HEAD AND NECK

Infections and foreign bodiesin the ear, nose and throatIan Street

AbstractInfections of the ear, nose and throat are exceedingly common. Foreign

bodies also frequently become impacted in these cavities. These prob-

lems affect all age groups and both sexes.

Initially, most of these infections can be dealt with medically. A prompt

decision for surgical intervention is usually needed if medical therapy is

not working. If the airway is under threat, an immediate surgical opinion

is necessary.

Purulent collections will often require incision and drainage. An under-

standing of the anatomy of the area is therefore essential.

Foreign bodies, however, almost invariably require surgical interven-

tion. The urgency of this is dictated by the foreign body itself and the

site of impaction.

Keywords Ear; foreign body; infection; nose; throat

Introduction

Infections and foreign bodies in the ear, nose and throat are some of

the most common reasons for attendance in primary care facilities.

They rarely need hospital referral but the patients can be extremely

ill; surgical intervention may become necessary. It is sometimes

important to consider underlying causes of such infections.

Anatomy of the ear

The ear is made up of external and middle ear components. It is

important to appreciate that the middle ear has a direct connection

to the nasopharynx via the Eustachian tube. The external ear is

a skin-lined, blind-ending passage, which is physically separated

from the middle ear by the tympanic membrane.

Anatomy of the nose

The nasal cavities are directly connected to the outside envi-

ronment by the nares and are separated by a cartilaginous and

bony septum. Posteriorly, the nasal cavities lead into the naso-

pharynx. The paranasal sinuses are direct offshoots of the nasal

cavities and connected directly via sinus openings or ostia. They

are lined with similar respiratory epithelium to the nasal cavities.

As mentioned above, the middle ear is of a similar arrangement

and also lined with respiratory epithelium.

Anatomy of the throat

The throat is best equated with the pharynx, which extends

from the base of the skull to the superior limit of the

Ian Street MRCS DO-HNS is a Specialty Registrar, Royal Hallamshire

Hospital, Sheffield. Conflicts of interest: none declared.

SURGERY 27:12 518

oesophagus, at the cricopharyngeus muscle. It essentially

consists of the constrictor muscles, of which there are three,

a superior, middle and inferior. They are stacked up like

beakers and help to initiate the process of swallowing,

a process also involving the palate, base of tongue and the

muscles that elevate the larynx.

Foreign bodies can become impacted in the throat when

swallowing. The usual sites are in the tonsils, the base of the

tongue or at the cricopharyngeus.

Anatomy of the neck

The surface anatomy of the neck is well defined; the superior

limit of the neck consists of the mandible anteriorly, the

mastoid process laterally and the superior nuchal line posteri-

orly. The sternocleidomastoid muscle is an important landmark

within the neck and divides it into anterior and posterior

triangles.

It is not possible to understand neck infections fully without

first describing the fascial layers in the neck. These layers are like

concentric rings within the neck, each enclosing different planes

of tissue. Infections tend not to cross these fascial layers and

instead usually track along the plane of tissue, known as the

tissue space, enclosed within each fascial layer. This is by no

means an inviolate rule, however. Furthermore, sharp foreign

bodies or ones introduced at high velocity can breach these

fascial layers easily.

The fascial layers can be described from superficial to deep as

follows:

� Superficial cervical fascia, which encloses the platysma

muscle and the muscles of facial expression

� Deep cervical fascia, which is itself split into three:

B The superficial layer of the deep cervical fascia

B The middle layer of the deep cervical fascia

B The deep layer of the deep cervical fascia.

To further elaborate, the superficial layer of the deep cervical

fascia splits to envelope the sternocleidomastoid muscle and the

major salivary glands.

The middle layer encloses the larynx, pharynx, trachea and

thyroid.

The deep layer encloses the vertebral bodies and their asso-

ciated ligaments and muscles. It is itself split into an alar layer

and a prevertebral layer; the latter extends from skull base to

superior mediastinum, whilst the latter runs the entire length of

the vertebral column.

The last important associated point is that the carotid sheath,

containing the carotid artery, internal jugular vein and vagus

nerve, is composed of all three layers of the deep cervical fascia.

Thus, the different fascial layers of the neck enclose different

tissue planes, or spaces, along which infection will track in

preference to crossing the fascial layers. It is worth also knowing

about the tissue spaces.

These spaces are most easily subclassified by their relation-

ship to the hyoid bone. Some spaces extend the entire length of

the neck, even into the thorax. Others are limited by the hyoid.

Neck spaces that run the entire length of the neck

The spaces that run the length of the neck are as follows:

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HEAD AND NECK

� The superficial space e this surrounds platysma and is the

space where cellutis and superficial abscesses may appear.

Abscesses in this area should be treated by incision along skin

tension lines and treatment with antibiotics to cover staphylo-

coccal and streptococcal bacteria.

� The retropharyngeal space e this space is indeed posterior to

the pharynx and oesophagus and is limited posteriorly by the

deep layer of the deep cervical fascia, superiorly by the skull base

and inferiorly by the superior mediastinum (T1/T2).

� The danger space e this is a narrow space between the alar

and prevertebral components of the deep cervical fascia which

stretches from the skull base and into the mediastinum. It allows

easy movement of the pharynx and thus only contains loose

areolar tissue. This areolar tissue, unfortunately, allows fast

spread of infection in this space into the mediastinum and thus

‘danger’.

� The prevertebral space e this space lies just deep to the danger

space, between the prevertebral fascia and the vertebral bodies

themselves. This space extends the length of the vertebral

column. Pott’s abscess and osteomyelitis of the vertebral bodies

can be common causes of purulent collections here.

� The visceral vascular space e this is the space within the

carotid sheath; infection here would be extremely concerning

due to the proximity of the large vessels of the neck.

� Other spaces are partially defined by their relationship with

the hyoid bone. They are named the submandibular space, the

parapharyngeal space, the peritonsillar space, the parotid space

and the pretracheal space.

Thus, it must be appreciated that neck space infections pose

a number of management challenges including the complex

anatomy and the proximity of nearby nerves and blood vessels,

as well as the communication of some neck spaces with each

other and the mediastinum.

Epidemiology of throat and neck infections

In the UK, throat and neck infections can affect all age groups,

from paediatric patients to the elderly. There is no particular

gender predilection. The more common neck and throat infec-

tions include tonsillitis and its complications, pharyngeal infec-

tions and salivary gland infections.

Underlying medical problems can also predispose individuals

to developing neck infections, particularly a history of diabetes

mellitus, intravenous drug abuse, human immunodeficiency

virus infection and other states of immunocompromise. In chil-

dren, congenital factors should be borne in mind, with branchial

arch abnormalities being an example of superficial neck infec-

tions which recur frequently. These usually manifest themselves

as lumps, sinuses or fistulae. Syndromic children, such as those

with Down’s syndrome, tend to be more prone to infections

generally. In other parts of the world and amongst immigrant

populations in the UK, exposure to tuberculosis is also something

to be aware of.

In children, lymphadenopathy progressing to suppurative

change is a common cause of neck abscesses whilst in adults,

they are usually odontogenic in origin. Other causes in adults

include tonsillar and pharyngeal infections, salivary gland

infection, iatrogenic (post-surgical) and foreign body impaction

or trauma. However, in approximately 20e50% of infections, no

cause is found.

SURGERY 27:12 519

Another important aspect of neck infections are those of

iatrogenic origin, happening after surgery. Postoperative infec-

tions, if left untreated will often develop into discharging sinuses

or cause complete wound breakdown. The classic worst possible

scenario is one of a postoperative wound infection involving the

carotid artery and its subsequent rupture, this being a complica-

tion with an extremely high mortality rate.

Pathology and pathogenesis

The infections may spread from their original sites out into the

neck by lymphatic drainage; it is postulated that lymph drainage

of the primary site causes an infective lymphadenopathy and

consequent suppuration. The resultant purulent fluid may well

drain from one neck space into another via the various

communications present. Alternatively, trauma to the neck with

the introduction of foreign material can certainly be a source of

infection.

The usual microflora which cause this problem are mixed

Gram-positive and Gram-negative aerobic and anaerobic organ-

isms. Typically, these include Group A beta-haemolytic strepto-

coccus (Streptococcus pyogenes), alpha-haemolytic streptococcus

(Streptococcus pneumoniae), Staphylococcus aureus, Bacteroides

species (associated with dental infections), Pseudomonas aeru-

ginosa, Escherichia coli and Haemophilus influenzae.

Diagnosis

The patient will often complain about the usual effects of an

infection, which can be divided into systemic and local effects.

Systemically, patients will complain of general malaise, chills,

loss of appetite and fatigue.

More local symptoms will correspond to the cardinal effects of

inflammation; this includes pain over the infected site, swelling,

erythema and loss of function. This includes the inability to

swallow and decreased neck range of movement.

The history, in the case of ingested or inhaled foreign bodies,

tends to be more straightforward; the patient will usually be able

to point to a precise period in time when the foreign body became

impacted and acutely uncomfortable. In adults, an ingested

foreign body will become impacted at the narrowest parts of the

oesophagus, namely:

� cricopharyngeus

� the level at which the left main bronchus crosses anterior to

the oesophagus

� the gastro-oesophageal junction at 15, 25 and 40 cm from the

incisors, respectively.1

In children, diagnosis becomes more difficult. They will only

sometimes admit to putting foreign bodies into their nose or ears.

It is often the parents who notice an unpleasant smell in the

child’s ear or nose, accompanied by a purulent discharge.

Indeed, a unilateral nasal discharge in a child is a foreign body

until proven otherwise.

An acutely choking, drooling, apyrexial child who cannot

swallow can be presumed to have an impacted oesophageal or

pharyngeal foreign body. Unfortunately, a large foreign body in

the oesophagus can impinge on the airway enough to cause

breathing difficulties and stridor, complicating the picture.

Inhaled foreign bodies, particularly in children, present yet

another degree of difficulty. Unless the inhalation event was

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Figure 1 Laryngopharyngoscopy.

HEAD AND NECK

witnessed, inhalation should be suspected if a child suddenly has

a choking fit, particularly if playing with small objects, classically

peanuts. They may become tachypnoeic or cyanotic. Often, this

phase is only for a limited time, after which the child will settle.

This happens if the foreign body enters a main bronchus, usually

the right. However, if the larynx or trachea is obstructed, the

patient, predictably, will not settle. The diagnosis is made on the

history in this case, unless X-ray evidence of the foreign body can

be obtained.

If there is no definite history of foreign body inhalation, it

should be presumed that the child is suffering from acute epi-

glottitis. This is a serious airway emergency and if there is the

slightest suspicion of this infection, no effort should be made to

do more than a cursory examination. No investigations should be

performed. Effort must be expended in keeping the child calm.

The priority is the airway and a senior anaesthetist and otolar-

yngologist must be involved to secure the airway, whether this is

by endotracheal or tracheostomy tube. Antibiotic therapy can

then be started. Thankfully, this is becoming a less frequent

condition since the use of childhood vaccinations against

H. influenzae.

On examination, they will usually be tachycardic, whilst the

blood pressure may be high in early sepsis and lowered in more

advanced sepsis. There may be associated tachypnoea; patients

with laryngeal infections such as epiglottitis or croup usually

have stridor, drooling or both.

On inspection, a visibly swollen, erythematous region will be

seen in more superficial neck infections. Thorough examination

of the oral cavity and oropharynx is necessary, with particular

attention to be paid to the tonsils and soft palate. Any associated

scars, sinuses or fistulae should also be noted.

If patients are complaining of severe throat pain or odynophagia,

but there is no sign of inflammation on inspection of the

oropharynx, a hypopharyngeal infection or laryngeal infection

should be considered. These diagnoses can only be confirmed by

laryngopharyngoscopy, which must only be performed by experi-

enced medical staff with equipment nearby to secure the airway. As

mentioned above, in children, even this should not be performed.

Laryngopharyngoscopy is also necessary in patients with

suspected deep neck infections which may not be visible on

inspection of the outer neck. This examination will show partial

obstruction of the pharynx in such cases. It is important for an

experienced clinician to assess the viability of the airway at this

time, if this is a question. Infection of the floor of mouth, which

pushes the base of the tongue posteriorly, or supraglottis can put

the airway at definite risk. Figure 1 shows a patient undergoing

laryngopharyngoscopy.

Palpation should be attempted, albeit with care. Inflamed

areas of the neck will be exceedingly tender. It is necessary to

also assess site, size, fluctuance and transillumination.

Differential diagnosis

The most likely differential diagnosis of head and neck infections

is one of other inflammatory disorders such as autoimmune

processes. An example of this is an acute exacerbation of

Hashimoto’s thyroiditis, which may present with pyrexia and

throat pain. Underlying neoplasms can sometimes present as

acute infections.

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More chronic infections, such as tuberculosis (TB), can mimic

malignancies very closely. When in the nose, TB can also appear

very much like any other granulomatous condition, such as

Wegener’s granulomatosis. Foreign bodies can cause infections

in the head and neck if not removed in a timely fashion.

Management and complications

As mentioned above, the history and examination do give almost

all the information necessary for further management. The

exception to this is when the patient is a child with epiglottitis or

foreign body inhalation; in this situation, it is important to have

a low index of suspicion and to consider operative intervention

sooner rather than later.

Investigations should include blood tests: a full blood count

will allow identification of a leukocytosis, urea and electrolyte

levels can indicate dehydration and allow the administration of

intravenous fluid. Erythrocyte sedimentation rate or C-reactive

protein levels can also help guide management if done on first

presentation of the patient. Random venous blood sugar should

be done if repeated infections feed suspicions of underlying

diabetes mellitus.

Plain film X-rays may be the only radiological investigation

necessary; a lateral neck X-ray may show thickening of the

prevertebral soft tissue, indicating soft tissue swelling.

A radio-opaque foreign body may also be seen. This sign is

useful in children, who have a tendency to swallow, or even

inhale, small metallic objects such as coins. Naturally, in cases of

suspected inhalation or swallowing of foreign bodies, it is

important to be guided by the history. Organic matter, with the

exception of some animal bones, is not visible. The gas formed

by some infective organisms may also be detected. If the requisite

expertise is available, an orthopantomogram (OPG), which

produces a panoramic view of the dentition can also help to elicit

a dental origin to head and neck infections.

Further radiological investigations include contrast swallows,

often using barium or Gastrografin, which may outline the

location of foreign bodies in the oesophagus. In the case of

parapharyngeal abscesses, a contrast swallow may also outline

an extraluminal swelling and help locate the abscess.

Naturally, much more accurate abscess delineation can be

achieved by performing computed tomography (CT) scanning.

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Figure 2 Theatre arrangement for a rigid bronchoscopy.

Figure 3 Use of a binocular microscope.

HEAD AND NECK

Size, location and the proximity of pertinent structures are

exceedingly useful information to have to diagnose and plan

management.

Magnetic resonance imaging (MRI) scanning is not routinely

performed in hospitals to aid diagnosis in these cases. In itself, it

would be a useful tool; it can distinguish soft tissue planes very

well and gives an indication of localized oedema. However, it is

a time-consuming procedure relative to CT and not ideal when

dealing with a patient who may be notably acutely ill. Due to

their time-consuming nature, MRIs tend to be less accessible at

short notice.

In cases when there is only soft tissue infection, the only

intervention necessary may be supportive treatment, including

intravenous fluids if dehydration due to odynophagia, or pain

when swallowing, is a risk. Nasogastric feeding may even be

required.

Antibiotic therapy is empirical at first. This can be directed

more precisely once samples have been taken for microscopy and

culture and sensitivity. Many ear, nose, laryngeal and pharyngeal

infections are caused by viruses. Generally, these require no

more than supportive therapy.

Bacterial infections of the middle ear, paranasal sinuses and

soft tissues of the head and neck are usually caused by Gram-

positive aerobes, including staphylococci and alpha- or beta-

haemolytic streptococci. Other common offending organisms

include Pseudomonas, E. coli and H. influenzae. Abscesses and

odontogenic infections almost always have at least a partial

anaerobic cause.

In patients with acute tonsillitis or a quinsy which is putting

the airway at risk, steroids may help. They can decrease oedema

and may speed up the resolution of the infection by modulating

the immune response.

Surgical treatment is aimed at removal of foreign or purulent

material. Foreign bodies in the ear only really become impacted

in the external canal. They require removal on an urgent rather

than an emergency basis. There is a definite exception to this

rule; this is when the foreign body is a small battery. These can

leak corrosive fluid and need to be removed as soon as possible

on an emergency list.

Foreign bodies in the nose are ideally removed within

24 hours of presentation. There is a theoretical possibility of

inhalation of the object, although this rarely happens in practice.

As above, batteries must be removed as soon as possible.

Foreign bodies in the pharynx, oesophagus or larynx also

need to be removed as an emergency. There is a danger of

progression to perforation or tracheal obstruction, respectively,

both of which are life threatening. Figure 2 shows a typical

theatre arrangement for a rigid bronchoscopy, used to remove

laryngeal or bronchial foreign bodies.

Infection of the ear canal, known as otitis externa, requires

suction of the infected debris using a binocular microscope (seen

in Figure 3), with subsequent medical treatment of topical anti-

biotic and steroid combination drops. Surgery for infection in the

ear may mean little more than insertion of a grommet in cases of

otitis media not responding to antibiotics. Acute middle ear

infections can extend into the mastoid cavity posteriorly. If

mastoiditis does not improve with 24 hours of intravenous

antibiotics, a cortical mastoidectomy will have to be done. This

entails removal of the outer cortex of the mastoid bone and

SURGERY 27:12 521

removal of all the purulent material within. Any intracranial

complications of mastoiditis will require a cortical mastoidec-

tomy as well as treatment of the intracranial lesion.

Infection of the paranasal sinuses tends to be treated medi-

cally, but there are few instances when surgical treatment is

needed. Such instances generally occur when acute infection of

the frontal sinuses or sphenoid sinus cause intracranial compli-

cations. Similarly to mastoiditis, treatment of the intracranial

lesion should be accompanied by surgical decompression of the

frontal or sphenoid sinus.

Infection of the soft tissue of the neck will need empirical

antibiotic treatment if no abscess can be detected. Admission for

intravenous fluids and antibiotics may be needed if the patient is

unable to swallow. If 24 hours of intravenous antibiotics have been

given without improvement and an abscess has been confirmed on

CT scanning, listing for incision and drainage of the collection as

an emergency is required. This almost invariably needs to be done

under a general anaesthetic, unless the abscess is relatively small

and superficial. When draining an abscess, it is strongly advisable

to take biopsies for histology, microscopy and culture. A drain

should be left in the abscess cavity to drain residual pus. The drain

can be removed when no further purulent material escapes.

If neck abscesses are not dealt with in a relatively prompt

manner, pus may track into the mediastinum, requiring

involvement of thoracic surgical colleagues.

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HEAD AND NECK

Prognosis and prevention

If foreign bodies are removed promptly, no follow-up is neces-

sary. Consideration for referral to a child psychologist is advised

for paediatric patients who continually place foreign bodies in

their ears or noses.

Patients who have had repeated acute ear infections may be

offered long-term antibiotics or grommet insertion, which can

lower the risk of further acute otitis media. Adults with acute ear

infections need rigid endoscopic examination of their post-nasal

space to rule out nasopharyngeal carcinoma. Patients suffering

repeated acute ear infections or sinus infections should really

also be investigated for immune deficiency.

As above, patients having repeated neck abscesses should be

investigated for any immune deficient states, underlying retained

foreign bodies or dental problems. An interesting underlying

congenital abnormality is one of a persisting fourth branchial

arch sinus, which causes repeated episodes of thyroiditis.

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Conclusions

Infections and foreign bodies in the ears, nose and throat are

common although they are generally managed in primary care.

At least initially, most impacted foreign bodies need removing

and sharp ones always do. Neck space infections in addition form

a significant workload in any busy ENT department.

It is important to appreciate that infections in the neck usually

spread along the fascial planes in the neck but can expand from

one space into another. Therefore, if there is no prompt resolu-

tion with antibiotics, surgery is best performed as soon as

possible. A

REFERENCE

1 Snell RS. The thorax: part II the thoracic cavity. In: Snell RS, ed. Clinical

anatomy for medical students, 4th edn. Boston: Little, Brown and

Company, 1992: 142.

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