Surgical site infection (SSI) in head and neck surgery can prolong hospitalization, increase medical costs, and in some cases, such as carotid artery infection, may be life-threatening. In the head and neck region, an infection can cause scarring of the wound, leading to deterioration of swallowing function and other problems affecting the quality of life. These result in losses beyond a simple prolongation of the time to wound healing. The three measures against SSI can be summarized as follows: 1) preoperative measures to reduce the risk of infection, 2) measures to prevent (decrease) contamination of the surgical field during surgery, and 3) measures to increase the patient’s resistance to SSI, even if some bacterial contamination occurs. In this study, we will explain the measures to prevent SSI from these three perspectives, based on the guidelines.

A nationwide survey of allergic rhinitis in 2019 showed a significant increase in the prevalence of cedar pollinosis. Allergic rhinitis is known to be strongly associated with bronchial asthma; however, few reports in Japan have described asthma in patients with allergic rhinitis; therefore, the true status of asthma among patients with hay fever, who visited otorhinolaryngology facilities in recent years is unclear. In this study, we performed a questionnaire survey of asthma symptoms among 3,804 patients with allergic rhinitis who visited otorhinolaryngology facilities in Yamanashi Prefecture and adjacent areas during the pollen dispersal period between January and May. Of the 448 patients (12.3%) with physician-diagnosed bronchial asthma, 28 patients reported asthma symptoms over 12 months preceding their visit and had exacerbation of asthma during the pollen dispersal period. A high percentage of patients with asthma had moderate-to-severe nasal symptoms regardless of asthma diagnosis. The present study indicates that a certain percentage of patients with hay fever and asthma visit otorhinolaryngologists and that worsening of rhinitis symptoms secondary to hay fever is associated with exacerbation of asthma. Moreover, many patients present with asthma-like symptoms, which are not accurately diagnosed and treated. Physicians should be mindful of this presentation in patients who visit otorhinolaryngology facilities for management of hay fever.

Eosinophilic chronic rhinosinusitis (ECRS) is considered an intractable disease with a high recurrence rate. Dupilumab, an antiinterleukin-4/13 monoclonal antibody was introduced in Japan in March, 2020 as a novel agent for ECRS management. We prospectively investigated the effectiveness of dupilumab for ECRS treatment. The study included eight patients (mean age, 50.1 years) with severe ECRS based on the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis study scores. Nasal polyps, nasal obstruction, smell disorder, and the 22-item sinonasal outcome test scores were recorded at baseline and at 4, 12, and 24 weeks. The Lund-Mackay computed tomography score and ratio of eosinophils in peripheral blood were also recorded at baseline and at 24 weeks, in addition to complications and treatment with or without systemic corticosteroid administration. We observed that all evaluated parameters except the ratio of eosinophils significantly improved from baseline levels across all time-points. Furthermore, dupilumab was associated with minor complications and led to a decrease in the number of patients who required oral corticosteroid therapy. In conclusion, dupilumab was highly effective against the subjective symptoms and local findings in patients with ECRS and enabled a reduction in the systemic steroid dose.

Skull base osteomyelitis (SBO) is classified into typical SBO secondary to otitis externa and central SBO, which is associated with various etiologies. We report two cases of SBO (one patient each with typical and central SBO) accompanied by multiple cranial nerve paralyses, which partially improved after treatment.

Case 1: A 92-year-old man with a history of diabetes mellitus was referred to our department for evaluation of right-sided otorrhea after cleaning the ear and right facial nerve paralysis. Bacteriological analysis of the otorrhea specimens revealed methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, and histopathological examination of the ear canal granulation tissue showed no malignant findings. Contrast-enhanced computed tomography (CT) revealed bone destruction surrounding the stylomastoid foramen, and he developed vagus nerve paralysis during the disease course. The patient was diagnosed with typical SBO, and only vagus nerve paralysis improved after antibiotic treatment.

Case 2: A 76-year-old man with a history of diabetes mellitus was referred to our department for evaluation of dysphagia and hypoglossal nerve paralysis during a nasal cleaning procedure performed at a primary care clinic. Contrast-enhanced CT revealed a destructive bone lesion at the clivus. During a nasopharyngeal biopsy under general anesthesia, we observed drainage of pus from the posterior space of the prevertebral muscle. Bacterial culture yielded P. aeruginosa growth, and histopathological findings showed only inflammation. Therefore, the patient was diagnosed with central SBO. Vagus nerve paralysis occurred during the disease course. Antibiotic treatment led to improvement of only hypoglossal nerve paralysis. The sequence of appearance of paralysis in these cases reflects spillover inflammation. Future studies are necessary to investigate factors that improve SBO-induced cranial nerve paralysis.

Gemella haemolysans is a facultative anaerobic gram-positive coccus that resides in the oral cavity, pharynx, upper respiratory tract, gastrointestinal tract, and genitourinary tract of humans. G. haemolysans has a thin cell wall that can be decolorized in Gram staining, making it difficult to identify. We report a case of an orbital subperiosteal abscess caused by G. haemolysans. The patient was a 79-year-old woman with a history of extranasal sinus surgery. She was referred to our ophthalmology clinic by her ophthalmologist because she was having difficulty seeing, in addition to redness, swelling, and pain in her left cheek and eyelid, following a denture adjustment. She had decreased visual acuity and increased intraocular pressure. Based on a simple computed tomography (CT) scan of the face, nasal intraorbital complications were suspected leading to her visit to our department. A contrast CT scan of the sinus cavity revealed a postoperative maxillary cyst and abscess formation on the root of a tooth and in the subperiosteal space of the orbital wall. After puncture, incision, and drainage of the gingival region, intraocular pressure decreased and visual acuity improved. The patient was then admitted to the hospital and started on piperacillin/tazobactam. The following day, however, the eyelid swelling worsened and the intraocular pressure rose again, so the patient underwent endoscopic incision and drainage of the subperiosteal abscess and transnasal orbital decompression under general anesthesia. The eyelid swelling, decreased visual acuity, and elevated intraocular pressure improved promptly after the surgery, and the patient was discharged from the hospital on the fifth postoperative day. G. haemolysans was detected in an abscess specimen from the gingival region. This case highlights that nasal intraorbital complications refractory to conservative treatment require immediate surgical treatment.

We experienced a case of cervical and mediastinal tuberculous abscess. A 25-year-old man arrived to Japan from Vietnam over 3 years before and visited the clinic with a chief complaint of sore throat. Physical examination revealed bilateral cervical swelling. Computed tomography revealed bone destruction of the upper thoracic spine, considered to be secondary to spinal caries. Contrast-enhanced computed tomography showed many ring-enhancing lesions from the neck to the mediastinum and swollen lymph nodes on both sides of the neck. In addition, bone destruction of the Th2 vertebral body and bone resorption of the anterior surfaces of the Th1, 4, and 5 vertebral bodies were observed. Biopsy revealed caseous necrosis, and polymerase chain reaction of the pus sample was positive for tuberculosis, leading to a diagnosis of cervical and mediastinal tuberculous abscess. The patient underwent transcervical purulent drainage and anti-tuberculosis drug treatment and has been without recurrence. To diagnose tuberculosis of the head and neck, fine-needle aspiration cytology is preferable to excisional biopsy.