Use of intraoperative ultrasound for localizing difficult parapharyngeal space abscesses in children

While treatment of parapharyngeal and deep-space neck abscesses has progressed rapidly due to improvements in diagnostic imaging and medical therapy, surgical drainage remains the mainstay of treatment for larger and medically unresponsive abscesses. In many cases the intricate and delicate anatomy in children represents a challenging situation for the surgeon, particularly if he or she is not experienced in the care of the pediatric population. We present a novel idea used in the surgical management of parapharyngeal space abscesses in three children less that 6 years of age, in whom intraoperative ultrasound was used as an additional tool to locate and successfully drain the abscess.     

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.     

Bilateral peritonsillar abscesses

In the discussion about the management of the peritonsillar abscess (PTA) in regard to the pros and cons of tonsillectomy à chaud versus à froid, the risk of obscure contralateral abscesses is often neglected. To the authors knowledge, there are only a few series of PTA being analyzed for the abscess rate of bilateral PTA. A group of 541 abscess tonsillectomies was retrospectively analyzed for the presence of a bilateral manifestation of peritonsillar abscess. Twenty-one patients (3.88%) had bilateral abscesses. None of these had been detected prior to the operation. Of the 541 patients, 2.22% had postoperative hemorrhages that had to be arrested under general anesthesia. Within the discussion about abscess tonsillectomy versus stab incision followed by interval tonsillectomy (à froid), the rate of almost 4% bilateral abscesses should be taken into consideration as dangerous complications such as mediastinitis could develop from the remaining abscess formation of the contralateral side.     

小儿急性咽后脓肿的诊断与治疗

目的总结小儿急性咽后脓肿的诊治体会。方法回顾性分析8例小儿急性咽后脓肿患者的临床表现及治疗经过。结果5例首诊儿科并延误诊断。5例进行了颈部影像学检查,诊断准确率为100%。8例中6例经口内脓肿切开引流治愈;2例脓肿突然破裂,1例抢救后治愈,1例因全身感染中毒症状重而死亡。结论小儿急性咽后脓肿易被误诊,影像学检查有助提高诊断准确率,脓肿切开引流是最直接有效的治疗手段,倒提患儿是脓肿突然破裂时实用有效的急救措施。对于全身感染中毒症状较重的患儿,应及早行对症治疗。     

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.     

Spontaneous MRSA postcricoid abscess: A case report and literature review

Laryngeal abscesses are rare but potentially life‐threatening infections due to potential airway obstruction. Most abscesses occur in the epiglottis or preepiglottic space as a sequela of acute supraglottitis. Abscesses in the posterior larynx are extremely rare and typically due to instrumentation or trauma. Appropriate workup and management of the airway are essential for optimizing outcomes in these patients. We present an interesting case and our management of a spontaneous posterior laryngeal abscess due to methicillin‐resistant Staphlococcus aureus. Laryngoscope, 124:2583–2585, 2014     

The usefulness of abscess tonsillectomy followed by intraoral drainage for parapharyngeal abscess concomitant with peritonsillar abscess in the elderly

Parapharyngeal abscess (PPA) may cause life-threatening complications and peritonsillar abscess (PTA) and tonsillitis frequently precede PPA. The optimal management of PPA caused by PTA has been the subject of debate with respect to the surgical approach. We present three cases of PPA concomitant with PTA in elderly patients. In two cases, the abscesses in parapharyngeal space were drained by abscess tonsillectomy followed by intraoral incision of the tonsillar bed. On the other hand, the third case did not undergo abscess tonsillectomy because of his refusal of surgery and needed extraoral drainage after the aggravation of PPA. Based on the experience of those three cases, it was suggested that abscess tonsillectomy followed by intraoral incision of the tonsillar bed might be a useful surgical approach for the drainage of PPA concomitant with PTA, especially in elderly patients.     

Intracranial abscesses associated with chronic suppurative otitis media

Intracranial abscesses are serious complications of chronic suppurative otitis media (COM). This study included 32 patients presenting with intracranial abscesses from 780 patients hospitalized for treatment of COM. The 32 patients had 59 intracranial complications. Perisinus abscess (13 of 32) was the most common intracranial abscess, followed by temporal lobe abscess (8 of 32), epidural abscess (7 of 32), cerebellar abscess (6 of 32) and subdural empyema (2 of 32). Headache (93%), fever (87%) and altered mental status (62%) were the most common presenting symptoms and signs, along with symptoms of COM. All patients were treated with intravenous antibiotics and canal wall down mastoidectomy. Cholesteatoma with granulation tissue and bony defects at the sinus plate and/or dural plate were seen in most of the patients. Gram negative bacilli and anaerobes were the most common organisms cultured from the abscesses. Three patients had neurological sequels. One patient died. The early diagnosis of these complications requires a high index of suspicion and imaging studies. A multidisciplinary and coordinated approach is important for the management of these patients.The authors did not receive any financial support for the present study.     

Transtonsillar drainage of parapharyngeal abscess

We report a parapharyngeal abscess in an adult patient that was drained transorally by performing ipsilateral tonsillectomy and aspirating the pus through the tonsillar bed. This approach is unusual as most previous studies report the aspiration of such abscesses through the lateral pharyngeal mucosa. In addition, the majority of these studies are limited to pediatric cases. Our approach was effective and resulted in a rapid resolution of the symptoms. The management and different approaches to parapharyngeal abscess are discussed, and the literature is reviewed.     

耳源性脑脓肿105例临床分析

目的 本文的目的为探讨耳源性脑脓肿的发生、诊断和治疗。方法 对1952～2002年治疗的105例耳源性脑脓肿患者(颞叶66例,小脑38例),对疾病的发生、诊断和治疗方式进行回顾性分析,特别是手术所见、诊断方法、治疗方法和结果。结果本组中发病年龄主要在10～30岁,10岁以内和更高的年龄组较少见。头痛(99.05％)、淡漠和昏迷(91.43％)是较常见的症状。105例中神经系统检查异常者78例。23例经CT诊断。经乳突腔穿刺抽脓者63例,外科钻颅穿刺抽脓26例,脓肿切除17例。死亡15例,其中66例颞叶脓肿中11例死亡,38例小脑脓肿中3例,脓肿部位不明者1例。结论 正确掌握经乳突腔穿刺抽脓的适应证对耳源性脑脓肿的治疗十分重要。颅骨钻孔穿刺引流和脑室引流是脑疝的有效的紧急处理措施。自CT用于耳源性脑脓肿的诊断和随访以来,死亡率明显下降。     

Airway foreign bodies and brain abscesses: report of two cases and review of the literature

We report two cases of intracranial abscess in pediatric patients secondary to aspirated foreign bodies. Although foreign bodies are a significant cause of morbidity and mortality in the pediatric population, only four previous cases have been reported that resulted in a brain abscess. Our patients presented with neurological symptoms, and both were found to have a sharp foreign body in the bronchus. Both had brain abscesses caused by bacteria that normally colonize the aerodigestive tract with no other source of bacterial foci. When respiratory flora are isolated from brain abscesses in the absence of other possible sources, intrabronchial foreign body should be considered in evaluation of the etiology.     

Retropharyngeal and parapharyngeal abscesses or phlegmons in children. Is there an association with adenotonsillectomy?

BACKGROUND: Retropharyngeal and parapharyngeal abscesses or phlegmons are relatively uncommon. Since the tonsils and adenoids are part of the lymphoid tissues of the nasopharynx and oral cavity, one may hypothesize that their removal would lead to an increased susceptibility to pharyngeal infections. OBJECTIVE: Determine whether there is an association with a history of adenotonsillectomy and the development of retro- and parapharyngeal abscesses/phlegmons. METHODS: A case-control study was performed. The charts of 180 children admitted to a tertiary care pediatric hospital between 1996 and 2006 were reviewed. The patients were age-matched to 180 children having visited the emergency department of the same hospital. The charts of these children were reviewed and used as controls. RESULTS: 13.9% of children admitted with a retro- or parapharyngeal abscess or phlegmon had previously undergone an adenotonsillectomy as compared to only 2.2% of children in the control group. The calculated odds ratio was 7.10 (95% CI [2.52-19.93], p<0.001). CONCLUSION: In conclusion, the development of a retropharyngeal or parapharyngeal abscess or phlegmon is strongly associated with a history of adenotonsillectomy.     

Clinical characteristics for conservative therapy of pediatric parapharyngeal abscesses

IntroductionThe role of surgical drainage versus conservative therapy in treating patients with parapharyngeal abscesses is still a theme of debate.ObjectivesThis study aimed to investigate the characteristics associated with good outcomes in pediatric patients with parapharyngeal abscesses treated with conservative therapy.MethodsThis retrospective chart review was performed on children aged 0.3–14 years with the diagnosis of parapharyngeal abscesses confirmed by computed tomography from January 2013 to March 2018. Patients with a severe upper airway obstruction required early intervention, while those in a stable condition initially received conservative therapy with antibiotics. If the patients appeared unlikely to recover, additional surgical drainage was provided. Multivariate logistic regression models were constructed to investigate the clinical characteristics associated with a good response to conservative therapy. A receiver operating characteristic curve was used to identify the age and abscess size cutoff for predicting a successful response.ResultsA total of 48 children were included in the study. Patient age, antecedent illness, and abscess size were significantly associated with a response to therapy (Odds Ratio = 1.326, 2.314 and 1.235, respectively). The age cutoff associated with the conservative therapy was 4.2 years (76.9% sensitivity, 68.2% specificity), and the abscess size cutoff associated with the conservative therapy was 23 mm (84.6% sensitivity, 77.3% specificity).ConclusionThe findings suggested that younger age, smaller abscess size, and less frequent antecedent illnesses, such as upper respiratory tract infection and lymphadenitis, could predict a successful response to conservative therapy in pediatric patients with parapharyngeal abscesses.     

Deep neck abscess in neonatal period: Case report and review of literature

Deep neck abscess is very rare in neonatal period. We reported a deep neck abscess caused by methicillin-sensitive Staphylococcus aureus infection (MSSA) in a neonate. A 10-day male infant was admitted to our neonatal unit with the complaints of fever, irritability, and refused to food intake. Ultrasonography and magnetic resonance imaging revealed as an abscess in the neck. Needle aspiration from abscess revealed pus. Antibiotics and drainage were applied. We also reviewed the neonatal deep neck abscess reported in English literature and clinical presentation, risk factors, causing microorganisms, treatment, complication and outcome of deep neck abscesses were discussed.     

Benefits of ultrasound vs. computed tomography in the diagnosis of pediatric lateral neck abscesses

Objective

There are no studies comparing the accuracy of ultrasound and computed tomography in the same population of pediatric patients with lateral neck abscesses. This case series assesses the accuracy of the two imaging techniques.

Methods

One hundred and forty imaging studies (ultrasound n = 39 or CT n = 101) that were performed from 2005 to 2011 prior to incision and drainage of a lateral neck mass at a tertiary care academic institution were retrospectively reviewed. All children 0–18 years of age with lateral neck abscesses who underwent CT or ultrasound imaging prior to drainage were included. Sensitivity, specificity, and positive and negative predictive values of ultrasound and CT were determined as compared to the gold standard, incision and drainage of the suspected abscess.

Results

In children undergoing incision and drainage, the prevalence of an abscess was 89%. Ultrasound has a high specificity (100%) but a low sensitivity (53%). The positive predictive value (96%) is high while the negative predictive value is low (16%), assuming a positive abscess prevalence of 0.9. In contrast, CT has low specificity (18%) but slightly higher sensitivity (68%) compared to ultrasound. Similar to ultrasound, CT had low negative (6%) and high positive (88%) predictive values.

Conclusions

This study demonstrates that ultrasound may be an equivalently sensitive and more specific diagnostic tool when compared to CT in the work-up of lateral neck abscesses in children. It is safe and effective in diagnosis when there is an undetermined probability of an abscess.     

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.     

Absceso retrofaríngeo. Revisión clínica de veinticinco años

IntroductionRetropharyngeal abscess is a serious condition. Its rare occurrence, thus sharing symptoms with other processes, make it a diagnostic challenge for the clinician. Therefore, it is critical to make an early diagnosis to prevent delaying treatment and avoid complications.ObjectivesTo gain knowledge of the epidemiology, pathogenesis, clinical manifestations, the most commonly implicated microorganisms, the type of treatment used, morbidity and mortality of retropharyngeal abscesses at a tertiary institution over the last 25 years.MethodsA retrospective study was conducted by reviewing medical records of all patients diagnosed with retropharyngeal abscess in a single centre between 1 January 1990 and 31 February 2016. Thirty-three patients were included in our study. Data such as personal history, present illness, diagnoses and treatment procedures were collected from the medical records.ResultsThe incidence during the years of study was 0.2 cases/100 000 inhabitants/year. Personal medical histories most often associated were alcoholism, smoking, diabetes and obesity. The most common aetiology found was impaction of a foreign body (especially fishbone). The most common presenting symptoms were odynophagia and neck pain accompanied by fever. Preventive tracheotomy was performed in the initial management of the patient in 9 cases (27%). The most frequent complication was descending necrotizing mediastinitis. Surgical drainage of the abscess was required in 27 patients (82%), especially with external approaches (17 cases). Two patients had sequelae: paralysis of unilateral vocal cord and Horner's syndrome. No mortality was observed in the patients of the study.ConclusionRetropharyngeal abscesses must be considered medical-surgical emergencies as they are likely to produce serious complications. We must pay attention to the warning symptoms such as odynophagia and cervical pain, associated or otherwise with dyspnoea, stridor, trismus, and neck stiffness. Advances in diagnostic and therapeutic procedures together with advances in critical care have been a key factor in improving the prognosis and mortality of these patients.     

Drainage of retro-parapharyngeal abscess: an additional indication for endoscopic sinus surgery

Deep neck abscesses are life-threatening conditions, in early stages preferably treated by intravenous antibiotic therapy; in advanced stages, surgical drainage is mandatory. We report two cases of retro-parapharyngeal abscess with prevalent retronasopharyngeal extension in two men aged 60 and 82, both of whom underwent transnasal endoscopic drainage. The main surgical steps were incision of the posterior pharyngeal mucosal wall, widening of the incision, drainage of purulent collection and careful dissection and removal of the necrotic tissue. The first patient, with an abscess associated with chronic otitis media and presenting hypoglossal nerve palsy, quickly recovered from pharyngodinia, otalgia and trismus. Twenty-six months after surgery, he is symptom-free, with hemitongue atrophy due to denervation as the only residual sign. The second patient, affected by skull base osteomyelitis secondary to malignant external otitis, after a first successful drainage, underwent a second endoscopic procedure for the reoccurrence of an abscess in the contralateral retroparapharyngeal space. Twelve months after the first surgery, the patient reported an improvement of symptoms, except for persistent dysphonia related to vagal nerve palsy. At follow-up MR, another abscess was detected in the left retro-parapharyngeal space. In selected cases of abscess, transnasal endoscopic drainage may be an effective alternative to external approaches. Minimal morbidity, the absence of cervical or palatal scars and a short hospitalization time can be considered as important advantages in comparison to external approaches. Patients with abscess secondary to skull base osteomyelitis require close imaging surveillance because of the difficulty of definitive control of the disease.     

Potential role of biofilms in deep cervical abscess

Objectives

Deep neck abscesses are complex head & neck problems that can lead to significant complications including life threatening infections. It is understood that the pathology of these infections is primarily polymicrobial. Although broad spectrum antibiotics can be effective for small abscesses, larger abscesses can be recalcitrant and difficult to treat with antibiotics. It has been demonstrated for several infectious diseases, including some of head & neck, that biofilm phenotypes present a unique model for recurrence and chronicity of infectious diseases. It is suspected that biofilm phenotypes could play a crucial role in the recalcitrance of large deep neck abscesses. This study presents initial evidence indicating the presence of polymicrobial biofilms in deep neck space infections.

Methods

Fourteen samples obtained via biopsy of abscess walls from deep neck spaces of patients undergoing surgical drainage. Eight patients were male and 6 were female. All but one patient were pediatric with ages ranging from 18 months to 32 years. All samples were processed and analyzed with scanning electron microscopy.

Results

Electron micrographs of 12 out of 14 specimens showed discrete biofilm architecture with individual bacteria, both rods and cocci, embedded within the matrix. This was starkly different from tissue surfaces devoid of biofilms.

Conclusions

This initial evidence suggests that biofilm phenotypes could play a role in the pathogenesis and recalcitrance of deep neck infections, particularly in larger abscesses.     

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.