Parapharyngeal abscess: diagnosis and treatment

To study the circumstances of diagnosis, predisposing factors, bacteriology and therapeutic management of parapharyngeal abscesses. This retrospective study over a period of 7 years concerned 16 patients hospitalized in an ENT and Head and Neck surgery department for parapharyngeal abscess. All patients were treated by intravenous antibiotics and steroids for 5–7 days. The length of hospital stay was 6–15 days. Parapharyngeal abscesses associated with peritonsillar and retropharyngeal abscess were all initially aspirated transorally for evacuation and bacteriologic examination. Five patients underwent surgical drainage (two via cervical incision, three by immediate tonsillectomy techniques and one by intra-oral drainage). Two patients presented jugular vein thrombosis. No life-threatening complication was observed. Patients were considered to be cured when cervical CT scan performed on D21-45 was normal. Parapharyngeal abscess is the second most common deep neck abscess after peritonsillar abscess. The diagnosis is both clinical and radiologic. CT scan is the best imaging examination for diagnosis and follow-up of parapharyngeal abscess. Non-complicated parapharyngeal abscesses require first-line medical management (intravenous antibiotics (amoxicillin and clavulanic acid) combined with steroids) and follow-up CT scan.     

Retropharyngeal and parapharyngeal infections in children: the Toronto experience

OBJECTIVE: To review the Hospital of Sick Children, Toronto's experience of the diagnosis and management of retropharyngeal and parapharyngeal infections with particular emphasis on the role of computed tomography (CT) imaging in diagnosing the presence of an abscess. METHODS: A retrospective analysis of all patients diagnosed with retropharyngeal and parapharyngeal infections from 1987 to 1999 was performed. Demographic data, presenting symptoms, season of presentation, management and complications were reviewed. The CT scans of 27 patients who underwent surgical treatment were retrospectively examined by two neuroradiologists who were blinded to the patient's history and outcome. The sensitivity, specificity and predictive values for the specific features and overall assessment were calculated. RESULTS: Fifty-four children were identified. There were 46 retropharyngeal infections, 6 parapharyngeal infections and 2 patients had both retropharyngeal and parapharyngeal infections. All patients were treated with parenteral antibiotics. Thirty-seven patients underwent surgical drainage and in 27 there was a positive finding of pus. The retrospectively assessed CT scans of the 21 patients who underwent surgery were found to have a sensitivity of 81% in detecting an abscess by CT scan but the specificity was 57%. There were four complications including mediastinitis, aspiration pneumonia, internal jugular vein thrombosis and common carotid artery aneurysm. All patients recovered but abscess recurred in five patients. CONCLUSION: Not all patients with retropharyngeal and parapharyngeal abscesses require surgery. Whilst CT scans are helpful in diagnosing and assessing the extent of these infections they are not always accurate in detecting an abscess. A decision to drain an abscess should therefore not be made based solely on the CT findings.     

Intravenous antibiotic therapy for deep neck abscesses defined by computed tomography

OBJECTIVE: To determine the effectiveness of using intravenous antibiotics alone to treat clinically stable children with clearly defined deep neck abscesses diagnosed by contrast-enhanced computed tomography (CT). DESIGN: Retrospective chart and CT scan review. SETTING: Tertiary care children's hospital. PATIENTS: The study comprised clinically stable pediatric patients who presented with signs and symptoms of a deep neck infection and who had CT scans demonstrating an abscess in the parapharyngeal space, retropharyngeal space, or both that included (1) a well-formed ring enhancement around a nonenhancing density consistent with fluid and (2) a size greater than 1 cm in every dimension. MAIN OUTCOME MEASURES: Clinical resolution of the signs and symptoms of the deep neck abscess after treatment with intravenous antibiotics. RESULTS: Over a 22-month period (May 1999 to March 2001), 11 children ranging in age from 4 months to 16(1/2) years who had contrast-enhanced CT evidence of deep neck abscess and no clinical evidence of severe symptoms or significant airway compromise were initially treated with intravenous antibiotics. Ten (91%) of the 11 children responded to intravenous antibiotic therapy as their only treatment. All 10 responders began to improve clinically by 48 hours. The symptoms resolved in 5 children by treatment day 3. Five to 8 days of treatment were required to completely resolve the symptoms in the other 5 patients. The 1 child who did not respond to intravenous antibiotic therapy underwent surgical drainage of her deep neck abscess within 12 hours of admission, with purulence discovered at the time of surgery. CONCLUSION: In a select number of clinically stable children, deep neck abscesses diagnosed on contrast-enhanced CT scans using strict radiographic criteria can be effectively treated with intravenous antibiotics alone.     

Retropharyngeal abscesses: a clinical and radiologic correlation.

OBJECTIVE: This study evaluates the efficacy at our centre of the lateral neck x-ray and the computed tomography (CT) scan in differentiating retropharyngeal cellulitis from abscess in retropharyngeal space inflammatory process. METHOD: We reviewed the medical records of 37 patients with the diagnosis of retropharyngeal abscess or cellulitis hospitalized at the Centre Universitaire de Santé de l'Estrie in Sherbrooke between 1986 and 1997. Patients with a positive drainage at surgery were considered as retropharyngeal abscess and the rest as cellulitis. We measured the sensitivity, specificity, and positive and negative predictive values for the lateral neck x-ray and CT scan. Demographic and clinical data were also extracted for each patient. RESULTS: Twenty-five patients were classified as retropharyngeal cellulitis and only six patients as retropharyngeal abscess, although 13 patients went to the operating room for drainage. Results for the sensitivity and specificity were 80% and 100% for the lateral neck x-ray and 100% and 45% for the CT scan. Positive and negative predictive values for lateral neck x-ray were 100% and 94%, respectively. Forty percent and 100% were the values calculated for the CT scan. Clinical data were consistent with what has been reported in the literature. CONCLUSION: CT scan is helpful in the management of retropharyngeal abscess but has limits in differentiating cellulitis and abscess. Lateral neck x-ray was found to be very specific when the air sign was present.     

Lack of association of CT findings and surgical drainage in pediatric neck abscesses

OBJECTIVE: To evaluate the relationship between neck abscess characteristics on computerized tomography (CT) scan and surgical drainage in pediatric patients. METHODS: Retrospective data warehouse review identified 43 children younger than 19 years admitted to a tertiary care pediatric hospital during the first quarters of 2000 through 2003 who underwent CT imaging for suspicion of head and neck abscesses involving the neck; face; and peritonsillar, retropharyngeal, and parapharyngeal spaces. A total of 45 scans were graded by a radiologist blinded to management. Thickness of the prevertebral soft tissue; location, dimensions, and degree of enhancement of the abscess; patient age; steroid and preadmission antibiotic use; and surgical intervention were recorded. RESULTS: Surgical drainage was performed in 32 of 43 patients (74%). We found no significant correlation between prevertebral soft tissue thickness, abscess dimensions or enhancement on CT scan, and surgical drainage. There was no significant association between surgical drainage and patient age, administration of steroids, or preadmission antibiotic use. CONCLUSIONS: Neck abscess appearance on CT scan did not predict surgical drainage, although prevertebral soft tissue thickness and abscess dimensions may be important features. Abscess enhancement, patient age, and the use of steroids and prehospitalization antibiotics were not found to correlate with surgical drainage.     

Contribution of CT scan and CT-guided aspiration in the management of retropharyngeal abscess in children based on a series of 18 cases

ObjectiveThis study was designed to analyse the contribution of CT scan to the management of retropharyngeal abscess in children and the place of CT-guided percutaneous aspiration as an alternative to surgical drainage.Materials and methodsRetrospective study including 18 children with a mean age of 38 months [range: 5–67 months] presenting with retropharyngeal infection between 2006 and 2011. All cases were initially assessed by contrast-enhanced CT scan of the neck. Clinical, radiological treatment and bacteriological data were collected. Radiological results were correlated with surgical and percutaneous aspiration findings (presence or absence of an abscess).ResultsThe initial CT scan detected 14 abscesses, 3 cases of non-suppurative lymphadenitis and one case of retropharyngeal oedema. One case of non-suppurative lymphadenitis progressed to abscess after failure of antibiotic therapy and was treated surgically. Surgical drainage revealed a purulent collection in 11 cases and no collection in 3 cases. Four CT-guided percutaneous aspirations were successfully performed. Three cases were treated by antibiotics alone (2 cases of lymphadenitis and 1 case of retropharyngeal oedema). Bacteriological examinations revealed the presence of Streptococcus pyogenes in 78.5% of cases. The positive predictive value of the initial CT scan was 78.8% in our series.ConclusionContrast-enhanced neck CT scan confirmed the diagnosis of retropharyngeal abscess and the indication for surgical drainage. It must be performed urgently, on admission. When it is decided to treat the patient with antibiotics alone, follow-up imaging should be performed in the absence of improvement 24 to 48 hours after starting antibiotics. CT-guided percutaneous aspiration is both a diagnostic modality confirming abscess formation of an inflammatory lesion of the retropharyngeal space as well as a therapeutic tool, sometimes avoiding the need for surgical drainage.     

Parapharyngeal abscess: comprehensive management protocol

Parapharyngeal infections are rare, but they cause serious morbidity and mortality. Therefore, until now, the recommended treatment of parapharyngeal abscess has been early open surgical drainage. The purpose of this study is to review the clinical course and outcome of treatment in parapharyngeal abscess according to method of treatment. A prospective study was designed for parapharyngeal abscess in patients admitted for deep neck infection. During an 8-year period, from June 1994 to January 2003, 34 patients were enrolled. All had contrast-enhanced computed tomography (CT) imaging and confirmation of an abscess in the parapharyngeal space. All patients were treated with intravenous antibiotics. We treated 19 cases (conservative group) with antibiotics only or needle aspiration and 15 (surgical group) with intraoral or external drainage. The mean duration of hospitalization was 8.2 days in the conservative group and 11.6 days in the surgical group. There was no complication except mediastinitis in 1 case of the conservative group. Because of severe dyspnea, 5 patients required tracheotomy. Neck CT scan is a useful diagnostic tool to detect and establish the treatment plan of parapharyngeal abscess. Parapharyngeal abscess may, in some cases, respond to antibiotics, become localized to the parapharyngeal space and be treated conservatively with no need for early open surgical drainage.     

Parapharyngeal abscess: diagnosis,complications and management in adults

Parapharyngeal abscess may cause life-threatening complications. Peritonsillar abscess and tonsillitis may result in parapharyngeal abscess. Since the introduction of antibiotics, the incidence of parapharyngeal abscess secondary to tonsillitis and peritonsillar abscess has decreased dramatically. We present five cases of parapharyngeal abscess resulting from tonsillitis and peritonsillar infection extending to the parapharyngeal space in adult patients. Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. We emphasize the diagnostic role of computerized tomography (CT) scan and the importance of early and proper drainage of these abscesses.     

Redefining parapharyngeal space infections

OBJECTIVES: Our intent was to review the clinical signs, computed tomography (CT) scans, treatment, and outcome of parapharyngeal space infections (PPIs), and to define 2 types of infections of the parapharyngeal space (PPS) according to the location of the infectious process. METHODS: We performed a retrospective analysis of patients hospitalized in a tertiary university hospital with a diagnosis of PPI, abscess, or deep neck abscess between 1988 and 2004. Files and CT scans were reviewed after classification into 2 groups: 1) infection located in the posterior part of the PPS (PostPPI); and 2) infection located in the anterior part of the PPS (AntPPI). RESULTS: Twenty-two patients had a PostPPI; their ages ranged from 10 months to 24 years. Five patients underwent surgical drainage, and 17 others were treated solely with intravenous antibiotic therapy. No pus was found during surgery in 2 patients. The average time of hospitalization was 10 days. Only 1 complication (aspiration pneumonia) was observed. Seven patients had an AntPPI; their ages ranged from 1.5 years to 65 years. All patients underwent surgical drainage, and pus was detected in all cases. The average time of hospitalization was 35 days. Complications (septic shock, respiratory arrest, mediastinitis, pleural empyema, pericarditis) were observed in 4 patients. CONCLUSIONS: The term "parapharyngeal abscess" was assigned long before the CT scan era, and was based on physical examination and plain film radiology. In essence, the entity PPS "abscess" or "infection" is composed of 2 different disorders. Infection located in the posterior part of the PPS with no invasion into the parapharyngeal fat and with no extension into other cervical spaces except the adjacent retropharyngeal space may be termed posterior parapharyngeal infection or parapharyngeal lymphadenitis. This is a relatively benign condition, and nonsurgical treatment should be considered. Infection involving the parapharyngeal fat may be termed parapharyngeal abscess or deep neck abscess. Diffusion into the mediastinum and other severe complications are frequent. Urgent surgical drainage is therefore mandatory.     

Correlation between computed tomography and surgical findings in retropharyngeal inflammatory processes in children.

Retropharyngeal abscess (RPA) in children is a potentially life-threatening process which often requires immediate surgical intervention. Contrast enhanced computed tomography (CT) is utilized frequently to determine abscess versus cellulitis/phlegmon and aids in determining cases needing surgical drainage. The purpose of this retrospective study was to determine the accuracy of CT in distinguishing retropharyngeal abscess from cellulitis in children. The medical records of 32 children from 1989 to 1997 suspected of having a retropharyngeal abscess were reviewed. All patients included in the study underwent a CT scan as well as surgical exploration within 48 h of the scan. Two patients required two surgical procedures (n = 34). A comparison between CT results and operative findings was made to determine the accuracy of CT imaging in confirming the presence of RPA versus cellulitis. Suspected diagnosis of abscess or cellulitis/phlegmon on CT was confirmed at surgery in 25 of 34 cases (73.5%). The false positive rate of CT scan was 11.8% (4/34), while the false negative rate was 14.7% (5/34). Based on our results, CT is accurate in differentiating abscess from cellulitis in 73.5% of cases. Clinical findings, as well as radiologic findings, must be considered together prior to surgical drainage of a suspected retropharyngeal abscess in children.     

Sump catheter drainage of parotid abscess: an alternative to surgery

It is a clinical challenge to distinguish patients with parotid abscesses from those with acute sialadenitis. A case of parotid abscess is presented in which a CT scan with intravenous contrast enhancement localized the abscess cavity and guided its aspiration and drainage with an indwelling catheter. By using this percutaneous technique, the need for early surgical intervention by incision and drainage was eliminated. The dense overlying parotid fascia and position of the deep parotid lobe make differentiating between these two clinical entities difficult. Parotid abscesses are readily apparent on computerized tomographic (CT) scanning evaluation with intravenous contrast enhancement, presenting as discrete fluid-filled areas unlike the amorphous appearance of acute sialadenitis. CT scanning with intravenous contrast enhancement has been the preferred radiographic study of choice for evaluating parotid masses or parapharyngeal masses. The treatment of a patient with acute sialadenitis differs from that of a patient with a parotid abscess. Patients with acute sialadenitis will usually respond to vigorous intravenous (IV) hydration, use of sialagogues and appropriate antibiotic coverage. Following a period of conservative treatment with antibiotics and warm soaks, patients with parotid abscesses will usually undergo an incision and drainage procedure, and later, parotidectomy. A case of parotid abscess is presented in which a CT scan with intravenous contrast enhancement localized the abscess cavity and guided its aspiration and drainage with an indwelling catheter. Percutaneous drainage of parapharyngeal abscesses guided by CT has been previously described by Cole. By using this percutaneous technique, the need for early surgical intervention by incision and drainage was eliminated.     

Accuracy and usefulness of radiographic assessment of cervical neck infections in children.

OBJECTIVE: To determine the accuracy and usefulness of computed tomography (CT) in diagnosis and management of lateral and deep neck infections METHODS: An 11-year retrospective review of 110 children (age range 1 months to 17 years) was conducted at a tertiary care children's hospital. RESULTS: Fifteen patients treated medically (8 with cellulitis, 7 with early abscess) improved. Of the remaining 95 patients who had 107 cervical sites drained surgically, CT predicted accurately operative findings in 81 (76%) cases (72 with abscess, 9 with cellulitis). In the 26 (24%) cases with discrepancy between CT interpretation and operative findings, the most common problem was differentiating early abscess from cellulitis with 18 false positives (no abscess at surgery). In 8 cases, CT diagnosis other than abscess was made (4 cellulitis, 1 inflammatory mass, 1 hematoma, 1 lymphangioma, and 1 tumour); however, when the patients were operated on because of lack of improvement, an abscess was found. CONCLUSIONS: Although CT is helpful both in determining the presence and location of neck infections in children, the CT scan is less helpful in differentiating abscess from lymphadenitis, cellulitis, and some complex cervical masses.     

Parapharyngeale Raumforderungen Differenzialdiagnostik anhand von Fallbeispielen

INTRODUCTION: Parapharyngeal tumors account for only 0.8% of all head and neck tumors which often presents the problem of preoperative diagnosis. Up to 80% of parapharyngeal tumors are benign. PATIENTS: Starting November 1995 to March 2001, 16 patients with parapharyngeal tumors and 1 retropharyngeal abscess were treated. The median age was 54 years. Only 2 patients demonstrated peripheral nerve lesions preoperatively. RESULTS: 17 tumors and the retropharyngeal abscess were excised via transcervical approach, with an extension by parotidectomy and temporary mandibular split in 1 case. Histological entities were pleomorphic adenomas in 5 cases, a ganglioneurinoma, neurinoma of the vagal nerve and metastasis of a squamous cell carcinoma in 2 patients each, furthermore neuroblastoma, extramedullary plasmocytoma, T-cell lymphoma, and hemangioma in 1 patient each. CONCLUSIONS: We demonstrate the differential diagnosis of parapharyngeal tumors as well as their diagnostic and therapeutic management. The tumors should be excised by a transcervical approach to protect cervical vessels and nerves, which is limited by a transoral approach.     

Presentation,diagnosis, and management of deep-neck abscesses in infants

OBJECTIVE: To clarify the presenting signs and symptoms, clinical course, pathogenic organisms, and management of deep-neck-space abscesses in infants. DESIGN: Retrospective chart review. SETTING: Tertiary care academic children's hospital. PATIENTS: Records of 25 patients 9 months or younger with deep-neck-space abscesses from July 1989 through May 1999 were reviewed. MAIN OUTCOME MEASURE: Resolution of abscess. RESULTS: Presenting symptoms included neck mass, 92% (n = 23); fever, 60% (n = 15); and dysphagia and/or poor intake by mouth, 36% (n = 9). Overall, patients were symptomatic for a mean duration of 3.8 days before presenting to the hospital; 21 of 22 evaluated patients had elevated white blood cell counts. Imaging included 68% computed tomographic scan (n = 17) and 44% plain radiographs (n = 11). On the basis of radiology and operative findings, locations of the abscesses were as follows: anterior triangle, 8; parapharyngeal, 5; posterior triangle, retropharyngeal, and undefined, 3 each; submandibular, 2; and parotid, 1. Of 17 scanned patients, 13 had some degree of airway compromise evident on computed tomography. All were treated with incision and drainage, 3 of 25 intraorally and 22 of 25 externally. Pus was identified in all 25; 20 of these grew Staphylococcus aureus, 1 grew group A Streptococcus, and 4 grew no organism. All patients received intravenous antibiotics for a mean of 4.8 days and oral antibiotics for a mean of 11 days. Only 1 patient required a second procedure. CONCLUSIONS: Deep-neck-space abscesses in infants are rapidly progressive, often cause airway compromise, and usually present with fever and neck mass. The most common pathogen is S aureus. Patients are effectively treated with incision and drainage coupled with intravenous followed by oral antibiotics.     

Parapharyngeal abscesses.

Fifty-five patients with deep neck infections treated consecutively over a period of six and a half years between January 1983 and July 1989 were reviewed. Nine of these patients had abscesses localized to the pharapharyngeal space and form the basis of this study. The aetiology of the parapharyngeal abscess was odontogenic in two patients and remained unknown in the other seven. Five patients had associated systemic disease; four were diabetics and one patient had non-Hodgkin's Lymphoma. High dosage intravenous antibiotics directed towards the causative micro-organisms, airway control and early surgical intervention was the mainstay of treatment. All patients underwent open surgical drainage of the parapharyngeal abscess within 24 h of admission. Bacteriology results showed Klebsiella sp. to be the dominant micro-organism cultured in four patients. Morbidity was low; seven patients had no post-operative complications and were discharged from the hospital between 7-24 d (mean 12.9 d). There were two deaths. Early open surgical drainage remains the most appropriate method of treating parapharyngeal space infections; it avoids life threatening complications with rapid recovery.     

Surgical management of retropharyngeal space infections in children

OBJECTIVE: To study the perioperative management strategies in a large group of pediatric patients undergoing surgical therapy for suppurative adenitis of the parapharyngeal and retropharyngeal spaces. STUDY DESIGN: Retrospective analysis of all patients treated surgically from January 1, 1989, to December 31, 1998, in a tertiary care pediatric hospital. METHODS: Charts were reviewed for demographic data, duration and nature of symptoms, radiological workup, surgical approach, complications, duration of medical therapy and antibiotic choice, and bacteriological findings. Computed tomography (CT) results were correlated to surgical findings. RESULTS: A dramatic increase in the incidence of deep neck space infection was seen during the study period; this increase was congruent with the increase in culture-positive group A beta-hemolytic streptococcal abscesses. More than two-thirds of the patients were boys with the peak incidence being in the 3- to 5-year-old group. The duration of symptoms before presentation was less than might be expected, especially in the younger age groups. Seventy of 73 children were treated with a transoral approach. Sixty-eight of 73 were successfully treated with one operative intervention. Irregularity of the abscess wall was found to be a stronger predictor of the presence of pus than the presence of ring enhancement. CONCLUSIONS: The current study represents the largest series of pediatric retropharyngeal abscesses in the modern medical literature. Changes in the disease process and in management from the first half of the century to today are reviewed, and recommendations for optimal management presented. The data in this series support a transoral approach to these abscesses unless there is extension lateral to the great vessels.     

Deep neck cellulitis: limitations of conservative treatment with antibiotics

Conclusion: When the parapharyngeal space is infected, concurrent involvement of other spaces is likely, and involvement of multiple deep neck spaces is a key risk factor for abscess formation.

Objectives: Deep neck infection is treated with antibiotics when abscesses have not yet been formed. However, in some cases, abscesses will form later and surgical drainage is warranted. This study retrospectively examined which cases were less likely to achieve cure, to clarify the limitations of conservative treatment for deep neck cellulitis.

Patients and methods: Subjects comprised 19 patients with deep neck cellulitis who initially underwent conservative treatment with antibiotics. Patients were divided into two groups: Group A (n?=?7), patients who recovered by conservative treatment; and Group B (n?=?12), patients who did not recover and underwent surgical drainage. Age, state of DM control, etiology, treatment, spaces infected, and duration of hospitalization were investigated.

Results: The number of infected spaces was one in all Group A patients, whereas Group B showed multiple infected spaces in all except two cases. In particular, among the 10 cases with parapharyngeal space infection, eight (80%) showed multiple lesions.     

Demographics of pediatric head and neck infections in a tertiary care hospital

EDUCATIONAL OBJECTIVE: Discuss potential patterns in the epidemiology of infectious disease of the head and neck. STUDY OBJECTIVES: To investigate patterns in the epidemiology of severe head and neck infections that may reflect the impact of host factors. STUDY DESIGN: Population-based, historic cohort study. METHODS: Information on 1,010, incident head and neck infections occurring over a 5-year period was reviewed for demographics, location, and time of year. A nonparametric Kruskal-Wallis test was used to identify significant differences in the age distributions among the diagnosis groups. A Bonferroni, pair-wise comparison procedure was used for comparison of the average age of first onset of severe head and neck infections. Chi-square test was used to identify any significant association between season of the year and disease. RESULTS: Significant differences were identified in the age distributions among the diagnosis groups (P < .001). The average age of first onset of cellulitis of the neck and retropharyngeal abscess is earlier than peritonsillar abscess, at 2 to 3 years and 13 years, respectively. Parapharyngeal and periapical abscesses and cellulitis of the face occur at approximately age 6. The incidence of parapharyngeal abscess and diseases of the pharynx is decreased during Spring, whereas peritonsillar abscesses and acute periodontitis occurs more often in Spring and Summer. Age does not appear to be related to season of first occurrence. CONCLUSIONS: Head and neck infections are not random occurrences based on exposure alone; host factors are clearly important. Given the lack of correlation with school age, the results cannot be explained on the basis of exposure alone. Developmental patterns of the host immune response may be related to the age differential identified in the current study and are cause for further investigation.     

Orbital complications of ethmoiditis: B.C. Children's Hospital experience, 1982-89.

Orbital complications of ethmoiditis primarily affect children. Infection proceeds through contiguous spread to the orbit. We undertook a retrospective analysis of all children admitted to British Columbia Children's Hospital in Vancouver with a diagnosis of periorbital and orbital cellulitis due to ethmoiditis between 1982 and 1989. The majority of children presented with periorbital cellulitis, which resolved with aggressive parenteral antibiotic therapy. Five children (17%) progressed to subperiosteal abscess formation as documented by CT scan and required external ethmoidectomy as a drainage procedure. We conclude that early hospitalization and aggressive parenteral antibiotics are effective in resolving periorbital cellulitis. Surgical drainage is indicated when subperiosteal abscess is documented by CT scan. In our series, there were no cases of permanent visual deficit resulting from complications of ethmoiditis.     

Accuracy of computerized tomography in deep neck infections in the pediatric population

OBJECTIVES: Computerized tomography (CT) is used widely to diagnose deep neck infections (DNIs), and, generally, the decision of surgical intervention is based on findings of a CT study. This study examines the accuracy of CT in differentiating abscess versus cellulitis in DNIs (lateral pharyngeal and retropharyngeal). STUDY DESIGN: This is a retrospective chart review study with re-evaluation of the CT scans by a blinded observer. METHODS: A retrospective review of medical records of 80 patients with DNIs who were evaluated with a CT study was performed. CT scans of these patients were reviewed by a radiologist who was blinded to the clinical and surgical findings and to the original CT study report. To diagnose the infection and differentiate abscess from cellulitis, our radiologist scored the CT scans regarding the following variables: low-density core, rim enhancement, soft-tissue swelling, obliterated fat planes, and mass effect. Radiologic diagnosis was compared with operative findings (whether pus found at surgery or not) in all cases treated surgically. Accuracy, sensitivity, specificity, and positive and negative predictive values of CT study were calculated. RESULTS: Thirty-nine (49%) patients were treated medically with intravenous (IV) antibiotics alone, and 41 (%51) patients were treated both surgically and medically. The overall accuracy of CT in DNI was 63%. The sensitivity, specificity, and positive and negative predictive values were 68%, 56%, 71%, and 53%, respectively. CONCLUSION: CT study has important limitations in differentiating abscess versus cellulitis in DNIs. Clinical findings as well as CT diagnosis should guide the decision of surgery.