axial or horizontal plane with the temporal bone. Facial nerve paralysis was found in 6 of our patients, which is less than the expected incidence when compared to adults. Hearing loss was found in 24 patients, the most common of which was conductive hearing loss, which had a higher incidence than expected when compared with adults.

Pediatric gunshot wounds to the head and neck

Gunshot wounds to the head and neck in the pediatric population have become alarmingly common. They often result in death of the victim, devastate families, and inflict a considerable financial burden to hospitals and society. We present a retrospective study of cases treated at a level I trauma center in Houston, Texas, from July 1990 to July 1993. We identified 115 cases of gunshot wounds in children, 32 of which were exclusively confined to the head and neck region. There were 26 male and 6 female patients. Ages ranged from 3 to 17 years. The cranial cavity was involved in 13 cases, leading to 9 deaths and 1 institutionalization. The shootings took place at home in 11 cases, and they involved play in 12 cases. The shooter was known to 14 of the victims, and the wounds were self-inflicted in 7 cases. The most common type of weapon was the .22 caliber pistol, which caused four of the deaths. Two of our cases involved BB air rifles, one of which mandated a craniotomy for the evacuation of an epidural hematoma. Our findings indicate that gunshot wounds to head and neck in children are in most instances preventable and result in high fatality rates because of common intracranial involvement, even when low-energy missiles are used.

Orbital Blowout Fractures as a Cause of Sinonasal Obstructive Disease

Six cases of orbital blowout fracture with inferomedial herniation of orbital contents into the sinonasal ostiomeatal unit causing obstruction to maxillary sinus outflow are presented. Potential hazards during endoscopic sinus surgery in these cases are outlined.