Deep Neck Infections in Children: A New Approach to Diagnosis and Treatment

Forty-seven children presented with the diagnosis of a deep neck infection-either cellulitis or abscess-between January 1991 and July 1996. Forty-four (94%) had contrast-enhanced computed tomography (CT) imaging consistent with this diagnosis. Three patients with no CT scan had confirmation of an abscess at surgical drainage. Parenteral antibiotics alone were effective in the treatment of 24 of 47 infections (51%): seven parapharyngeal, one retropharyngeal, and 16 combined. By CT scan these infections represented cellulitis in 17 of 24 (71%), an abscess in three of 24 (13%), and incomplete abscess in four of 24 (17%). The average duration of hospitalization for this group was 4.8 days, with symptomatic improvement usually seen within 24 hours. Surgical drainage was performed on 23 of 47 infections (49%): three parapharyngeal, 17 combined, and three of unknown specific location. In 22 of these 23 children (96%), transoral drainage of the abscess was used as the primary surgical approach. In 21 of these 22 (95%) there was complete resolution without complications or recurrence; one abscess required a subsequent external approach. CT scanning with contrast revealed that all deep neck infections were located medial (usually anteromedial) to the great vessels. Abscesses with volumes estimated to be greater than 2000 mm³ were more likely to undergo surgery, but these differences were not statistically significant. The use of contrast-enhanced CT scanning provides information regarding abscess size, location, and relative position of the great vessels for safe and successful transoral drainage. Thus we recommend CT-assisted transoral drainage for combined retropharyngeal/parapharyngeal abscesses and selected isolated parapharyngeal abscesses that do not respond to parenteral antibiotics.     

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.     

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.     

Vacuum-assisted closure for managing neck abscesses involving the mediastinum

A 57-year-old immunocompetent male patient with a deep neck abscess involving the mediastinum was referred to us following unsuccessful treatment at his local hospital with medical therapy and ultrasound-guided aspiration. After initial evaluation and resuscitation, a contrast-enhanced computed tomography (CT) scan was performed, and the patient was transferred for surgical drainage. A vacuum-assisted closure (VAC) device was used as a surgical drain to help prevent reaccumulation of the purulent collections. A repeat CT scan on day 3 confirmed the absence of residual pus in the mediastinum and in the neck spaces, and the VAC device was removed. Perfect healing of the deep tissues with successful mediastinal toilette was observed. The patient resumed oral meals on postoperative day 10, and 2 days later he was discharged. A 1-month follow-up CT again demonstrated the complete healing and absence of the neck abscess. This case illustrates the possibility of avoiding more extensive and life-threatening procedures, such as open thoracotomy, in the treatment of neck abscesses extending into the mediastinum, and highlights the utility of VAC in the management of deep neck abscesses.     

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.     

Methicillin-resistant Staphylococcus aureus as a pathogen in deep neck abscesses: a pediatric case series

OBJECTIVES: Pediatric deep neck space abscesses are frequently treated by the otolaryngologist. We report four children with deep neck abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA), including the first described case of descending mediastinitis caused by MRSA in a child. METHODS: Records from March 2001 to April 2002 were reviewed. RESULTS: Four patients presented with neck swelling, and three of these also had leukocytosis. All abscess cultures were positive for MRSA. Abscess drainage with antibiotic therapy successfully treated three cases without complication. The fourth case developed descending mediastinitis but survived after additional surgical treatment and prolonged antibiotic therapy. CONCLUSIONS: MRSA should be considered as a potential pathogen in deep neck space abscesses. A high index of suspicion is needed as well as aggressive treatment including incision and drainage along with culture-directed medical therapy. Surgical drainage may be the most important aspect of therapy.     

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.     

A quartet of lateral sinus thrombosis, extradural abscess, subdural abscess and occipital abscess: complications of acute mastoiditis in a pre-adolescent child

Neurological complications of acute mastoiditis are rare but can be life threatening. Their presentation may be masked by the use of antibiotics. We present a unique case of acute otitis media progressing to occipital, extradural and subdural abscess formation and lateral sinus thrombosis in a child. The clinical course and management of a pre-adolescent male is presented and discussed. We review the incidence, presentation and treatment of occipital abscesses and lateral sinus thrombosis with acute mastoiditis. Following extended cortical mastoidectomy, neck exploration and broad spectrum intravenous antibiotics, the patient made a full recovery. This is the first reported case of acute mastoiditis associated with occipital abscess in a child. Early, aggressive treatment is required for a successful outcome. The rarity of neurological complications, in addition to the insidious onset and subtle symptoms associated with antibiotic therapy, can make diagnosis extremely difficult. Patients with acute otitis media who fail to respond fully to treatment should be referred early for a specialist otology opinion.     

Laryngeal abscess formation in an immunosuppressed patient: A case report

Prior to the onset of the antibiotic era, laryngeal perichondritis and abscess formation were more frequent complications of systemic infections. We report a case of 54‐year‐old male who was medically immunosuppressed after kidney transplantation and developed multiple pseudomonas abscesses of his larynx. After failing initial treatment and with worsening signs and symptoms, the patient eventually was treated with a prolonged course of intravenous and oral antibiotics, with resolution of his symptoms and clinical findings. Although this pathophysiology remains uncommon, laryngeal abscess formation should remain in the differential for persistent symptoms, especially in cases of patients on immunosuppression. Laryngoscope, 127:2827–2829, 2017     

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.     

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.     

Bacteremic methicillin-resistant Staphylococcus aureus deep neck abscess in a newborn—Case report and review of literature

We describe an unusual localization of methicillin-resistant Staphylococcus aureus infection (MRSA) in a very young newborn. A 3-week-old male infant was admitted with fever, irritability, sialorrhea and stiffed left neck. The ENT examination revealed a deep neck mass and an ultrasound examination showed diffuse swelling of the left latero-pharyngeal area. A CT examination confirmed a deep neck abscess with difficult-to-define borders. Blood and nasopharyngeal cultures returned positive for MRSA. Treatment was started with intravenous teicoplanin and continued for 14 days with a marked decrease in abscess's dimensions and improvement in patient's general condition. MRSA should be suspected in the etiology and treatment of neck abscesses in newborns, infants and young children.     

Retropharyngeal and parapharyngeal abscess in children—Epidemiology, clinical features and treatment

Objective

To describe the clinical presentation, diagnosis, management and complications of children with retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs).

Methods

A retrospective chart review was conducted at two tertiary care, pediatric hospitals in Israel. The medical records of all children <18 years who had been admitted with a diagnosis of RPA or PPA during an 11-year period (January 1997 to February 2008) were reviewed. Data on demographics, presenting symptoms, physical examination findings, imaging studies and interpretation, laboratory results, hospital course, medical treatment and surgical interventions were retrieved.

Results

A total of 39 children were diagnosed as having RPA (n = 26, 67%) or PPA (n = 13, 33%). There was a predominance of boys (61.5%). The mean age of all the children at diagnosis was 4 years. The annual incidence increased over the 11-year period. The most common symptoms at presentation included fever (n = 27, 70%) and neck pain (n = 24, 62%). The physical examination revealed cervical lymphadenopathy in 30 children (77%), limitation of neck movements in 25 (64%), torticollis in 21 (54%), drooling in three (8%), and stridor in two (5%). Computerized tomographic (CT) scanning with contrast was performed in 37 patients (95%), of whom 17 underwent surgical drainage. Thirteen children were positively diagnosed as having an abscess by the finding of pus at surgery, of whom 12 had been found to have an abscess on their CT scan. All the patients received intravenous antibiotics. There was no significant difference in the duration of hospital stay between those who underwent surgery and those who were treated with antibiotics alone. There were no treatment failures and no complications in either of the two groups.

Conclusion

Children with RPA most commonly present with restricted neck movements, fever and cervical lymphadenopathy, and rarely with respiratory distress or stridor. Many patients with RPA and PPA can be treated successfully without surgery. CT scans are helpful in diagnosing and assessing the extent of the infection, but they are not always accurate.     

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.     

Carotid artery occlusion in association with a retropharyngeal abscess

Deep neck space infections in children are not an uncommon presentation to an otolaryngologist and with appropriate antibiotic therapy, often in conjunction with surgical drainage, complications are rare. We report on a case of a 4-year boy who presented with a retropharyngeal abscess that was complicated by ipsilateral carotid artery and internal jugular vein compression. The patient was treated with intravenous broad-spectrum antibiotics and heparin. There were no subsequent neurological or vascular complications. An overview of the management of deep neck infections and their complications are discussed.     

Cases presenting as parotid abscesses in children

BACKGROUND: A parotid abscess is a rare complication of acute suppurative parotitis which most often requires hospitalization, intravenous antibiotic therapy, and surgical drainage. OBJECTIVE: To investigate the clinical picture, treatment, and prognosis of children with a parotid abscess in a search for optional clinical guidelines for treatment. METHODS: A retrospective chart review was performed for 10 children (age相似文献   

Orbital complications of acute sinusitis: comparison of computed tomography scan and surgical findings.

The accuracy of computed tomography (CT) in distinguishing an abscess from cellulitis in children who present with orbital manifestations of paranasal sinus infection remains in question. In this 10-year retrospective study, CT results are compared with surgical findings in 19 patients with orbital complications who underwent surgical exploration within 24 hours of their CT scans. Fifteen of the 19 CT scan interpretations indicated abscesses that were verified intraoperatively. Two patients had negative surgical explorations despite CT interpretations predicting abscesses. An abscess was also surgically documented in 1 of 2 patients whose preoperative scans indicated cellulitis alone. We conclude that the correlation between radiologic and operative findings in 16 of these 19 cases, although not absolute, does substantiate the use of CT scanning as a therapeutic guide in children presenting with orbital disease secondary to paranasal sinusitis.     

Streptococcus milleri head and neck abscesses: a case series

Streptococcus milleri infections and abscesses in the head and neck region have been previously reported, but there is still a dearth of clinical literature on this topic. To add to the available reports and to promote a better understanding and awareness of this clinically important entity, we present this retrospective review of 7 cases of head and neck abscess caused by S milleri infection. We have placed particular emphasis on antibiotic sensitivity patterns. These patients-6 men and 1 woman, aged 28 to 73 years (mean: 42.7)-had been seen at a district general hospital in Gosford, Australia, over a 6-month period. All patients had undergone surgical intervention and had been treated with intravenous antibiotics. All the S milleri cultures were sensitive to penicillin G, cephalexin, and erythromycin. Six of these patients experienced a resolution of their abscess, while 1 patient died from overwhelming sepsis. We believe that the initiation of penicillin G, cephalexin, or erythromycin is a good starting point for empiric therapy. S milleri should be considered as a causative organism in a patient who presents with a head and neck abscess, especially in the presence of a dental infection. Such a patient should be monitored closely for airway obstruction and distal infective sequelae. Also in this article, we compare our findings with those reported in two other published series.     

Peritonsillar abscesses in children

A follow-up retrospective study was performed on 41 children who presented with peritonsillar abscesses from 1970–1980. The ages ranged from 3 to 16 years, with the mean age of 10 years. There were 26 females and 15 males. The abscesses were predominantly left-sided (28 vs. 13 right-sided) and the mean duration of symptoms was 3 days. Of the patients, 39% had been treated with antibiotics prior to the abscess development. Only 15% of the patients had a documented past history of exudative tonsillitis. Of the 41, 1 patient was lost to follow-up, and 11 underwent tonsillectomy for the abscess. Thus, 29 patients were reviewed who received no surgical therapy for their peritonsillar abscess other than incision and drainage. These patients were contacted for an interval history with a period of follow-up ranging from 6 months to 10 years. Only 2 of the 29 patients (7%) had recurrent abscesses. Two other patients (7%) had further recurrent bouts of exudative tonsillitis but not abscesses. These 4 children were in an initial group of 6 who had a prior history of documented tonsillitis. The incidence of recurrent peritonsillar abscesses reported in the literature has ranged from 7.6 to 16% in series which were comprised mainly of adults. The low incidence of recurrent abscesses (7%) in this series would indicate a need to reevaluate the indication for tonsillectomy for peritonsillar abscess in the pediatric age group. The authors recommend that tonsillectomy be performed in those children who present with a pervious history of documented tonsillitis or suffer a complication at the time of the first abscess (neck abscess or airway compromise).     

Deep neck space infections: a retrospective review of 173 cases

Purpose

The purpose of this study is to review our recent experience with deep neck infections and emphasize the importance of radiologic evaluation and appropriate treatment selection in those patients.

Materials and Methods

The records of 173 patients treated for deep neck infection at the Department of Otolaryngology and Head and Neck Surgery of Dicle University Hospital during the period from 2003 to 2010 were retrospectively reviewed. Their demography, symptoms, etiology, seasonal distribution, bacteriology, radiology, site of deep neck infection, durations of the hospital admission and hospital stay, treatment, complications, and outcomes were evaluated. The findings were compared to those in the available literature.

Results

Dental infection was the most common cause of deep neck infection (48.6%). Peritonsillar infections (19.7%) and tuberculosis (6.9%) were the other most common cause. Pain, odynophagia, dysphagia, and fever were the most common presenting symptoms. Radiologic evaluation was performed on almost all of the patients (98.3%) to identify the location, extent, and character (cellulitis or abscesses) of the infections. Computed tomography was performed in 85.3% of patients. The most common involved site was the submandibular space (26.1%). In 29.5% of cases, the infection involved more than one space. All the patients were taken to intravenous antibiotic therapy. Surgical intervention was required in 95 patients (59.5%), whereas 78 patients (40.5%) were treated with intravenous antibiotic therapy alone. Life-threatening complications were developed in 13.8% of cases; 170 patients (98.3%) were discharged in stable condition.

Conclusion

Despite the wide use of antibiotics, deep neck space infections are commonly seen. Today, complications of deep neck infections are often life threatening. Although surgical drainage remains the main method of treating deep neck abscesses, conservative medical treatment are effective in selective cases.