The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Case Report
Spontaneous MRSA Postcricoid Abscess: A Case Report and Literature Review Brian J. Boyce, MD; Brad W. deSilva, MD Abstract: Laryngeal abscesses are rare but potentially life-threatening infections due to potential airway obstruction. Most abscesses occur in the epiglottis or preepiglottic space as a sequela of acute supraglottitis. Abscesses in the posterior larynx are extremely rare and typically due to instrumentation or trauma. Appropriate workup and management of the airway are essential for optimizing outcomes in these patients. We present an interesting case and our management of a spontaneous posterior laryngeal abscess due to methicillin-resistant Staphlococcus aureus. Key Words: MRSA, laryngitis, laryngeal abscess, postcricoid abscess. Laryngoscope, 124:2583–2585, 2014
INTRODUCTION Laryngeal abscesses are rare but potentially lifethreatening infections due to the potential for airway obstruction. Most laryngeal abscesses occur in the epiglottis or preepiglottic space as a sequela of acute supraglottitis. Abscesses that occur in the posterior larynx, which are extremely rare, are typically caused by instrumentation or trauma. Appropriate workup and management of the airway are both essential for optimizing outcomes in these patients. In this article, we present an interesting case and our management of a spontaneous posterior laryngeal abscess due to methicillin-resistant Staphlococcus aureus.
CASE REPORT A 33-year-old African American female presented to the emergency department at the Wexner Medical Center at Ohio State University with sore throat and dysphonia of 2 months duration. The patient had been previously treated with two courses of oral antibiotics, including a 10-day course of amoxicillin and a 14-day course of penicillin. Symptoms continued to worsen despite these treatments. Associated symptoms included odynophagia and otalgia, but the patient denied fevers or dyspnea. Other than a 21=2 pack-year smoking history,
From the Department of Otolaryngology–Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A. Editor’s Note: This Manuscript was accepted for publication on June 12, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Brian Boyce, MD, 4000 Eye and Ear Institute, 915 Olentangy River Road, Columbus, OH 43212. E-mail: [email protected] DOI: 10.1002/lary.24819
Laryngoscope 124: November 2014
there was no significant past medical history that included diabetes mellitus or autoimmune disease. The patient’s past surgical history was unremarkable. The physical exam was significant for a rough and muffled voice without any stridor, stertor, or respiratory distress. The remainder of the exam was normal. A lateral neck X-ray and CT scan of the neck with contrast were performed. Although the plain film showed prevertebral edema at C4–5, the CT scan demonstrated a 1.6 3 1.5-cm rimenhancing lesion in the posterior larynx, and the retropharyngeal soft tissues were unremarkable (Figs. 1 and 2). Otolaryngology was consulted and transnasal flexible laryngoscopy revealed erythema and edema of the arytenoid mucosa and interarytenoid space, along with pooling of secretions. There was fullness of the postcricoid space consistent with an abscess. The true vocal folds were mobile, and the anterior glottic airway was patent. Laboratory data showed an elevated white blood cell count of 17.8 K/uL with a left shift. Intravenous ampicillinsulbactam and dexamethasone were administered. The patient was taken to the operating room (OR) for direct laryngoscopy, where awake transoral fiberoptic intubation was accomplished with a 6-0 cuffed endotracheal tube. Suspension laryngoscopy with endoscopic magnification was performed. The posterior larynx was erythematous and edematous with fluctuance in the postcricoid space. The abscess cavity was entered, and 3 ml of purulent fluid was expressed, which was cultured. The patient was extubated in the OR and admitted to the general ward. Cultures revealed methicillin-resistant Staphlococcus aureus (MRSA) sensitive to clindamycin, and the antibiotic regimen was adjusted accordingly. No immunosuppression workup or HIV testing was performed. There was no stridor or dyspnea noted throughout the patient’s stay. The patient was discharged on postoperative day 2 tolerating a regular diet on a full course of oral clindamycin and was lost to follow-up. Boyce and deSilva: Spontaneous MRSA Postcricoid Abscess
2583
Fig. 1. CT scan with contrast showing a sagittal view of the postcricoid space abscess.
DISCUSSION We present an unusual case of a spontaneous posterior laryngeal abscess due to MRSA. Posterior laryngeal abscesses are extremely rare and have not been previously reported in the absence of recent instrumentation of the upper aerodigestive tract. This case also highlights the increasing prevalence of community acquiredMRSA (CA-MRSA), which can manifest as complicated infections. Laryngeal abscesses can be fatal due to the potential for obstruction of the airway; this outcome was nearly universal in the era before antibiotics.1 Laryngeal abscesses have been most commonly described as a sequela from acute supraglottitis. In a series of 116 adult patients presenting with supraglottitis, Berger et al. found that the overall rate of abscess formation was 24%, and the rate was rising over the 15-year study period.2 As with our patient, near one-half of the patients with an abscess in that series did not present with acute upper airway obstruction. The incidence of laryngeal abscess ranges from 2% to 29%.2–4 With improved antibiotics and vaccinations, etiologies for abscess formation have been more recently described arising in the setting of trauma. These include reports of abscesses caused by ingestion of foreign bodies as well as injection of micronized human acellular dermis (Cymetra, Bridegwater, NJ) after medialization laryngoplasty.3–5 Posterior laryngeal trauma leading to an abscess has been described after intubation and nasogastric tube placement.6 Increasing severity and degree of laryngeal injury has been correlated with a larger endotracheal tube size and duration of intubation.7 In addition to mechanical trauma, a decreased ability to mount an appropriate immunologic response seems to predispose patients to forming laryngeal abscess. Cohen et al. reported a laryngeal abscess in a patient with lymphoma who had recently completed chemotherapy.8 Another case report involved a patient with systemic lupus erythematosus and a renal transplant who Laryngoscope 124: November 2014
2584
was on immunosuppressive therapy and developed a laryngeal abscess.5 Diabetes mellitus is also known to cause an impaired immune response and has been described in a patient with a laryngeal abscess.6 Interestingly, Shah and Klein demonstrated, in the largest MRSA laryngitis case series to date, that all of their patients with MRSA laryngitis also had diabetes mellitus.9 Additionally, radiation treatment is known to cause fibrosis, vasculitis, and the obliteration of lymphatic channels, which can impair a local inflammatory response and has been associated with two cases of abscess formation in patients treated for laryngeal cancer.1,6 Lastly, the only other reported MRSA laryngeal abscess was described by Reed et al., but their patient had previous instrumentation to the larynx and had been hospitalized for 4 days prior to obtaining cultures.10 Our patient represents the first community-acquired MRSA laryngeal abscess in the literature and is unusual in that there is no history of trauma or immunosuppression. Treatment for laryngeal abscesses has varied widely, but always includes systemic antibiotics and endoscopy. Appropriate management of the airway is critical in all cases, and many patients required tracheostomy in advanced airway compromise. In the most extreme case, a laryngectomy was performed due to persistent laryngeal dysfunction and persistently infected cartilaginous sequestra after a laryngeal abscess.6 In other cases, both endoscopic and transcutaneous drainage of the abscess were performed.5,6 Purely medical management with antibiotics was shown to be effective treatment for a 1.3-cm paraglottic abscess.4 It is also important to note the ranges in duration from the inciting trauma to the presentation. In immunocompetent adults, the presentation has been described as early as 2 to 4 days after nasogastric tube placement.6 The interval between trauma and presentation of symptoms can be much longer in immunocompromised patients. McNellis and Hoang reported an interval of 5 months for their patient with lupus and a kidney transplant after the patient was intubated.5 The pathologic mechanism leading to abscess formation has not been clearly elucidated, but it does
Fig. 2. CT scan with contrast showing an axial view of the postcricoid space abscess.
Boyce and deSilva: Spontaneous MRSA Postcricoid Abscess
appear that mechanical trauma and either a local tissue or host immunocompromised state are important risk factors. Identification of risk factors as well as expeditious evaluation and treatment are essential for optimizing outcomes and avoiding fatal complications.
CONCLUSION This is the first description of a laryngeal abscess due to MRSA located in the postcricoid space in a patient who had no history of previous instrumentation or trauma to the upper aerodigestive tract. A high level of suspicion for an abscess and a need for highresolution imaging are warranted in patients who are presenting with sore throat, odynophagia, and voice changes for a prolonged period and who have failed multiple courses of antibiotics. Appropriate management of the airway is critical in patients with laryngeal abscesses due to the potential for fatal airway obstruction. Given the increasing incidence of head and neck infections due to MRSA, initial treatment should include
Laryngoscope 124: November 2014
antibiotics that cover MRSA based on local susceptibility data until culture results are obtained.
BIBLIOGRAPHY 1. Harvey M, Quagliotto G, Milne N. Fatal epiglottic abscess after radiotherapy for laryngeal carcinoma. Am J Forensic Med Pathol 2012;33:297– 299. 2. Berger G, Landau T, Berger S, Finkelstein Y, Bernheim J, Ophir D. The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol 2003;24:374–383. 3. Stack BC Jr, Ridley MB. Epiglottic abscess. Head Neck 1995;17:263–265. 4. Zapanta PE, Bielamowicz SA. Laryngeal abscess after injection laryngoplasty with micronized AlloDerm. Laryngoscope 2004;114:1522–1524. 5. McNellis EL, Hoang KG. Immunosuppression and systemic lupus erythematosus predisposing to laryngeal abscess. Otolaryngol Head Neck Surg 1997;116:107–109. 6. Souliere CR, Kirchner JA. Laryngeal perichondritis and abscess. Arch Otolaryngol 1985;111:481–484. 7. Santos PM, Afrassiabi A, Weymuller EA Jr. Risk factors associated with prolonged intubation and laryngeal injury. Otolaryngol Head Neck Surg 1994;111:453–459. 8. Cohen E, et al. Unilateral vocal cord paralysis as a result of a Nocardia farcinica laryngeal abscess. Eur J Clin Microbiol Infect Dis 2000;19: 224–227. 9. Shah MD, Klein AM. Methicillin-resistant and methicillin-sensitive Staphylococcus aureus laryngitis. Laryngoscope 2012;122:2497–2502. 10. Reed J, Shah RK, Jantausch B, Choi SS. Aryepiglottic abscess manifesting as epiglottitis. Arch Otolaryngol Head Neck Surg 2009;135:953–955.
Boyce and deSilva: Spontaneous MRSA Postcricoid Abscess
2585
Rhinological and Otological Society, Inc.
Case Report
Spontaneous MRSA Postcricoid Abscess: A Case Report and Literature Review Brian J. Boyce, MD; Brad W. deSilva, MD Abstract: Laryngeal abscesses are rare but potentially life-threatening infections due to potential airway obstruction. Most abscesses occur in the epiglottis or preepiglottic space as a sequela of acute supraglottitis. Abscesses in the posterior larynx are extremely rare and typically due to instrumentation or trauma. Appropriate workup and management of the airway are essential for optimizing outcomes in these patients. We present an interesting case and our management of a spontaneous posterior laryngeal abscess due to methicillin-resistant Staphlococcus aureus. Key Words: MRSA, laryngitis, laryngeal abscess, postcricoid abscess. Laryngoscope, 124:2583–2585, 2014
INTRODUCTION Laryngeal abscesses are rare but potentially lifethreatening infections due to the potential for airway obstruction. Most laryngeal abscesses occur in the epiglottis or preepiglottic space as a sequela of acute supraglottitis. Abscesses that occur in the posterior larynx, which are extremely rare, are typically caused by instrumentation or trauma. Appropriate workup and management of the airway are both essential for optimizing outcomes in these patients. In this article, we present an interesting case and our management of a spontaneous posterior laryngeal abscess due to methicillin-resistant Staphlococcus aureus.
CASE REPORT A 33-year-old African American female presented to the emergency department at the Wexner Medical Center at Ohio State University with sore throat and dysphonia of 2 months duration. The patient had been previously treated with two courses of oral antibiotics, including a 10-day course of amoxicillin and a 14-day course of penicillin. Symptoms continued to worsen despite these treatments. Associated symptoms included odynophagia and otalgia, but the patient denied fevers or dyspnea. Other than a 21=2 pack-year smoking history,
From the Department of Otolaryngology–Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A. Editor’s Note: This Manuscript was accepted for publication on June 12, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Brian Boyce, MD, 4000 Eye and Ear Institute, 915 Olentangy River Road, Columbus, OH 43212. E-mail: [email protected] DOI: 10.1002/lary.24819
Laryngoscope 124: November 2014
there was no significant past medical history that included diabetes mellitus or autoimmune disease. The patient’s past surgical history was unremarkable. The physical exam was significant for a rough and muffled voice without any stridor, stertor, or respiratory distress. The remainder of the exam was normal. A lateral neck X-ray and CT scan of the neck with contrast were performed. Although the plain film showed prevertebral edema at C4–5, the CT scan demonstrated a 1.6 3 1.5-cm rimenhancing lesion in the posterior larynx, and the retropharyngeal soft tissues were unremarkable (Figs. 1 and 2). Otolaryngology was consulted and transnasal flexible laryngoscopy revealed erythema and edema of the arytenoid mucosa and interarytenoid space, along with pooling of secretions. There was fullness of the postcricoid space consistent with an abscess. The true vocal folds were mobile, and the anterior glottic airway was patent. Laboratory data showed an elevated white blood cell count of 17.8 K/uL with a left shift. Intravenous ampicillinsulbactam and dexamethasone were administered. The patient was taken to the operating room (OR) for direct laryngoscopy, where awake transoral fiberoptic intubation was accomplished with a 6-0 cuffed endotracheal tube. Suspension laryngoscopy with endoscopic magnification was performed. The posterior larynx was erythematous and edematous with fluctuance in the postcricoid space. The abscess cavity was entered, and 3 ml of purulent fluid was expressed, which was cultured. The patient was extubated in the OR and admitted to the general ward. Cultures revealed methicillin-resistant Staphlococcus aureus (MRSA) sensitive to clindamycin, and the antibiotic regimen was adjusted accordingly. No immunosuppression workup or HIV testing was performed. There was no stridor or dyspnea noted throughout the patient’s stay. The patient was discharged on postoperative day 2 tolerating a regular diet on a full course of oral clindamycin and was lost to follow-up. Boyce and deSilva: Spontaneous MRSA Postcricoid Abscess
2583
Fig. 1. CT scan with contrast showing a sagittal view of the postcricoid space abscess.
DISCUSSION We present an unusual case of a spontaneous posterior laryngeal abscess due to MRSA. Posterior laryngeal abscesses are extremely rare and have not been previously reported in the absence of recent instrumentation of the upper aerodigestive tract. This case also highlights the increasing prevalence of community acquiredMRSA (CA-MRSA), which can manifest as complicated infections. Laryngeal abscesses can be fatal due to the potential for obstruction of the airway; this outcome was nearly universal in the era before antibiotics.1 Laryngeal abscesses have been most commonly described as a sequela from acute supraglottitis. In a series of 116 adult patients presenting with supraglottitis, Berger et al. found that the overall rate of abscess formation was 24%, and the rate was rising over the 15-year study period.2 As with our patient, near one-half of the patients with an abscess in that series did not present with acute upper airway obstruction. The incidence of laryngeal abscess ranges from 2% to 29%.2–4 With improved antibiotics and vaccinations, etiologies for abscess formation have been more recently described arising in the setting of trauma. These include reports of abscesses caused by ingestion of foreign bodies as well as injection of micronized human acellular dermis (Cymetra, Bridegwater, NJ) after medialization laryngoplasty.3–5 Posterior laryngeal trauma leading to an abscess has been described after intubation and nasogastric tube placement.6 Increasing severity and degree of laryngeal injury has been correlated with a larger endotracheal tube size and duration of intubation.7 In addition to mechanical trauma, a decreased ability to mount an appropriate immunologic response seems to predispose patients to forming laryngeal abscess. Cohen et al. reported a laryngeal abscess in a patient with lymphoma who had recently completed chemotherapy.8 Another case report involved a patient with systemic lupus erythematosus and a renal transplant who Laryngoscope 124: November 2014
2584
was on immunosuppressive therapy and developed a laryngeal abscess.5 Diabetes mellitus is also known to cause an impaired immune response and has been described in a patient with a laryngeal abscess.6 Interestingly, Shah and Klein demonstrated, in the largest MRSA laryngitis case series to date, that all of their patients with MRSA laryngitis also had diabetes mellitus.9 Additionally, radiation treatment is known to cause fibrosis, vasculitis, and the obliteration of lymphatic channels, which can impair a local inflammatory response and has been associated with two cases of abscess formation in patients treated for laryngeal cancer.1,6 Lastly, the only other reported MRSA laryngeal abscess was described by Reed et al., but their patient had previous instrumentation to the larynx and had been hospitalized for 4 days prior to obtaining cultures.10 Our patient represents the first community-acquired MRSA laryngeal abscess in the literature and is unusual in that there is no history of trauma or immunosuppression. Treatment for laryngeal abscesses has varied widely, but always includes systemic antibiotics and endoscopy. Appropriate management of the airway is critical in all cases, and many patients required tracheostomy in advanced airway compromise. In the most extreme case, a laryngectomy was performed due to persistent laryngeal dysfunction and persistently infected cartilaginous sequestra after a laryngeal abscess.6 In other cases, both endoscopic and transcutaneous drainage of the abscess were performed.5,6 Purely medical management with antibiotics was shown to be effective treatment for a 1.3-cm paraglottic abscess.4 It is also important to note the ranges in duration from the inciting trauma to the presentation. In immunocompetent adults, the presentation has been described as early as 2 to 4 days after nasogastric tube placement.6 The interval between trauma and presentation of symptoms can be much longer in immunocompromised patients. McNellis and Hoang reported an interval of 5 months for their patient with lupus and a kidney transplant after the patient was intubated.5 The pathologic mechanism leading to abscess formation has not been clearly elucidated, but it does
Fig. 2. CT scan with contrast showing an axial view of the postcricoid space abscess.
Boyce and deSilva: Spontaneous MRSA Postcricoid Abscess
appear that mechanical trauma and either a local tissue or host immunocompromised state are important risk factors. Identification of risk factors as well as expeditious evaluation and treatment are essential for optimizing outcomes and avoiding fatal complications.
CONCLUSION This is the first description of a laryngeal abscess due to MRSA located in the postcricoid space in a patient who had no history of previous instrumentation or trauma to the upper aerodigestive tract. A high level of suspicion for an abscess and a need for highresolution imaging are warranted in patients who are presenting with sore throat, odynophagia, and voice changes for a prolonged period and who have failed multiple courses of antibiotics. Appropriate management of the airway is critical in patients with laryngeal abscesses due to the potential for fatal airway obstruction. Given the increasing incidence of head and neck infections due to MRSA, initial treatment should include
Laryngoscope 124: November 2014
antibiotics that cover MRSA based on local susceptibility data until culture results are obtained.
BIBLIOGRAPHY 1. Harvey M, Quagliotto G, Milne N. Fatal epiglottic abscess after radiotherapy for laryngeal carcinoma. Am J Forensic Med Pathol 2012;33:297– 299. 2. Berger G, Landau T, Berger S, Finkelstein Y, Bernheim J, Ophir D. The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol 2003;24:374–383. 3. Stack BC Jr, Ridley MB. Epiglottic abscess. Head Neck 1995;17:263–265. 4. Zapanta PE, Bielamowicz SA. Laryngeal abscess after injection laryngoplasty with micronized AlloDerm. Laryngoscope 2004;114:1522–1524. 5. McNellis EL, Hoang KG. Immunosuppression and systemic lupus erythematosus predisposing to laryngeal abscess. Otolaryngol Head Neck Surg 1997;116:107–109. 6. Souliere CR, Kirchner JA. Laryngeal perichondritis and abscess. Arch Otolaryngol 1985;111:481–484. 7. Santos PM, Afrassiabi A, Weymuller EA Jr. Risk factors associated with prolonged intubation and laryngeal injury. Otolaryngol Head Neck Surg 1994;111:453–459. 8. Cohen E, et al. Unilateral vocal cord paralysis as a result of a Nocardia farcinica laryngeal abscess. Eur J Clin Microbiol Infect Dis 2000;19: 224–227. 9. Shah MD, Klein AM. Methicillin-resistant and methicillin-sensitive Staphylococcus aureus laryngitis. Laryngoscope 2012;122:2497–2502. 10. Reed J, Shah RK, Jantausch B, Choi SS. Aryepiglottic abscess manifesting as epiglottitis. Arch Otolaryngol Head Neck Surg 2009;135:953–955.
Boyce and deSilva: Spontaneous MRSA Postcricoid Abscess
2585
