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。     

A sterile acute retropharyngeal abscess

A 12-year-old male admitted to ENT ward on an emergency basis with history of foreign body in throat. It came out along with induced vomiting, followed by fever, Odynophagia and restricted Neck movements. It is proved as a case of acute retropharyngeal abscess. But it turned out to be the sterile abscess, which is rare and new thing for us. Hence presented herewith-brief review of literature.     

Retropharyngeal abscess: recent trends

Retropharyngeal abscess (RPA) is relatively rare today. A study of 17 cases of RPA treated at our hospital in the past 10 years showed a shift in the disease from children below 6 years of age (41%) to older children and adults (58%). Upper respiratory tract infection (URTI) was found to be the commonest (52%) aetiological predisposing factor in all age groups. Other aetiological factors were septicaemia (11%) in children below the age of 6 years and trauma due to foreign body (35%) in the older children and adult age groups. Klebsiella, Staphylococcus and Streptococcus were the commonest species of microorganisms grown from pus. The changing clinical trends, microbiology, choice of antibiotics, usefulness of radiology, and complications of this potentially fatal illness are discussed.     

咽后脓肿14例临床回顾

目的：探讨咽后脓肿的临床特点,提高对该病的诊治水平。方法：直接喉镜引导下经口行咽后脓肿切开引流术,术后辅以全身抗炎治疗。结果：13例痊愈,1例放弃治疗,自动出院,无严重并发症发生。结论：对咽后脓肿应做到早期诊断。全身应用有效抗生素,及时切开引流,以提高治愈率,减少并发症的出现。     

颈深部脓肿50例临床分析

目的探讨颈深部脓肿患者的临床表现、微生物学、影像学及治疗经验。方法对1997年1月—2002年12月收治的50例颈深部脓肿患者的临床资料进行了回顾性分析。结果颈深部脓肿的感染来源有：牙源性3例，急性化脓性扁桃体炎及喉炎8例，上呼吸道感染9例，咽喉及食道异物14例，糖尿病伴感染5例，不明原因11例。50例中21例作了脓液细菌培养，其中13例(64％)为阳性。通过采用脓肿切开引流术，经颈一纵隔引流术，大剂量抗生素等综合治疗，50例中治愈46例(92％)，死亡4例(8％)。死亡原因：2例为咽旁脓肿致颈部大血管破裂出血死亡，1例食道周围脓肿伴消化道大出血死亡，1例咽旁脓肿合并糖尿病中毒性休克死亡。结论颈深部脓肿一经确诊，应及时引流，合理应用抗生素，有效控制其他伴发病。重视对严重并发症的认识及处理，以提高治愈率。     

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.     

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.     

Intraoperative hypotension associated with massive deep space neck abscesses in a 9-month old: A case report

The neck is divided into multiple compartments by cervical fasciae. The deep space compartments, which all have a potential for becoming infected, are interconnected, providing a mechanism for the spread of infections. Thus, infections of the deep spaces can lead to devastating consequences, especially when there is extension to the mediastinum. Here we report a case of intraoperative hypotension in a 9-month-old child with extensive bilateral parapharyngeal and retropharyngeal abscesses with mediastinal extension with a focus on when hemodynamic monitoring should be considered.     

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.     

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.     

Possible role of anti-inflammatory drugs in complications of pharyngitis. A retrospective analysis of 163 cases

ObjectivesComplications of pharyngitis (peritonsillar abscess, retropharyngeal abscess, and cervical cellulitis) are rare, but appear to be on the increase over recent years and many of these patients have been treated by anti-inflammatory drugs prior to admission. The purpose of this study was to review the current epidemiological data concerning these complications and investigate a possible correlation with anti-inflammatory drug use.Material and methodsA single-centre retrospective review of epidemiological, clinical and microbiological data was performed on the medical charts of patients hospitalised for peritonsillar abscess, retropharyngeal abscess or cervical cellulitis between 2005 and 2010.ResultsOver a six-year period, 163 patients were hospitalised for complications of pharyngitis, with a sex-ratio of 1.82 (104/57). The number of cases of peritonsillar abscess (PTA) increased from 13 to 28 cases per year from 2005 to 2010 and the number of cases of retropharyngeal abscess increased from three to six cases per year over the same period. The number of cases of cellulitis remained stable with an average of 1.82 cases per year. Each year, significantly more patients with an abscess were admitted to our unit with a history of anti-inflammatory drug use (13.3 ± 4.6) than without anti-inflammatory drug use (7.8 ± 4.3) (P < 0.01). Micro-organisms were identified in 80% of cases, with mixed strains in 73% of cases, Streptococcus in 72% of samples and Streptococcus pyogenes in 19% of cases of PTA. A favourable outcome was observed in all patients in response to medical and surgical treatment.ConclusionIn line with the literature, we observed an increasing incidence of complications of pharyngitis. The present series comprised significantly more patients admitted for PTA with a history of anti-inflammatory drug use. A multicentre prospective controlled study in Nantes on a large cohort is currently underway and will probably confirm these preliminary results.     

Pediatric retropharyngeal abscesses: a national perspective

OBJECTIVES: To determine the resource utilization and national variation in the management of pediatric retropharyngeal abscesses. METHODS: The Kids' Inpatient Database (KID) 2003 was analyzed. International Classification of Diseases, Ninth Revision code 478.24 was the inclusion criteria. RESULTS: One thousand three hundred and twenty-one admissions with retropharyngeal abscess were sampled from the KID in 2003; there were no deaths. The mean age of patients was 5.1 years (S.D. 4.4 years); 63% were male. Of all admissions, 563 (43%) patients underwent surgical drainage of their infection; surgical patients had longer length of stays and total charges than patients managed medically. The average state spending per admission varied from $5126 (Utah) to $27,776 (California). There was seasonal variation in admissions with the highest percentage of admissions occurring in March (10.7%) and lowest in August (3.8%). Indicators of increased resource utilization included age (older patients), increased length of stay, non-elective admission, discharge quarter, and number of other diagnoses on record. There is a statistically significant decrease in the length of stay and total charges in patients admitted in the Midwest compared to other regions of the country. CONCLUSIONS: This study demonstrates national demographics and normative data on a commonly treated pediatric disease process, retropharyngeal space infections. The average demographic of such a patient is a 5-year-old male from an urban location admitted in a non-elective fashion via the emergency department. The mean total charges were $16,377; 90% of admissions had total charges less than $28,511. Patients who underwent surgical procedures had mean total charges of $22,013. There exists significant national variation in resource utilization for this commonly treated disease process.     

Indicators of a more complicated clinical course for pediatric patients with retropharyngeal abscess

Objective

Determine clinical signs or symptoms associated with a more complicated clinical course in patients with retropharyngeal abscesses (RPAs).

Design

Retrospective chart review at a tertiary care level Children's hospital.Main Outcome Measures Age, presenting signs and symptoms, laboratory tests, imaging results, antibiotic therapy, surgical approach, pathogens isolated, and duration of hospitalization were evaluated to determine any factors associated with a more complicated clinical course (CCC).

Results

Fifteen of one hundred thirty pediatric patients with RPA were identified with a complicated clinical course (CCC). Eight of the fifteen required more than one procedure before the abscess resolved. Patients with multiple abscess sites had a statistically significantly greater chance of requiring multiple procedures to clear the infections (p < 0.001). Another seven presented with airway obstruction requiring an admission into the Pediatric Intensive Care (PICU) and/or intubation. All the patients requiring admission to the PICU presented with signs or symptoms of airway obstruction compared to ten of the one hundred fifteen patients (8.7%) with a smooth clinical course (SCC) (p < 0.001). Five patients from the CCC group required a bronchoscopy to secure the airway; seven patients required intubation following incision and drainage of the abscess for an average of 5 ± 3 days. There was no statistically significant difference between the two groups with respect to pathogens isolated, or antibiotics used.

Conclusion

Our study suggests that patients with a CCC are more likely to present with airway obstruction or multiple abscess sites than patients with SCC.     

Deep-neck space infections — a diagnostic dilemma!

Deep Neck Space Infections (DNI) are a potentially life threatening condition. This paper highlights the importance of their early diagnosis and early intervention. The deep-neck space infections may be odontogenic in origin. The severe airway compromise caused by them may make diagnosis difficult. Suspicion of simultaneous occurrence of tetanus and retropharyngeal space infection in a child can further increase the dilemma.     

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.     

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.