Scary Head and Neck Infections: From Necrotizing Fasciitis,Malignant Otitis Externa,to Osteoradionecrosis

The modern-day otolaryngologist, whether comprehensive or subspecialized, academic or community-based, cares for multiple vital organ systems and encounters a wide variety of acute, chronic, benign, malignant, inflammatory and infectious conditions. With a rising number of patients with auto-immune diagnosis (now projected at roughly 10% of the global population), increased availability and use of immunosuppressants (including many of the biologics we prescribe), ¹ and surging antibiotic resistance ² ; entities once thought of as the rare ‘zebra’, are now just horses, scary horses.

Ostrowski et al describe a case of chronic otitis media in an immunosuppressed individual that progressed from a chronic effusion to skull base dehiscence with intracranial abscess formation and meningitis, a rare dreaded complication of an ordinary condition. Critical to the care of this patient was aggressive surgical and medical care coordination, highlighting the importance of multidisciplinary care. ³ Zhu et al echo this sentiment with their description of a fairly routine mastoidectomy for an acutely infected chronic cholesteatoma complicated by postoperative Lemierre’s syndrome. Quick recognition of subtle neck erythema along with out-of-proportion pain and laboratory values, lead to prompt treatment. While anticoagulation for thrombophlebitis has debated utility, they describe compelling reasons to revisit its use. ⁴

With a steadily rising provenance of autoimmune diseases, rare and unusual head and neck manifestations must remain on our differential. Short et al describe a scary case of bilateral progressive ulcerative skin lesions over a patient’s parotid glands with resulting facial nerve palsies. Skin biopsy along with a recent prostate biopsy and chest imaging helped make the diagnosis of a multiorgan system manifestation of granulomatosis with polyangiitis in an otherwise healthy patient. Upon initiation of rituximab therapy, the patients’ lesions quickly regressed with return of normal facial nerve function. ⁵ Xu et al describe a case of a patient with Sjogren’s syndrome on chronic immunosuppression presenting with a dark necrotic nasolabial skin ulcer caused by an extensive underlying mucormycosis infection. They reiterate the importance of rapid, aggressive, and multidisciplinary care. ⁶

As pathogen virulence intensifies with rising antibiotic resistance, even routine infections require thoughtful evaluation. Luk et al review the Chandler staging and the importance of appropriate pediatric sinusitis management. ⁷ Mirza et al share a terrifying case of a seemingly routine peritonsillar abscess that progressed into necrotizing fasciitis of the neck and death in 5 days in an otherwise healthy patient with a low LRINEC score. ⁸

In recent years, hyperbaric oxygen therapy has become more widely available and its usefulness in many head and neck conditions has been described. Chen and Chen review a case of extensive nasopharyngeal and skull base osteoradionecrosis with multiple cranial neuropathies after resection and radiotherapy for an adenoid cystic carcinoma, successfully managed with nasal irrigations and hyperbaric oxygen therapy. ⁹ An often-used adjuvant to hyperbaric oxygen therapy, is the PENTO or PENTOCLO protocol. Ringenbach et al provide a comprehensive review of the protocol with an impressive response rate of 54% to 100%, in often very complicated post-radiation ulcerations, bisphosphonate- or radio-induced skull base and mandible osteonecrosis sparing patients morbid surgical interventions. ¹⁰ Finally, Thabet et al review advances in surgical and antifungal approaches to fungal necrotizing otitis externa. ¹¹

The world is certainly becoming a more complicated and scarier place, with increasing antibiotic resistance, increasing prevalence of autoimmune diseases, and rising use of immunosuppressants. Herein, we sought to poll our colleagues to collect and share many of these ‘scary horses’ and review approaches to evaluation and management. This edition highlights the importance of thoughtful physical evaluations, multidisciplinary teams, utilizing adjuvant wound healing and hyperbaric protocols, and most of all, the importance of sharing our collective experiences and knowledge.