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).     

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.     

Age-, site-, and time-specific differences in pediatric deep neck abscesses

OBJECTIVE: To clarify presentations, organisms, and locations of deep neck abscesses in children. DESIGN: Retrospective review. SETTING: Tertiary children's hospital. The study population comprised 169 patients younger than 19 years who were surgically treated for deep neck abscesses between 1989 and 1999. MAIN OUTCOME MEASURE: Resolution of abscess. RESULTS: Neck mass (91%), fever (86%), cervical adenopathy (83%), poor oral intake (66%), and neck stiffness (59%) were common in all ages. Patients younger than 4 years, compared with patients 4 years or older, presented with agitation (50% vs 14%), cough (35% vs 14%), drooling (27% vs 12%), lethargy (46% vs 33%), oropharyngeal abnormalities (45% vs 60%), respiratory distress (5% vs 2%), retractions (5% vs 2%), rhinorrhea (53% vs 15%), stridor (4% vs 2%), and trismus (14% vs 53%). Children younger than 1 year were infected with Staphylococcus aureus (79%) vs group A streptococcus (6%). Children 1 year or older were infected with group A streptococcus (29%) vs S aureus (16%). Retropharyngeal or parapharyngeal regions were involved in children 1 year or older (49%) vs younger than 1 year (21%). Anterior or posterior triangles and submandibular or submental regions were involved in 39% and 36%, respectively, of children younger than 1 year vs 30% and 23%, respectively, of children 1 year or older. Retropharyngeal and parapharyngeal abscesses yielded group A streptococcus (34%) vs S aureus (11%). Anterior and posterior triangle abscesses yielded S aureus (35%) vs group A streptococcus (19%), as did submandibular and submental abscesses (42% vs 19%). CONCLUSIONS: Abscesses in children younger than 1 year affected anterior or posterior triangles and submandibular or submental regions, yielding S aureus. Abscesses in children 1 year or older affected retropharyngeal or parapharyngeal regions, yielding group A streptococcus.     

Deep neck abscesses: the Singapore experience

This study aims to review our experience with deep neck abscesses, identify key trends, and improve the management of this condition. This is a retrospective chart review of patients diagnosed with deep neck abscesses in the Department of ENT (Otorhinolaryngology) at Tan Tock Seng Hospital, Singapore between 2004 and 2009. Patient demographics, etiology, bacteriology, systemic disease, radiology, treatment, complications, duration of hospitalization, and outcomes were reviewed. 131 patients were included (64.9% male, 35.1% female) with a median age of 51.0 years. 54 (41.2%) patients had diabetes mellitus. The parapharyngeal space (23.7%) was the most commonly involved space. Odontogenic and upper airway infections were the leading causes of deep neck abscesses (28.0% each). Klebsiella pneumoniae (27.1%) was the most commonly cultured organism in this study and among the diabetic patients (50.0%). 108 (82.4%) patients underwent surgical drainage. 42 patients suffered complications. All 19 patients, who had upper airway obstruction, had either a tracheostomy or intubation. Patients with multi-space abscesses, diabetes mellitus, and complications had prolonged hospitalizations. Old age and diabetes are risk factors for developing deep neck abscesses and their sequelae. The empiric choice of antibiotics should recognize that a dental source is likely, and that Klebsiella is most common in diabetics. Surgical drainage and adequate antibiotic coverage remains the cornerstone of treatment of deep neck abscesses. Therapeutic needle aspiration may successfully replace surgical drainage, if the abscesses are small and no complications are imminent. Airway obstruction should be anticipated in multi-space and floor of mouth abscesses.     

Management of nonperitonsillar abscesses of the head and neck with needle aspiration.

Ten patients in a three-year period with various abscesses of the head and neck (nonperitonsillar) were treated with needle aspiration as the primary surgical modality. Eight were successfully managed with antibiotics and needle aspiration alone. Two required incision and drainage. Three patients had large volume abscesses (greater than 10 cc). Two of these resolved with multiple needle aspirations. These data suggest that certain nonperitonsillar abscesses of the head and neck may be successfully managed with needle aspiration and antibiotics.     

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.     

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.     

Needle aspiration of nonperitonsillar head and neck abscesses. A six-year experience

Twenty-five patients with various head and neck abscesses have been managed with needle aspiration as the initial surgical modality over a six-year period. Twenty (83%) of 24 patients' abscesses resolved without formal surgical intervention. Patient 25 in the series whose abscess, though initially resolving, reaccumulated within two weeks requiring an incision and drainage. Recurrent cancer was then diagnosed. Eight of ten large-volume abscesses (over 10 mL) were controlled with needle aspiration. Fourteen patients required multiple aspirations, five of whom had indwelling catheters placed to facilitate abscess decompression. These data confirm that needle aspiration is an effective means of controlling nonperitonsillar abscesses of the head and neck.     

Parapharyngeal and retropharyngeal infections in children: Argument for a trial of medical therapy and intraoral drainage for medical treatment failures

Objective

To review the outcomes of parapharyngeal infections (PPI) and retropharyngeal infections (RPI) in children after medical and surgical management.

Methods

The charts of all children who presented to a tertiary-care pediatric hospital between March 2005 and February 2007 with a diagnosis of parapharyngeal infection or retropharyngeal infection were reviewed. Thirty-two patient records were analyzed.

Results

The mean age of our patients was 4.4 years, 63% of whom were boys. The majority of patients presented during the winter months with some combination of fever, neck stiffness, and neck swelling. Ten patients had surgery less than 1 day after admission (early surgical intervention). Twenty-two patients were given a trial of at least 24 h of intravenous (IV) antibiotics (medical trial group), nine of whom were treated exclusively with IV antibiotics (medical therapy alone). The remaining 13 patients failed medical therapy, and went on to surgical drainage (late surgical intervention). All patients requiring surgical drainage were treated successfully with an intraoral approach. Patients given a trial of IV antibiotics had an average hospital stay of 3.3 days (3.0 days for medical therapy alone and 3.5 days for late surgical intervention). Patients with early surgical intervention stayed 2.7 days. All patients were discharged home with oral antibiotics. There was no statistically significant difference in the length of stay between the medical trial and early intervention groups. Those who failed medical therapy had significantly larger abscesses than those who responded to medical therapy (1.53 versus 5.38 cm²).

Conclusions

A trial of IV antibiotics does not adversely affect outcome and may obviate the need for surgery, particularly for patients with smaller abscesses. When surgery is required, an intraoral procedure is usually adequate.     

Peritonsillar abscess: a comparison of a conservative and a more aggressive management protocol

A two-year prospective study was undertaken to compare acute treatment modalities for peritonsillar abscesses. The most widely used modality, incision and drainage, with subsequent hospitalization for intravenous antibiotics and hydration, was compared with incision and drainage, with subsequent oral antibiotics and oral hydration. The results in 27 randomized patients showed no difference in morbidity, recovery time, or recurrence rate between the two groups. The authors conclude that initial incision and drainage, and oral antibiotics, is an effective, safe and less expensive treatment modality for peritonsillar abscesses. These results suggest that with a compliant patient population, peritonsillar abscesses may be effectively treated in an outpatient setting.     

Ultrasonography in the evaluation of neck abscesses in children

A prospective study evaluating the benefits of preoperative ultrasonography of paediatric neck abscesses is presented. Twenty-three consecutive children who presented with suspected neck abscesses to the Accident and Emergency Department at the Temple Street Children's Hospital between 1990 and 1992 have been evaluated prospectively. On admission, ultrasonography showed a collection of pus in 11 children and these underwent incision and drainage. The other 12 had intravenous antibiotics. Six of these remained pyrexial and had a repeat ultrasound after 72 h revealing pus which was drained. The remaining were managed successfully with medical treatment. In this study there were no negative surgical interventions and we recommend ultrasonography for preoperative evaluation of children with suspected inflammatory neck abscesses.     

Factors influencing palatoplasty and pharyngeal flap surgery

An experience of 154 patients undergoing palatoplasty or pharyngeal flap surgery at the University of California, Davis, Medical Center (Sacramento) was retrospectively analyzed. There were 114 palatoplasties, 37 pharyngeal flaps, and three combined palatoplasty and pharyngeal flap procedures performed. Factors that could affect postoperative airway compromise, as well as those thought to influence the number of days hospitalized postoperatively, were evaluated using a three-way analysis of covariance. Some degree of airway compromise occurred in 24 patients. The duration of mouth-gag usage strongly correlated with the incidence and severity of airway compromise. Neither steroids nor antibiotics decreased the incidence of respiratory compromise. However, steroids were associated with a decrease in number of days hospitalized (2.7 days vs 4.2 days). The use of intraoperative antibiotics was also associated with a shorter hospitalization (3.5 vs 4.0 days) and with fewer cases of postoperative fever. The high correlation between significant respiratory compromise and duration of mouth-gag usage, as well as clinical observations, suggest that airway compromise in these patients is due to edema of the tongue and related structures secondary to ischemia.     

Preoperative blood sugar and C‐reactive protein associated with persistent discharge after incision and drainage for patients with deep neck abscesses

Objectives: The aim of this study was to investigate whether preoperative C‐reactive protein (CRP) and blood sugar correlated with persistent discharge after incision and drainage for patients with deep neck abscesses. Study design: Retrospective data analysis. Setting: Tertiary referral centre. Participants: A total of 204 patients who underwent operation for deep neck abscess. Main outcome measures: Persistent discharge after operation. Results: One hundred seventy patients were included for final analyses. Most of the patients were male (n = 115; 68%) and the average age was 54 years. Using logistic regression analyses, age >55 years [odds ratio (OR): 3.053; P = 0.002], preoperative CRP >15 mg/dL (OR: 2.174; P = 0.027), and preoperative blood sugar >8.3 mmol/L (OR: 3.280; P = 0.001) were independent factors correlated with persistent discharge. Conclusions: Older age, elevated preoperative CRP level and blood sugar had a statistically significant association with persistent discharge after operation in deep neck abscesses patients.     

Neck masses confined to the submental space: our experience with 24 cases

We conducted a study to identify the clinical and histopathologic features of masses confined to the submental space and to outline an approach to the diagnosis and treatment of these lesions. Our study population was made up of 24 patients-17 males and 7 females, aged 13 to 68 years (mean: 45.88 ± 8.48)-who had undergone surgery at our tertiary care center for the treatment of masses of the submental triangle. Our findings were based on a retrospective review of demographic data, signs and symptoms, diagnostic and therapeutic methods, histopathologic outcomes, and recurrences. Fine-needle aspiration biopsy and ultrasonography were performed on all patients as standard diagnostic procedures. Surgical excision was the mainstay of treatment, although abscesses were treated with local drainage and systemic antibiotics. Histopathology identified a wide variety of entities, including reactive lymphoid hyperplasia (n = 12), non-Hodgkin lymphoma (n = 3), dermoid cyst (n = 3), abscess (n = 3), sarcoidosis (n = 1), hemangioma (n = 1), and lipoma (n = 1). The clinical picture was complicated by dental problems in 9 patients and by cheilitis in 2. During a follow-up of up to 74 months, no local recurrences were detected. We conclude that lesions of the submental space are most likely to occur secondary to local and benign pathologies of the head and neck. However, malignancies or systemic diseases must also be ruled out. Careful assessment of the oral cavity and nose is important, and treatment must be based on the underlying etiology.     

Increased isolation of methicillin-resistant Staphylococcus aureus in pediatric head and neck abscesses

OBJECTIVE: To compare the proportion of community-associated, methicillin-resistant Staphylococcus aureus (MRSA) infections in pediatric head and neck abscesses between 2 study periods. DESIGN: Retrospective case review. SETTING: Tertiary care pediatric otolaryngology practice. Patients Pediatric patients with head and neck abscesses presenting over 2 separate 2.5-year intervals: July 1999 through December 2001 and January 2002 through June 2004. INTERVENTIONS: Incision and drainage of abscess. MAIN OUTCOME MEASURES: Type and antimicrobial susceptibility of cultured organisms. RESULTS: We identified 21 abscesses in 19 patients from July 1999 through December 2001 and 32 abscesses in 32 patients from January 2002 through June 2004. Of the 21 abscesses in the first study period, 15 demonstrated pathogen growth compared with 29 of 32 abscesses in the second study period. In the first period, 6 (40%) of 15 abscesses yielded S aureus compared with 17 (58.6%) of 29 abscesses in the second period. The proportion of abscesses yielding MRSA increased from 0% (0/6) in the first study period to 64.7% (11/17) in the second study period (P<.01). All MRSA infections were considered to be community acquired. CONCLUSIONS: Our study demonstrates a statistically significant rise in the proportion of community-associated MRSA infections of the head and neck in the pediatric population at our institution. For communities where similar microbial recovery patterns exist, we suggest that a culture be obtained as soon as possible in a child presenting with a head and neck abscess to identify the organism. Until that time, the best empirical treatment is clindamycin, with other agents available if warranted by culture and sensitivity results. A treatment algorithm is presented.     

Drenaje percutáneo ecoguiado vs. drenaje quirúrgico en abscesos cervicales profundos de origen odontógeno. Ensayo clínico controlado y aleatorizado

IntroductionThe most common cause of deep neck infections is dental infection. They are diagnosed with physical examination, imaging studies, ultrasound, or computed tomography. Surgical drainage of collections should always be performed early in a classical or percutaneous way, depending on the case. The aim of the study was to compare ultrasound-guided percutaneous drainage techniques vs. surgical drainage in deep cervical abscesses of odontogenic origin in a controlled and randomized trial.MethodsA randomized controlled clinical trial was performed from January 2015 to December 2019. Hospital stay was evaluated as an efficiency variable. Epidemiological and secondary variable data (tumour, trismus, fever, pain), leukocytosis, cosmetic result comparing both techniques were analysed. Statistical analysis was carried out with STATA v 14.0.Results128 patients were analysed, 51 women and 77 men. Average age 27.3 (SD = 10.13). The percutaneous group had a mean hospital stay of 3.03 (SD = 2.86) days and the surgical group 5.46 (SD = 2.96). The p-value was <.001. Cosmetic results showed differences favouring the percutaneous drainage group. None of the other variables showed statistically significant results.DiscussionSurgical treatment (cervicotomy and debridement) should be undertaken early with evidence of extensive collection in deep spaces. Minimally invasive image-guided procedures are an alternative. These can be performed in well-located, unilocular collections, without compromising of the patient's airway. Percutaneous drainage and suction techniques if necessary, serially, or drainage placement may be performed.ConclusionsUltrasound-guided and serially guided percutaneous drainage is the best therapeutic option in patients with mild and/or moderate dental infections.     

Ultrasound-guided percutaneous drainage of deep neck abscesses

Deep neck abscesses may still result in significant morbidity and mortality. Surgical therapy carries the risk of damage to cranial nerves and arteries. Excellent results of ultrasound-guided percutaneous catheter drainage of abdominal abscesses led us to apply this technique to the management of deep neck abscesses. Five patients were treated with ultrasound-guided catheter drainage and antibiotics. All patients were cured without complications or recurrences. We consider this cheap and highly effective treatment as a valuable alternative to conventional therapy.     

Postsurgical prevertebral abscess of the cervical spine

OBJECTIVES: Prevertebral abscess formation is an uncommon occurrence following cervical spine fusion surgery. Abscesses may present early or in a delayed fashion and require surgical drainage and long-term antibiotic treatment. The issues of osteomyelitis and the need for plate removal remain unresolved. STUDY DESIGN: A case series of six tetraplegic patients admitted for rehabilitation to the Chaim Sheba Medical Center (Tel Hashomer, Israel) is presented. METHODS: Five patients were trauma patients; one patient underwent repeated procedures and irradiation for tumor of the cervical spine. All patients developed prevertebral abscesses after a mean period of 30 days from their fusion surgery. Computed tomography scan was used in all patients to establish the diagnosis and define the extent of the infective process. All patients underwent one or more drainage procedures. The plate was removed in two patients at 1 and 4 months. RESULTS: Infection completely resolved in four patient and was refractory in one patient with malignant tumor, and a chronic small fistula remained in one case. Staphylococcus aureus was the main infective organism, but mixed infections were the rule. Even for a protracted course of infection, no significant osteomyelitis was encountered. CONCLUSIONS: Abscess formation after instrumentation of the neck may be more common than formerly recognized. Despite the prolonged course of disease and treatment, osteomyelitis is not a major concern. There is no automatic indication for plate removal to control infection, although plating may be safely removed after 10 to 12 weeks if the neck is explored and the cervical spine is stable. A high index of suspicion is warranted, and early recognition and diagnosis, prompt surgical drainage under general anesthesia, and long-term antibiotic treatment are key for eradication of the infective process. Prophylactic antibiotics may be of value. Meticulous antisepsis and surgical technique should be maintained to reduce the incidence of these severe complications.     

颈深部间隙脓肿临床危险因素分析

目的 探讨颈深部间隙脓肿可能增加手术治疗风险及增加药物治疗失败风险的临床危险因素.方法 回顾性分析2009年1月~2016年6月颈深部间隙脓肿患者111例,采用Logistic回归模型筛选危险因素.结果 所有患者均经药物治疗和(或)手术治疗痊愈.在α=0.05的水准,呼吸困难是增加手术治疗风险的临床危险因素(β=3.001,OR=20.099);脓肿最大直径>2.0 cm是增加手术治疗风险和药物治疗失败风险的临床危险因素(β=2.396,OR=10.979;β=4.618,OR=101.313).年龄、性别、白细胞计数、发热、糖尿病、颈部肿胀及多间隙感染不会增加手术治疗的风险.结论 对于存在呼吸困难及脓肿最大直径>2.0 cm的颈深部间隙脓肿患者应积极术前准备,尽早手术干预;而无呼吸困难及脓肿最大直径≤2.0 cm的患者,在经足量有效抗生素治疗及严密监护下,往往能避免手术切开引流.     

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.