Elsevier

Auris Nasus Larynx

Volume 32, Issue 1, March 2005, Pages 55-58
Auris Nasus Larynx

Head and neck infections caused by Streptococcus milleri group: An analysis of 17 cases

https://doi.org/10.1016/j.anl.2004.09.003Get rights and content

Abstract

Backgrounds:

Streptococcus milleri group (SMG) is a common inhabitant of the mouth and gastrointestinal tract, and can be an aggressive pathogen causing abscess formation at various sites in the body. However, it has rarely been listed as a cause of head and neck infections.

Objectives:

The present study was performed to evaluate the clinical significance of SMG by reviewing the microbiology and clinical records of patients with SMG in head and neck infections retrospectively.

Study design:

A retrospective review of all patients diagnosed as having SMG bacterial infections at Onomichi General Hospital, Hiroshima, between the years 2001 and 2002 was performed; 17 patients developed head and neck infections with SMG. Here, we describe the clinical features and management of SMG in head and neck infection.

Results:

The patient population consisted of 12 males and 5 females with a median age of 62 years (age range, 8–78 years). The sites of infection were as follows: maxillary sinus (n = 6), peritonsillar region (n = 4), subcutaneous (n = 3), submandibular space–retropharyngeal space (n = 1), deep neck–mediastinum (n = 1), parapharyngeal space (n = 1), submandibular space (n = 1), tonsil (n = 1), parotid gland (n = 1), and masseter muscle (n = 1). Ten cases (59%) were of suppurative diseases. Six cases (35%) had mixed SMG with anaerobe infection. Three cases showed deteriorating clinical courses, and all three of these cases were culture-positive for SMG with anaerobes. In addition, one deteriorating case showed gas gangrene regardless of repeated surgical debridement and intravenous antibiotic therapy; hyperbaric oxygen therapy improved this patient's condition.

Conclusion:

It is important to recognize SMG as a pathogen in head and neck infection. In addition, the care should be taken with infectious diseases caused by SMG with anaerobes as the patient's clinical course can deteriorate rapidly.

Introduction

The nomenclature of Streptococcus milleri group (SMG) remains controversial. At the present time, Streptococcus intermedius, Streptococcus anginosus, and Streptococcus constellatus are collectively referred to as the “Streptococcus milleri” group [1].

SMG is a common commensal in the mouth and gastrointestinal tract [2]. It can be an aggressive pathogen and causes brain abscess [3], subperiosteal abscess of the orbit [4], lung abscess, pleural empyema, and intra-abdominal abscess [5]. On the other hand, there is a paucity of published data regarding this organism as a serious pathogen in head and neck infections.

We report 17 patients who developed head and neck infections with SMG during a 2-year period at Onomichi General Hospital. Here, we describe the clinical features and management of SMG in head and neck infection.

Section snippets

Materials and methods

A retrospective review of all patients diagnosed as having SMG bacterial infections at Onomichi General Hospital, Hiroshima, between the years 2001 and 2002 was performed. Organisms were isolated with a conventional biphasic aerobic/anaerobic blood culture system. Samples were cultured on sheep blood agar and incubated in a CO2-enriched atmosphere for 24 h. Microorganisms recovered from blood cultures were identified using BBL CRYSTAL GP and RGP (BECTON DICKINSON, Mountain View, CA).

Results

SMG was isolated from 77 patients over a period of 2 years. The sites of infection were as follows: head and neck (n = 17), abdominal cavity (n = 12), sputum (n = 10), lachrymal sac (n = 8), trachea (n = 4), thoracic cavity (n = 4), anus (n = 4), limbs (n = 3), urine (n = 2) and others (n = 13). Nineteen cases (26%) had abscess formation in the brain, spinal epidural cavity, bladder, anus, or subcutaneously. The strains were identified in 10 of the 77 cases (13%): S. anginosus (n = 3), S. constellatus (n = 4), S.

Discussion

SMG has been reported by some researchers to be an aggressive pathogen in the head and neck [6], [7], [8]. However, SMG is not well recognized as an important pathogen in head and neck infections. There are two factors responsible for this. First, culture of SMG requires some special methods; incubation must be performed in air containing carbon dioxide or in an anaerobic atmosphere [6], [9]. Second, SMG is a common inhabitant of the mouth and gastrointestinal tract, and so might be not

Conclusions

The key points in the management of head and neck abscess are early diagnosis, adequate drainage, and control of infection by appropriate agents. It is important to recognize SMG as a pathogen in head and neck infection and to be aware of its predisposing factors, especially the co-existence of anaerobes. In cases with gas gangrene caused by SMG, combination therapy consisting of surgical debridement, antibiotic therapy, and hyperbaric oxygen should be considered.

References (19)

  • M. Yamamoto et al.

    Brain abscess caused by Streptococcus intermedius: two case reports

    Surg Neurol

    (1999)
  • J. Gosling

    Occurrence and pathogenicity of the Streptococcus milleri group

    Rev Infect Dis

    (1988)
  • P.M. Poole et al.

    Occurrence and cultural features of Streptococcus milleri in various body sites

    J Clin Pathol

    (1979)
  • B.J. Williams

    Subperiosteal abscesses of the orbit due to sinusitis in childhood

    Aust N Z J Opthal

    (1991)
  • P. Van der Auwera

    Clinical significance of Streptococcus milleri

    Eur J Clin Microbiol

    (1985)
  • T. Fujiyoshi et al.

    Clinical relevance of the Streptococcus milleri group in head and neck infections

    J Otolaryngol Jpn

    (2002)
  • J.K. Han et al.

    Streptococcus milleri: an organism for head and neck infections and abscess

    Arch Otolaryngol Head Neck Surg

    (2001)
  • T. Fujiyoshi et al.

    Clinical and bacteriological significance of the Streptococcus milleri group in deep neck abscesses

    J Otolaryngol Jpn

    (2001)
  • H. Jousimies-Somer et al.

    Bacteriologic findings in peritonsillar abscesses in young adults

    Clin Infect Dis

    (1993)
There are more references available in the full text version of this article.

Cited by (32)

  • Clinical and bacteriological differences of deep neck infection in pediatric and adult patients: Review of 123 cases

    2017, International Journal of Pediatric Otorhinolaryngology
    Citation Excerpt :

    Interestingly, Streptococcus anginosus group (SAG) bacteria were identified only in one of four (25%) pediatric patients positive for Streptococcus species, whereas 37 of 60 (62%) adult patients were positive for SAG bacteria. SAG bacteria have been reported to play a critical role in the pathogenesis of DNI by producing tissue-destroying enzymes and immunosuppressive substances, resulting in rapid spreading or synergic infection [11,23–25]. The lower incidence of SAG bacteria in pediatric DNI is consistent with the abovementioned decreased extension of fascial spaces.

  • A life-threatening complication of acute parotitis

    2008, British Journal of Oral and Maxillofacial Surgery
    Citation Excerpt :

    The incidence of necrotising fasciitis increases in middle age, and is more common in patients with diabetes mellitus.1 The microbiological investigations in this case suggested a polymicrobial infection dominated by S. milleri with facultative anaerobes of the enterococcus species, necrotising fasciitis Type I.2 The S. milleri group is common in the mouth and gastrointestinal tract, but is increasingly recognised as a highly aggressive pathogen in the head and neck.3 The infection in this case originated in the parotid gland and spread downwards in a pattern consistent with cervical necrotising fasciitis.4

  • The Use of Hyperbaric Oxygen Therapy in Ophthalmology

    2008, Survey of Ophthalmology
    Citation Excerpt :

    In a detailed review of cases with rhino-orbital-cerebral mucormycosis, Yohai et al found that HBO therapy had a favorable effect on prognosis.80 HBO might be a treatment of choice in ocular and periocular infections of anaerobic origin.33 In addition, HBO is a therapy of choice in rhino-orbital-cerebral mucormycosis, a rare, life-threatening condition, because of its efficacy in leukocyte-mediated oxidative killing of certain anaerobes and its clinical benefits that have been shown in uncontrolled studies.

View all citing articles on Scopus
View full text