Head and Neck Infections

• Children and adolescents: S. aureus, Enterobacter, Group A Streptococcus sp., or H. influenzae • Adults: S. aureus and rarely Enterobacter and Streptococcus sp. • Sickle cell anemia patients: Salmonella sp.

Figure 1 is an x-ray image involving osteomyelitis of the calcaneus:

Figure 1

The most common method of spread of infection to bone is contiguous spread, followed by hematogenous spread, penetrating trauma, and iatrogenic causes (internal fixation of fractures and joint replacements). Because hematogenous spread is possible, a blood culture should also be done. The best way to monitor treatment is to follow the erythrocyte sedimentation rate (ESR). A swab of the ulcer is highly inaccurate. The bone scan and the MRI are equally sensitive for excluding osteomyelitis but the MRI is more specific so it is the preferred test.

If the ESR is still elevated after 4-6 weeks of an appropriate antibiotic, then surgical debridement should be considered. The single-most organism to cover for is S. aureus with oxacillin or nafcillin IV for 4-6 weeks (if sensitive). If MRSA is isolated, the treatment is vancomycin, dalbavancin, oritavancin, daptomycin, ceftaroline, or linezolid. Oral therapy is never recommended for S. aureus osteomyelitis. If the disease is chronic, it needs debridement. The patient may need a PICC line or central line for longterm antibiotic use. Amputation is necessary for the most severe cases.

If the organism is Salmonella or Pseudomonas (or another gram-negative bacillus), the treatment of choice would be to treat with a culture-sensitive antibiotic. There is no need to treat chronic osteomyelitis. A biopsy can be obtained and cultured before starting the culture-sensitive antibiotic.

There are a number of head and neck infections seen in a typical outpatient or ED setting. Most are obvious and easily treated.