Postoperative infection of the skull base surgical site due to suppurative parotitis: A case report

INTRODUCTION

Paragangliomas are a rare neuroendocrine tumor of the autonomic nervous system[1]. The diagnosis depends on pathology findings. Malignant paragangliomas are diagnosed based on the presence of distant metastasis. It is reported that benign paragangliomas account for 76.1% of the total number of paragangliomas[2]. For benign paragangliomas, surgical resection is currently the only possible cure for the disease[3].

Attention should be paid to postoperative infection of the lateral skull base surgical site. Once infection occurs, the transplanted tissue may become necrotic, the length of hospital stay increases significantly, and the time of postoperative adjuvant treatment may be delayed. In the case of meningitis or encephalitis, patients are in life-threatening danger[4]. Incomplete filling of the cavity defect, poor localized blood supply of the free tissue flap, and a postradiotherapy state are all risk factors of postoperative infection at the surgical site of the lateral skull base[5]. Suppurative parotitis can be a complication of general anesthesia surgery and has an incidence rate of 1 in every 1000 postoperative cases[6]. Predisposing factors of suppurative parotitis are dehydration, malnutrition, oral neoplasms,immunodeficiency, sialolithiasis, and medications that diminish salivation[7].

6 One night, as he was tossing about in bed, full of cares and worry, he sighed and said to his wife: What s to become of us? how are we to support our poor children, now that we have nothing more for ourselves? I ll tell you what, husband, answered the woman; early to-morrow morning we ll take the children out into the thickest part of the wood; there we shall light a fire for them and give them each a piece of bread; then we ll go on to our work and leave them alone

Herein, we report a patient presenting with a paraganglioma of the lateral skull base that was surgically treated, followed by postoperative surgical site infection due to suppurative parotitis. We need to be alert to the emergence of postoperative suppurative parotitis, find the inflammation evidence in the adjacent area of the surgical site as soon as possible, and prevent it from spreading, which could result in adverse consequences for patients. Vacuum sealing drainage (VSD) is worth considering for such complicated postoperative infections of the lateral skull base.

CASE PRESENTATION

Chief complaints

A 30-year-old male patient with a 1-year history of left-side tinnitus.

History of present illness

The patient had 1-year of persistent tinnitus and 5 mo of hearing loss on the left side. He developed progressive facial paralysis on the left side, accompanied by hoarseness, left tongue extension, choking while drinking, and occasional difficulty swallowing. Contrast-enhanced magnetic resonance imaging(MRI) of the head revealed a mass surrounding the jugular foramen.

I had returned to work after only six weeks leave and on the tail end of postpartum blahs. I felt fat and incompetent4. My husband felt guilty and alienated5. The few words in passing each morning and the brief hug and peck in the evening were, at best, meager6 tokens of the attention we desperately7 needed to give each other.

History of past illness

The authors declare that they have no conflict of interest to report.

Personal and family history

The patient had no systematic diseases, and no significant personal and family history.

Physical examination

He presented with a swollen external auditory canal containing a dark red mass within the tympanic cavity that pulsated in sync with his pulse rate, facial (House-Brackmann IV grade), glossopharyngeal,and vagal palsy, as well as hearing loss. All the symptoms above appeared on his left side.

Laboratory examinations

VSD, proposed by Fleischmann

[10], is a highly effective treatment for wound drainage. The combination of saline irrigation and negative pressure suction promotes the discharge of wound exudation and healing. Compared with traditional dressing changes, the VSD flushing area is larger, the drainage effect is more significant, the infection control period is shorter, and the local blood circulation is improved[11,12], which is conducive to the growth of granulation tissue.

Imaging examinations

Computed tomography (CT) of the temporal bone showed bone destruction of the left jugular foramen and the horizontal segment of the internal carotid artery (Figure 1A). Enhanced MRI of the temporal bone showed an uneven enhanced mass with a size of 47 mm × 38 mm × 34 mm involving the left jugular foramen, which partially wrapped around the internal carotid artery and extended to the cerebellar pontine region with invasion within the meninges (Figure 1B).

First-stage operation and postoperative conditions

Given the rarity of this condition, the unforgettable setbacks we experienced, and the lessons we learned, we consider this case report clinically significant.

Let us see what is in the other casket, before we get into a bad humor, saidthe Emperor. So the nightingale came forth5 and sang so delightfully7 that atfirst no one could say anything ill-humored of her.

FINAL DIAGNOSIS

Zhao Y, Zhao Y and Feng GD substantially contributed to the conception or design of the work;or the acquisition, analysis, or interpretation of data for the work; Zhao Y, Zhang LQ and Feng GD drafted the work or revising it critically for important intellectual content; all authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; and All authors made final approval of the version to be published.

TREATMENT

The two stage-surgery strategy is safe for large paragangliomas within the skull base which may induce significant meningeal defects. During the first-stage surgery, the extradural portion of the tumor needs to be removed and the surgical site deficit needs to be filled with the pedicled tissue flap or abdominal fat. After the transposed tissue survives, the residual tumor can be safely removed during the second-stage operation. The two stage-surgical strategy has some obvious advantages. First, when dealing with the epidural portion of the tumor, the meninges remain intact. Even if the surgical site gets infected, the probability of meningitis or encephalitis is low. Second, once the surgery is divided into two stages the local blood supply becomes relatively rich when the transposed tissue survives and becomes significantly more favorable for the growth of the repaired meninges after the second stagesurgery. Third, structure of the lateral skull base region is so complex that the operation often has an extended duration of up to more than 20 h. If the operation is divided into two parts, it can avoid excessive fatigue of the doctors and is safer for the patients. In addition, the removal of the epidural portion might induce a tumor reduction effect[8]. When the extracranial region has been resected, the portion of the tumor that protrudes inwards into the meninges may retract outwards. This can help reduce brain damage and leads to an increased distance between the tumor and brain stem or other vital structures, improving the safety of the second-stage surgery.

Half a year later, the residual cavity remained at a size of 4 cm x 3 cm x 5 cm. The cavity could not be reduced further and there was intermittent purulent exudation within the surgical site. VSD was chosen to control wound infection. With one month of persistent VSD, the wound eventually healed(Figure 3C). One year after the first operation, he underwent the second-stage operation to remove the intracranial portion of the tumor. The tumor that invaded the meninges was resected (Figure 4A), and artificial dura mater was used to repair the meninges of the posterior fossa (Figure 4B). The abdominal fat and the temporal muscle flap were transposed to the lateral skull base deficit.

OUTCOME AND FOLLOW-UP

The operation wound healed without infection. There were no signs of infection or tumor recurrence on MRI at 6 mo after the second-stage surgery (Figure 5).

DISCUSSION

Postoperative parotitis is rare and is detrimental to a patient's recovery[9]. Due to the close relationship between the parotid gland and the surgical site at the skull base, once suppurative parotitis occurs, the inflammation may spread to the operative area where the transposed free fat tissue can become infected or necrotic. Once the fat becomes necrotic, the affected tissue should be removed and the wound opened for adequate drainage. In severe cases, meningitis and even encephalitis are possible and are lifethreatening[4]. Through the review of this case, the occurrence of suppurative parotitis 25 d after surgery may be related to insufficient oral food intake and decreased parotid gland secretion[9]. It is necessary to pay attention to the patient's oral intake after surgery; therefore, timely intervention is needed if there is insufficient food intake.

Debridement was performed, the wound was kept clean, and received daily wound dressing changes(Figure 3A). Broad-spectrum antibiotics were used for infection control. The antibiotic regimen initially included ceftazidime (1 g q8h) and metronidazole (0.5 g bid) intravenous drips. During the dressing changes, bacteria culture and drug sensitivity tests were performed. Pseudomonas aeruginosa was cultivated intermittently, and ciprofloxacin (0.4 g qd) was replaced according to the drug sensitivity test.After the serum inflammatory biomarkers returned to normal, there were no other abnormalities except for a small amount of purulent exudation when changing the wound dressing. An infectious disease physician evaluated the advantages and disadvantages of continuous use of systemic antibiotics and considered that continually antibiotic therapy might not further effectively control the infection;however, might lead to the emergence of antibiotic resistant bacteria. The appropriate method to promote local wound healing should be continuous dressing changes and adequate drainage. The antibiotics were stopped, and the duration of systemic antibiotic usage after debridement was 3 wk.

In April a ship was to start for Norway, and Jurgen was to sail init. He was full of life and spirits, and looked so sturdy and wellthat Dame Bronne said it did her good to see him.

The blood serum levels of norepinephrine were 84.86 μg/24 h (normal reference ≤ 40.65 μg/24 h) and all serum inflammatory biomarkers were normal.

According to the patient's medical history, and physical examination results, the tumor is likely a paraganglioma. A two-stage surgery was designed for the resection of the mass. The patient underwent first-stage surgery to remove the extradural portion of the tumor. The pathological findings suggested a paraganglioma. Furthermore, the abdominal fat and the temporal flap were transposed in order to fill the cavities deficit. The surgery was successful. The patient received an intravenous infusion of ceftriaxone (2 g qd) for 7 d after surgery and was replaced with ceftazidime (1 g q12h) due to elevated blood transaminase. After the replacement, the antibiotics were continued for 2 wk until the inflammatory biomarkers returned to normal and then therapy was stopped. However, 25 d post-surgery, the patient suddenly developed swelling and tenderness under his left ear, with his body temperature reaching 40.5℃. A yellow purulent secretion appeared on the left buccal mucosa, followed by ulceration of the swollen area under the left ear. Laboratory examination indicated a 15.12 × 10

/L total white blood cell count (normal reference ≤ 9.5 × 10

/L) and a neutral granule percentage of 83.1% (normal reference ≤ 75%). Neck CT showed a hypodensity shadow in the caudal lobe of the left parotid gland(Figure 2). The diagnosis of suppurative parotitis was confirmed, and ceftazidime was given intravenously (2 g q8h) for 9 d. The swelling and tenderness in the parotid gland area gradually subsided, and no abnormalities were found within the surgical incision. However, the skin under the left ear ruptured and yellow fluid was discharged. Liquefaction necrosis occurred within the transposed abdominal fat of the skull base surgical site. Bacterial culture revealed a pseudomonas aeruginosa infection. According to the time sequence of suppurative parotitis and liquefaction necrosis, the infection of the surgical site was considered to be caused by suppurative parotitis.

Then he took it off, and they each kissed him and wished him good fortune, and then they began again their eternal dance round the golden tree, for it is their business to guard it till the new times come, or till the world s ending

CONCLUSION

After a lateral skull base surgery, suppurative parotitis can spread into the operative cavity leading to infection of the surgical site. VSD can help to effectively heal the infected wound. A two-stage surgical approach offers a safer option for removing the lateral skull base paraganglioma that involves the meninges.

But when she went up to the Prince s room he was again asleep, and, let her call him, or shake him, or weep as she would, he still slept on, and she could not put any life in him

FOOTNOTES

Postoperative infection of the skull base surgical site, with pseudomonas aeruginosa.

The patient was informed that data concerning the case would be submitted for publication and gave his consent.

The patient had no systematic diseases, and no significant personal and family history.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Yong Zhao 0000-0001-8867-3266; Yang Zhao 0000-0002-5880-9465; Li-Qin Zhang 0000-0002-0844-0567;Guo-Dong Feng 0000-0002-3622-5848.

His first act was to seek the Fairy under whose protection he had been placed, and he implored40 her to give him all the assistance of her art and counsel in this important matter

She left Skjagen and went to Norway two days later. He remainedbehind, and made himself useful on the farm and at the fishery. Hewent out fishing, and in those days fish were more plentiful andlarger than they are now. The shoals of the mackerel glittered inthe dark nights, and indicated where they were swimming; thegurnards snarled, and the crabs gave forth pitiful yells when theywere chased, for fish are not so mute as people say.

Ma YJ

A

Ma YJ

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