Deep neck abscesses--changing trends

Is conservative treatment of deep neck space infections appropriate?

BACKGROUND

A 31-patient prospective series on deep neck infections, managed at Hospital Ramón y Cajal in Madrid, Spain, is presented.

METHODS

A prospective study was conducted from January 1994 to December 1997, including all parapharyngeal or retropharyngeal infections. Clinical and radiologic findings and length of stay in the hospital were registered. Medical treatment was instituted with broad-spectrum antibiotics, and surgery was reserved for those patients not responding to medical treatment.

RESULTS

Twenty-four patients (77.42%) had parapharyngeal, 3 (9.68%) retropharyngeal and 4 (12.90%) mixed infections. On the basis of clinical and CT findings, 19 cases (61.29%) were considered abscesses and 12 (38.71%) cellulitis. Medical treatment was successful in all but 3 cases (90.32%), with no major complications. All the patients were discharged from the hospital within 20 days after admission (mean, 8.09 days).

CONCLUSIONS

Despite the wide use of antibiotics, deep neck space infections are commonly seen. Although most reports are based on surgical treatment followed by antibiotics, medical treatment could be as successful as open surgical drainage in most cases.

Ludwig's angina in the pediatric population: report of a case and review of the literature

Ludwig's angina is a rapidly progressing cellulitis involving the submandibular neck space. It is characterized by brawny induration of the submental region and floor of mouth, bearing the potential for rapid airway obstruction. Airway management, antibiotics, and judicious surgical intervention are the mainstays of successful therapy. We present a case of Ludwig's angina in a 5-year-old child and offer a meta-analysis of pediatric cases of Ludwig's angina described in the literature over the past 30 years. The presentation, etiology, management, and potential complications of this disorder in the pediatric population are discussed.

Retropharyngeal abscess management in children: current practices

Retropharyngeal abscesses (RAs) in children are uncommon in the modern antibiotic era. As a result, there are few large series outlining the management of these infections in contemporary literature. The goal of this study is to determine the current standard of care for RA. The membership of the American Society of Pediatric Otolaryngology was surveyed, and the response rate was 77.5%. Seventy-two percent of practitioners reported that CT is their preferred diagnostic method. Nearly two thirds recommended a trial of intravenous antibiotics at least occasionally for suspected RA before operative drainage was considered; 51% of respondents indicated that 20% to 40% of RA may resolve with antibiotics alone. Intraoral incision and drainage is the surgical technique preferred by 83% of respondents. Tracheotomy and short-term intubation (24 to 72 hours) are rarely required. This study defines current management practices for RA in children among pediatric otolaryngologists. Results are compared with those in the existing literature.

Limitations of imaging for foreign bodies in parapharyngeal abscess and the importance of surgical exploration

A rare cause of parapharyngeal abscess in association with a wooden skewer is presented. Despite the use of both ultrasound and computed tomography (CT) scanning as diagnostic tools, the foreign body could not be identified. Only through a meticulous exploration of the neck was the foreign body located. The importance of surgical exploration even with negative imaging is discussed.

Neck abscess: an unusual presentation of a thoracic malignancy

In general, malignancies presenting as abscesses are uncommon. We report on a patient that presented with a neck abscess originating in a cluster of metastatic lymph nodes from a primary squamous cell carcinoma arising in the thoracic oesophagus.

Retropharyngeal and epidural abscess from a swallowed fish bone

Retropharyngeal abscess is not uncommon, but the incidence of epidural extension of a retropharyngeal abscess is very rare. Intraspinal involvement of the deep neck infection should be suspected if the patient has neurologic deficits. Emergent surgical drainage and aggressive antibiotic treatment are necessary. The outcome is strongly associated with the level of neurologic function at the time of diagnosis. Contrast-enhanced computed tomography is an excellent diagnostic method for any deep neck infection. A case is presented in which a perforating pharyngeal foreign body (fish bone) induced a retropharyngeal and epidural abscess. The literature is reviewed to improve the early recognition and treatment of this complication of deep neck infection.

Lateral neck abscess caused by Streptococcus bovis in a patient with undiagnosed colon cancer

Bacteraemia or endocarditis caused by Streptococcus bovis, a non-enterococcal group D streptococcus, is a very common finding in patients suffering from intestinal tumours or other colon diseases. A case of a patient with a laternal neck abscess caused by S. bovis is reported. During the treatment the patient was found to have colonic malignant lesions. The problems in the appropriate diagnosis and the possible correlation between these two clinical entities are presented and discussed.

Parapharyngeal abscess: a rare complication of elective tonsillectomy

We report a case of parapharyngeal abscess complicating an elective tonsillectomy in a healthy thirty-three-year-old woman. The clinical features and management of this very rare complication are discussed. In addition, we review the possible aetiology and pathogenesis of this potentially life-threatening condition.

A rare case of Salmonella neck abscess

A case of a deep neck abscess caused by Salmonella enteritidis in a 29-year-old previously undiagnosed diabetic patient is reported. Review of relevant literature has shown 11 cases of Salmonella neck abscess. Predisposing conditions include immunosuppression due to any cause. Salmonella sp. should be included in the differential diagnosis of head and neck abscesses in predisposed individuals and treated accordingly.

Characterization and management of deep neck infections

A retrospective review was conducted of 91 patients with deep neck infections to determine the pattern of clinical disease and formulate a management plan. The spaces involved, as determined by clinical, radiologic, and operative findings, were the peritonsillar space (72 patients), parapharyngeal space (eight patients) submandibular space (seven patients), retropharyngeal space (one patient) superficial space (one patient), anterior visceral space (one patient), and visceral vascular space (one patient). Of the 19 patients who did not have a peritonsillar space infection the origin of the infection was found in eight; four of these were odontogenic. Thirty-eight patients required surgical drainage of the abscess. Five patients underwent tracheotomy due to increasing dyspnea. One patient with diabetes mellitus and a past history of myocardial infarction died of unknown cause. All other patients had an uneventful recovery without major complications. The combination of early radiologic diagnosis, effective antimicrobial therapy, and intensive surgical management contributed to the good prognosis.

Supraglottic airway infections

Supraglottic infections are included among the more serious pediatric infections, although they are less common than other pediatric respiratory infections. Supraglottic infections include epiglottis (supraglottitis), retropharyngeal cellulitis, retropharyngeal abscess, and peritonsillar abscess. A high index of suspicion combined with rapid diagnosis and treatment are crucial to reducing the morbidity and mortality associated with these infections. A review of these infections, including diagnosis and treatment, is presented.

Management of necrotizing fasciitis in the neck

Necrotizing fasciitis is a soft tissue infection, usually polymicrobial, characterized by necrosis of fascia and subcutaneous tissue. Although it more commonly involves the groin, abdomen, and extremities, it may also occur in the head and neck. We report a case of cervical necrotizing fasciitis arising from a dental infection and review the cause, pathophysiology, diagnosis and treatment of this potentially lethal entity. Early detection and accurate intervention are emphasized. Extensive surgical debridement completed with hyperbaric oxygen therapy and antibiotics are the mainstay of treatment.

Space-occupying and life-threatening infections of the head, neck, and thorax

Infections of the deep structures of the head and neck are polymicrobial, rapidly progressive, and frequently life-threatening. The bacteriology, clinical presentation, and the need for multidisciplinary management of these infections are stressed. In addition, this article discusses selected head and neck infections of immunocompromised hosts and postexposure prophylaxis for serious infections of the pharynx.

Squamous cell carcinoma of the pharynx and larynx presenting as a neck abscess or cellulitis

Head and neck tumours presenting as a neck abscess or cellulitis are extremely rare. We report two cases of supraglottic squamous cell carcinoma which presented as an abscess in the site of metastatic neck nodes, one of which was occult and a third case of squamous cell carcinoma of the pyriform fossa which presented as cervical cellulitis. Biopsy of the abscess wall at the time of drainage and careful follow-up may lead to an earlier diagnosis of occult carcinoma.

Cervical necrotising fasciitis with pharyngeal perforation: treatment and reconstruction

We present a case of life-threatening necrotising fasciitis of the neck with acute pharyngeal perforation following a parapharyngeal abscess caused by tonsillitis. The joint occurrence of cervical necrotising fasciitis and acute pharyngeal perforation has not been previously reported. A new way of reconstructing the pharyngeal defect using an islanded submental perforator flap is presented.

Retropharyngeal abscess-an unusual complication of anorexia nervosa

An unusual case of an adult female with anorexia nervosa, who developed a retropharyngeal abscess, is presented. This case is reported both because of the paucity of reports on retropharyngeal abscess and because of the dramatic unusual aetiology.

Adult retropharyngeal abscess: a case report and review of the literature

The case of an 18-yr-old otherwise healthy adult with retropharyngeal abscess (RPA) presenting with sore throat and syncope is reported. The case illustrates that sore throat with symptoms out of proportion to oropharyngeal findings should prompt a search for pathology other than simple pharyngitis. A literature search for case reports of RPA in adults was done to derive characterizations about this disease. Adult RPA patients present with sore throat, dysphagia, neck pain and, less commonly, stridor. Adult RPA occurs as a complication of procedures or blunt trauma to the neck, or spread of infection from an adjacent focus. The incidence of underlying disease causing immunosuppression is high. RPA in adults without history of preceding trauma or coexistent illness is unusual.

Dysphagia in a diabetic patient

Images