Prediction of deep neck abscesses by contrast-enhanced computerized tomography in 76 clinically suspect consecutive patients

Prognostic Factors for Retropharyngeal Abscess in Children Receiving Surgery or Antibiotic Therapy

OBJECTIVE

Effective management of retropharyngeal abscess (RPA) may predicate upon identification of key patient characteristics. We analyzed characteristics and outcomes of pediatric patients with RPA to identify prognostic factors associated with successful surgical intervention.

METHODS

A financial database was searched for pediatric otolaryngology patients with RPA from 2010 to 2021. Medical charts were reviewed for demographics, presenting history, physical examination, laboratory testing, imaging, surgical findings, and hospital course. Bivariate analyses were performed to identify potentially significant predictors of positive drainage. These variables were included in multivariate analysis of surgical outcomes.

RESULTS

Of 245 total patients, 159 patients (65%) received surgery and 86 patients (35%) received antibiotics only. Patients with restricted cervical motion, neck swelling, and computed tomography (CT) cross-sectional area (CSA) >2 cm2 were more likely to receive surgery. Rim enhancement on CT imaging was associated with positive surgical drainage (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.16-5.74). However, no variables from clinical symptoms or physical exam were associated with positive drainage. Variables that approached significance were included in multivariate analysis, which revealed only rim enhancement predicted positive drainage (OR 2.57, 95% CI 1.13-5.83). The mean length of stay (LOS) was 2.6 versus 3.5 days (p < 0.001) for medical vs surgical treatment groups, respectively.

CONCLUSION

Our study revealed a high success rate of medical management. Although patient characteristics and clinical features were not significant predictors of surgical outcomes, CT findings such as rim enhancement were strongly associated with positive surgical drainage.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1955-1960, 2024.

Distinguishing sterile inflammation from graft infection

We describe the case of a 68-year-old man who underwent ascending aortic replacement and thoracic endovascular aortic repair. Four years later, the patient developed neck pain on the right side and chest computed tomography showed expansion of fluid in the mediastinum which had extended to the neck. Echocardiography revealed advanced severity of aortic regurgitation and decreased ejection fraction. Given the progression of aortic regurgitation, decreased cardiac function, and rapidly expanding fluid accumulation causing neck pain, reoperation was indicated. All microbiological test including polymerase chain reaction were negative indicating absence of any infection. The patient is being followed-up without antibiotics and CT has not shown peri-graft fluid 2 years postoperatively. Since infection cannot be excluded completely, it is important to assess the condition with selective medium, extended culture periods, genetic testing, and consultations with microbiology laboratories when normal culture tests for general bacteria, and fungi are negative which can help avoid drug-resistant bacteria count, elevated medical costs, and drug side effects due to the improper use of antibiotics through proper diagnosis.

The assessment and management of deep neck space infections in adults: A systematic review and qualitative evidence synthesis

OBJECTIVES

To summarise current practices in the diagnosis and management of deep neck space infections (DNSIs). To inform future studies in developing a framework in the management of DNSIs.

DESIGN

This review was registered on PROSPERO (CRD42021226449) and reported in line with PRISMA guidelines. All studies from 2000 that reported the investigation or management of DNSI were included. The search was limited to English language only. Databases searched included AMED, Embase, Medline and HMIC. Quantitative analysis was undertaken with descriptive statistics and frequency synthesis with two independent reviewers. A qualitative narrative synthesis was conducted using a thematic analysis approach.

SETTING

Secondary or tertiary care centres that undertook management of DNSIs.

PARTICIPANTS

All adult patients with a DNSI.

MAIN OUTCOME MEASURES

The role of imaging, radiologically guided aspiration and surgical drainage in DNSIs.

RESULTS

Sixty studies were reviewed. Thirty-one studies reported on imaging modality, 51 studies reported treatment modality. Aside from a single randomised controlled trial, all other studies were observational (n = 25) or case series (n = 36). Computer tomography (CT) was used to diagnose DNSI in 78% of patients. The mean percentage of management with open surgical drainage was 81% and 29.4% for radiologically guided aspiration, respectively. Qualitative analysis identified seven major themes on DNSI.

CONCLUSIONS

There are limited methodologically rigorous studies investigating DNSIs. CT imaging was the most used imaging modality. Surgical drainage was commonest treatment choice. Areas of further research on epidemiology, reporting guidelines and management are required.

MRI of odontogenic maxillofacial infections: diagnostic accuracy and reliability

OBJECTIVES

To determine the diagnostic accuracy of emergency magnetic resonance imaging (MRI) in odontogenic maxillofacial infections, the clinical and surgical significance of MRI findings, and whether MRI can identify the tooth responsible for the infection.

METHODS

A retrospective cohort study reviewed 106 emergency neck MRI scans of patients with neck infections of odontogenic origin. The diagnostic accuracy of MRI in identifying abscesses was studied relative to surgical findings. Correlations were analyzed between various MRI findings and clinical results and outcomes, such as the surgical approach (intraoral vs. extraoral). The ability of MRI findings to predict the causative tooth was assessed in a blinded multi-reader setting.

RESULTS

Of the 106 patients with odontogenic infections, 77 (73%) had one or more abscesses. Imaging showed a sensitivity, specificity, and accuracy of 0.95, 0.84, and 0.92, respectively, for MRI diagnosis of an odontogenic abscess. Among the imaging findings, mediastinal edema was the strongest predictor of extraoral surgery. MRI showed bone marrow edema in the majority of patients, and multi-reader assessment showed good reliability. MRI was also able to predict the causative tooth accurately.

CONCLUSIONS

Emergency neck MRI can accurately detect odontogenic abscesses and reliably point to the causative tooth. These results can increase the utility and reliance on emergency MRI in clinical decision-making.

MRI of acute neck infections: evidence summary and pictorial review

Infection of the deep neck spaces is a life-threatening acute illness that requires prompt diagnosis and treatment. Magnetic resonance imaging (MRI) offers unsurpassed soft tissue discrimination and is therefore well suited for imaging neck infections. Recently, the feasibility, diagnostic accuracy, and clinical significance of this method have been documented in patients with acute neck infections. This review article summarizes the scientific evidence, provides a practical guide to image acquisition and interpretation, reviews the most common imaging findings, and discusses some difficult diagnoses and pitfalls in acute neck infections, to help both radiologists and clinicians in managing these critically ill patients.

Diagnostic accuracy of contrast-enhanced CT for neck abscesses: A systematic review and meta-analysis of positive predictive value

OBJECTIVES

To review the diagnostic accuracy of contrast-enhanced computed tomography (CT) in differentiating abscesses from cellulitis in patients with neck infections, using surgical findings as the reference standard.

MATERIALS AND METHODS

Previous studies in the last 32 years were searched from PubMed and Embase. Because of partial verification bias (only positive abscess findings are usually verified surgically), sensitivity and specificity estimates are unreliable, and we focused on positive predictive value (PPV). For all studies, PPV was calculated as the proportion of true positives out of all positives on imaging. To estimate pooled PPV, we used both the median with an interquartile range and a model-based estimate. For narrative purposes, we reviewed the utility of common morphological CT criteria for abscesses, such as central hypodensity, the size of the collection, bulging, rim enhancement, and presence of air, as well as sensitivity and specificity values reported by the original reports.

RESULTS

23 studies were found reporting 1453 patients, 14 studies in children (771 patients), two in adults (137 patients), and seven including all ages (545 patients). PPV ranged from 0.67 to 0.97 in individual studies, had a median of 0.84 (0.79-0.87), and a model-based pooled estimate of 0.83 (95% confidence interval 0.80-0.85). Most morphological CT criteria had considerable overlap between abscesses and cellulitis.

CONCLUSIONS

The pooled estimate of PPV is 0.83 for diagnosing neck abscesses with CT. False positives may be due to limited soft tissue contrast resolution. Overall, none of the morphological criteria seem to be highly accurate for differentiation between abscess and cellulitis.

Polymicrobial periprosthetic joint infection and osteomyelitis of the tibia with circumferential abscess and skin ulcer 11 years after total knee arthroplasty

We report the case of a 71-year-old woman with a skin ulcer derived from an abscess around the tibia. The abscess resulted in periprosthetic joint infection and osteomyelitis 11 years after total knee arthroplasty. The first symptom was a skin ulcer of the lower leg. Magnetic resonance imaging revealed a circumferential mass around the proximal tibia. A skin biopsy taken around the ulcer showed thrombosis and degenerated collagen. Contrast-enhanced computed tomography showed a circumferential mass around the proximal tibia with ring enhancement. Biopsies of the skin ulcer and circumferential mass showed an abscess caused by Enterococcus faecium and methicillin-resistant Staphylococcus epidermis. We conducted debridement of the abscess, a gastrocnemius flap and split-thickness skin grafting and a 2-stage revision of the total knee component with a hinged prosthesis. Two years later, the infection did not reoccur and the patient can walk without a cane. This case is unique as abscess around proximal tibia caused necrotic skin ulcer and appearance of abscess was fibrous and different from typical bacterial abscesses containing pus or fluid. Contrast-enhanced computed tomography was effective for differentiation of the pathological condition.

MRI Findings in Acute Tonsillar Infections

BACKGROUND AND PURPOSE

Previous literature is vague on the prevalence and exact nature of abscesses in tonsillar infections, ranging from intratonsillar and peritonsillar collections to deep extension involving the parapharyngeal and retropharyngeal spaces. MR imaging has excellent diagnostic accuracy in detecting neck infections and can potentially clarify this issue. We sought to characterize the spectrum of MR imaging findings regarding tonsillar infections.

MATERIALS AND METHODS

We conducted a retrospective cohort study of emergency neck MR imaging scans of patients with tonsillar infections. Imaging data were assessed in terms of signs of infection and the location of abscesses and were compared with clinical findings, final diagnoses, and surgical findings as reference standards.

RESULTS

The study included 132 patients with tonsillar infection. Of these, 110 patients (83%) had ≥1 abscess (99 unilateral, 11 bilateral; average volume, 3.2 mL). Most abscesses were peritonsillar, and we found no evidence of intratonsillar abscess. Imaging showed evidence of parapharyngeal and retropharyngeal extension in 36% and 10% of patients, respectively. MR imaging had a high positive predictive value for both abscesses (0.98) and deep extension (0.86). Patients with large abscesses and widespread edema patterns had a more severe course of illness.

CONCLUSIONS

Emergency neck MR imaging can accurately describe the extent and nature of abscess formation in tonsillar infections.

Magnetic resonance imaging findings in pediatric neck infections-a comparison with adult patients

BACKGROUND

Differences in the functioning of the immune system and the anatomical proportions of the neck between children and adults lead to different manifestations of deep neck infections. Magnetic resonance imaging (MRI) may serve as an alternative to computed tomography (CT) as the primary imaging modality.

OBJECTIVE

To study characteristic MRI findings and the diagnostic accuracy of MRI in pediatric deep neck infections.

MATERIALS AND METHODS

We retrospectively studied a cohort of pediatric patients who underwent a neck 3-tesla MRI study over a five-year period. Inclusion criteria were: 1) emergency MRI findings indicating an infection, 2) infection as the final clinical diagnosis, 3) diagnostic image quality verified by the radiologist reading the study and 4) age under 18 years. Patient record data, including surgery reports, were compared with the MRI findings.

RESULTS

Data of 45 children were included and analysed. Compared to adults, children had a higher incidence of retropharyngeal infection and lymphadenitis, and a lower incidence of peritonsillar/parapharyngeal infection. MRI showed evidence of an abscess in 34 children. Of these 34 patients, 24 underwent surgery, which confirmed an abscess in 21 but no abscess in three patients. In addition, three patients underwent surgery without MRI evidence of abscess, and an abscess was found in one of these cases. The measures of diagnostic accuracy among the children were sensitivity 0.96, specificity 0.77, positive predictive value 0.89, negative predictive value 0.91 and accuracy 0.89. Compared with adults, children had lower C-reactive protein, but a similar proportion of them had an abscess, and abscess size and rate of surgery were similar.

CONCLUSION

Despite the differences in the infection foci, emergency MRI in children had equal diagnostic accuracy to that in adults.

Clinical and prognostic significance of emergency MRI findings in neck infections

OBJECTIVES

Due to its superior soft-tissue contrast and ability to delineate abscesses, MRI has high diagnostic accuracy in neck infections. Whether MRI findings can predict the clinical course in these patients is unknown. The purpose of this study was to determine the clinical and prognostic significance of various MRI findings in emergency patients with acute neck infections.

MATERIALS AND METHODS

We retrospectively reviewed the 3-T MRI findings of 371 patients with acute neck infections from a 5-year period in a single tertiary emergency radiology department. We correlated various MRI findings, including retropharyngeal (RPE) and mediastinal edema (ME) and abscess diameter, to clinical findings and outcomes, such as the need for intensive care unit (ICU) treatment and length of hospital stay (LOS).

RESULTS

A total of 201 out of 371 patients (54%) with neck infections showed evidence of RPE, and 81 out of 314 patients (26%) had ME. Both RPE (OR = 9.5, p < 0.001) and ME (OR = 5.3, p < 0.001) were more prevalent among the patients who required ICU treatment than among those who did not. In a multivariate analysis, C-reactive protein (CRP) levels, RPE, and maximal abscess diameter were independent predictors of the need for ICU treatment, and CRP, ME, and maximal abscess diameter were independent predictors of LOS.

CONCLUSION

In patients with an acute neck infection that requires emergency imaging, RPE, ME, and abscess diameter, as shown by MRI, are significant predictors of a more severe illness.

KEY POINTS

• Two hundred one out of 371 patients (54%) with neck infection showed evidence of retropharyngeal edema (RPE), and 81 out of 314 patients (26%) had mediastinal edema (ME). • Maximal abscess diameter, RPE, and C-reactive protein (CRP) were independent predictors of the need for intensive care unit (ICU) treatment, and maximal abscess diameter, ME, and CRP were independent predictors of length of hospital stay. • Prognostic significance of MRI findings was evident also while controlling for CRP values.

External carotid artery pseudoaneurysm following upper respiratory infection masquerading as a pharyngeal abscess in an 8-month-old

Pseudoaneurysms are very rare with an incidence of less than 0.1% in the pediatric population. Approximately 30 cases of carotid artery aneurysms in children have been published in the literature, usually affecting children over one year of age. We present one of the youngest cases in the literature; the patient is an 8-month old female with a strep throat infection complicated by pseudoaneurysm development of the external carotid artery. Because of the rarity of these lesions, there is little known regarding the types of clinical presentation and management. They are commonly the result of direct arterial trauma; however, they can also occur secondary to infection, connective tissue disease or arteritis. We are presenting a case with a highly atypical presentation. When present, pseudoaneurysms harbor the potential risk of life-threatening hemorrhage and warrant immediate management. It is important to be aware of cases and the treatment modalities used to guide future diagnosis and planning.

Emergency neck MRI: feasibility and diagnostic accuracy in cases of neck infection

Background

Computed tomography (CT) has traditionally been the first-line imaging method in neck emergencies such as deep neck infections. Due to superior soft-tissue contrast, magnetic resonance imaging (MRI) may be an alternative to CT, also in emergency situations.

Purpose

To characterize the use of routine MRI in neck emergencies, with an emphasis on clinical feasibility and diagnostic accuracy in cases of neck infection.

Material and Methods

We conducted a retrospective cohort study of all primary neck MRI scans performed using a 3-T MRI device during a five-year follow-up period in a tertiary emergency radiology department. Imaging data were compared with final clinical diagnosis and surgical findings as reference standards.

Results

The search identified 461 primary neck MRI scans, of which 334 (72%) were performed on the basis of clinical suspicion of infection. Radiological evidence of infection was observed in 95% of these scans, and at least one abscess was detected in 229 cases (72% of confirmed infection). MRI had an overall technical success rate of 95% and had high positive predictive value for both infection (0.98) and detection of abscess (0.95).

Conclusion

We found that emergency neck MRI can be successfully performed on most patients, and that MRI detects neck infection with a high accuracy. These results suggest that MRI may be an alternative to CT as the first or only imaging modality in neck emergencies.

Severe deep neck space infection caused by Eggerthia catenaformis

A 64-year-old woman was acutely referred to the Department of Otorhinolaryngology, Head and Neck Surgery, Aalborg University Hospital due to rapidly progressing neck swelling, fever and dysphagia. Clinical examination revealed submental swelling, trismus and laryngeal inflammation. A contrast-enhanced CT scan showed infection in the deep neck spaces with multiple abscesses. The patient underwent acute surgery and antimicrobial therapy was initiated and she was transferred to an intensive care unit. Three additional surgical procedures were needed before sufficient drainage was achieved. There was growth of different oral commensals from four separate pus aspirates, while Eggerthia catenaformis was cultured in all samples. Due to the extent of the infection, the patient stayed in the intensive care unit for 16 days, but recovered completely due to adequate surgery and antimicrobial therapy for 4 weeks. Here we present the third reported case of a severe deep neck space infection with multiple abscesses due to E. catenaformis.

Diagnostic and therapeutic approaches in deep neck infections: an analysis of 74 consecutive patients

Introductıon

Deep neck infections are a group of diseases with serious complications and mortality, which can occur as a result of common diseases in the community and which have surgical and medical treatment options.

Objectives

Patients ages, genders, complaints, physical examination findings, hospitalization complaints, history of antibiotic use before the application, additional diseases, radiological tests and analysis of examinations, type of treatment method, antibiotic agents selected in treatment, bacterial culture results, duration of hospitalization, complications, mortality rates were systematically recorded. In the study, anaerobic bacterial factors, which are difficult to produce in routine, were produced by considering special transport conditions and culture media.

Methods

A total of 74 patients who were hospitalized in the Department of Otorhinolaryngology, University of Mersin, between 01.07.2016 and 01.07.2017 for deep neck infection were evaluated prospectively. The study included 37 female and 37 male patients. The ages of the patients ranged from 1 to 69 and the mean age was 31 years.

Results

According to the analysis of the obtained data, there was a statistically significant relationship between the patients with additional diseases and the treatment modalities of the patients (p = 0.017). The surgical treatment rate was increased in this group of patients. In patients with a history of antibiotic use, it was found that patients in the pediatric group were in hospital longer in terms of length of stay compared to adults (p = 0.036). In adult patients who underwent surgery, the absorptive long axis was found to be longer in mm than in patients receiving isolated medical treatment (p = 0.008).

Conclusions

Deep neck infections is a disease group that seriously concerns public health, with significant mortality and morbidity. Ensuring airway safety of patients should be the first intervention. Abscesses located lateral to the tonsil capsule may not drain adequately without concomitant tonsillectomy.

Premaxillary abscess without bony erosion: An unusual complication of pediatric acute maxillary sinusitis

OBJECTIVES

To report an unusual complication of pediatric acute maxillary sinusitis: premaxillary abscess. To describe clinical, radiological and biological presentation, treatment strategy and progression.

MATERIAL AND METHODS

A retrospective study included all pediatric patients treated for premaxillary abscess complicating acute maxillary sinusitis in two ENT reference centers between 1999 and 2017. Disease history, clinical presentation, biological and radiological findings, treatment modalities and progression were studied.

RESULTS

Ten patients were included, with a mean age of 10±4.2 years. All presented with fever, rhinorrhea and premaxillary edema. Contrast-enhanced CT scan systematically found complete opacity of the maxillary sinus, without bone lysis, and extensive effusion along the intersinonasal wall up to the premaxillary region, extending in 3 cases back toward the parapharyngeal space. Bacteriology isolated Streptococcus anginosus most frequently (n=4; 40%). Treatment comprised intravenous wide-spectrum antibiotics, with surgical drainage of the abscess if>10mm (n=9; 90%). Seven of these 9 patients (78%) had recurrent abscess requiring surgical revision and 3 (33%) required a third drainage. All patients were cured without sequelae at 1 month.

CONCLUSION

In case of acute maxillary sinusitis with premaxillary edema, premaxillary abscess should be suspected. The high recurrence rate argues for maximalist surgery associated to close clinical monitoring with radiological examination.

Computed tomography use patterns for pediatric patients with peritonsillar abscess

OBJECTIVES

The objective of this study is to examine the impact that an institution-wide policy to reduce radiation exposure in pediatric patients had on the use of computed tomography (CT) imaging in children presenting with suspected peritonsillar abscess (PTA)1.

METHODS

A single institution retrospective review was conducted for all pediatric patients under the age of 18 who presented to the emergency department with suspected PTA over a ten-year period. Patients were divided into two groups; those that presented during the years prior to policy implementation and those that presented during the years following. Main outcome measures were the frequency of patients who underwent CT scanning as a part of their workup, the specialty of the ordering physician, and the treatment for suspected PTA.

RESULTS

A total of 317 patients with suspected PTA were seen prior to policy implementation, with an additional 275 patients seen in the years after. The frequency of CT use was 41% (131/317) in pre-policy patients, and 28% (77/275) in post-policy patients (p = 0.004). The most common specialty of ordering physician was Pediatrics in the pre-policy patients (45%), and Otolaryngology in the post-policy patients (41%) (p = 0.0003). Of the 131 patient who underwent CT scanning before policy implementation, 36 patients (27%) required incision and drainage (I&D) of their PTA in the OR. This is in comparison to 42/77 patients (55%) in the post-policy group who underwent I&D in the OR (p < 0.0001).

CONCLUSION

An institution-wide policy to decrease unnecessary imaging studies in pediatric patients resulted in a significant reduction in the use of CT imaging in the work-up for suspected PTA. Additionally, there was increase in the frequency of patients who underwent surgical intervention for their PTA after CT imaging, suggesting a more scrutinized approach to CT usage since policy implementation.

Infants Are More Likely Than Older Children to Have Surgery for Cervical Infections

Objectives

To identify differences in cervical infection management in infants versus older children.

Methods

Charts of patients 0–18 years, diagnosed with a cervical infection at our institution between 2004 and 2015, were included. Age, gender, presenting symptoms, comorbidities, CT scan findings and management including admission, procedures, antibiotics, cultures, length of stay, readmission rates, and complications were included.

Results

239 patients were included: mean age was 4.6 years, with 55.6% boys and 44.4% girls. Mean length of stay was 3.2 days, with no significant difference between age categories. 12.55% were readmitted within 30 days with no significant difference when stratified for age (p = 0.268). The most common presenting symptoms were fever (74.3%), swelling (71.4%), and neck pain (48.2%). Infants had fewer symptoms documented than older children. 51% has lateral neck infections, and these were more common in younger children (p < 0.001). The most common antibiotic used was amoxicillin-clavulanic acid in 53.96% of inpatients and 48.05% of outpatients. Infants were most likely to have MRSA isolates (29.2% versus 11.7% of older children, p = 0.011). 70.0% went to the operating room for incision and drainage procedures. Younger children were more likely to undergo surgery, with an odds ratio of 2.38 for children under 1 year. (p = 0.029). 90.9% of infants underwent surgery with radiolucencies of at least 1 cm diameter in contrast to 50% of children over 8 years old.

Conclusions

This study emphasizes the importance of considering early operative treatment of cervical abscesses in infants despite fewer symptoms and smaller radiolucencies on CT.

Increasing Use of Intensive Care Unit for Odontogenic Infection Over One Decade: Incidence and Predictors

PURPOSE

To determine whether intensive care unit (ICU) admissions for odontogenic infections have increased during the past decade and whether certain clinical features are associated with a greater rate of ICU admission.

MATERIALS AND METHODS

The data from patients undergoing surgery for odontogenic infections at the Royal Brisbane and Women's Hospital in the 24 month from January 2003 to December 2004 were compared with those from patients treated from January 2013 to December 2014. A χ² analysis was used to compare the demographic, admission, and clinical patient data in each cohort. A multiple logistic regression model was used to determine which clinical features were associated with greater rates of ICU admission.

RESULTS

The rate of ICU admission increased significantly from 7 to 24% during the decade (χ² = 12.74; P = .000), although the clinical presentation of patients admitted to the ICU was similar in both cohorts. The mean number of days spent in the ICU increased significantly from 1.7 ± 0.5 to 3.24 ± 2.5 days (t = -3.63; P = .001), and the overall length of stay increased from 1.7 ± 0.5 to 3.5 ± 4.1 days (t = 2.99; P = .004). The use of preoperative computed tomography (CT) increased significantly from 42.9 to 93.3% (χ² = 13.25; P = .000). The most significant predictors of ICU admission were lower third molar involvement (P = .026), dysphagia (P = .020), and C-reactive protein (CRP) levels exceeding 150 mg/L (P = .039).

CONCLUSIONS

The use of the ICU in the management of odontogenic infection has increased significantly at the Royal Brisbane and Women's Hospital over 1 decade. The demographic data and clinical presentation of the patients admitted to the ICU did not change significantly. However, the length of ICU stay and the total length of stay have both increased. A significant increase in CT usage for odontogenic infections also occurred. Third molar infections, dysphagia, and elevated CRP might be relevant clinical predictors of a more complicated course of care requiring ICU admission. More judicious use of CT scanning, combined with prompt surgical consultation and intervention, might reduce the rate of ICU admissions for odontogenic infections.

Contrast-enhanced computed tomography combined with Chitosan-Fe3O4 nanoparticles targeting fibroblast growth factor receptor and vascular endothelial growth factor receptor in the screening of early esophageal cancer

Esophageal cancer is a malignant tumor with a relatively high invasiveness, metastatic potential and worldwide incidence among human cancers. The majority of patients with esophageal cancer are diagnosed in a late tumor stage due to a lack of advanced and sensitive protocols for the diagnosis of patients with early-stage esophageal cancer. In the current study, contrast-enhanced computerized tomography (CECT) combined with Chitosan-Fe₃O₄ nanoparticles targeting fibroblast growth factor receptor (FGFR) and vascular endothelial growth factor receptor (VEGFR; CECT-CNFV) were used to diagnose patients with suspected esophageal cancer. A Chitosan-Fe₃O₄-parceled bispecific antibody targeting FGFR and VEGFR was produced and its affinity to esophageal cancer cells was determined both in vitro and in vivo. A total of 320 patients with suspected esophageal cancer were voluntarily recruited to evaluate the efficacy of CECT-CNFV in the diagnosis of early-stage esophageal cancer. All participants were subjected to CT and CECT-CNFV to detect whether tumors were present in the esophageal area. A Chitosan-Fe₃O₄ nanoparticles contrast agent was orally administered at 20 min prior to CT and CECT-CNFV. The results demonstrated that CECT-CNFV improved diagnostic sensitivity and provided a novel protocol for the diagnosis of tumors in patients with suspected gastric cancer at an early-stage. Furthermore, the resolution ratio of images was enhanced by CECT-CNFV, which enabled the visualization of tiny tumor nodules in esophageal tissue. Clinical data demonstrated that CECT-CNFV diagnosed 200 patients with suspected early-stage esophageal cancer and 120 patients as tumor free. In addition, CECT-CNFV exhibited higher signal enhancement of tumor nodules than CT, suggesting a higher accuracy and accumulation of nanoparticle contrast agent within the tumor nodules of esophageal tissue. Notably, the survival rate of patients with esophageal cancer diagnosed at an early-stage by CECT-CNFV was higher than the mean five-year survival rate (P<0.01). In conclusion, CECT-CNFV enhanced the sensitivity and accuracy of CT in the diagnosis of early-stage esophageal cancer. Thus, CECT-CNFV may improve the accuracy of CT in the diagnosis of mural enhancement in patients with esophageal cancer.

Application of novel targeting nanoparticles contrast agent combined with contrast-enhanced computed tomography during screening for early-phase gastric carcinoma

Gastric cancer is one of the most common human tumors worldwide. The biggest bottleneck is a lack of advanced and sensitive protocols for the diagnosis of patients with early-stage gastric cancer. Therefore, more sensitive methods of diagnosing gastric cancer are urgently required to improve survival rates. In this clinical study, contrast-enhanced computed tomography (CECT) with targeting nanoparticles contrast agent (CECT-TNCA) was used to diagnose early-stage gastric cancer. The specific-targeted tyrosine kinase inhibitors of gastric cancer, including platelet-derived growth factor receptor-β, Ret and Kit, were used as TNCAs. A total of 484 patients with suspected gastric cancer were voluntarily recruited to investigate the efficacy of CECT-TNCA in the diagnosis of patients with early-stage gastric cancer. Patients with suspected gastric cancer were subjected CT and CECT-TNCA to detect whether gastric tumors existed. TNCA was orally administered before CT and CECT-TNCA (20 min). Our diagnostic data revealed that CECT-TNCA improved sensitivity and provided a new protocol to diagnose tumors in patients with suspected gastric cancer at the early stage. In addition, imaging using CECT-TNCA enabled the visualization of tiny nodules in the gastric area. CECT-TNCA diagnosed 182 patients with suspected gastric cancer as tumor-free. CECT-TNCA confirmed gastric cancer in 302 patients. Our novel diagnosis indicated significantly (P<0.01) differential signal enhancement in the gastric nodules via CECT-TNCA compared with CT, suggesting higher accuracy and the accumulation of TNCA in tumor nodules in the stomach. Furthermore, survival rates of patients detected by early-diagnosis of CECT-TNCA were significantly higher than the mean five-year survival (P<0.01). In conclusion, our investigations demonstrate that the sensibility and accuracy of CT is improved through combination with liposome-encapsulated nanoparticle contrast agent for the diagnosis of early stage gastric cancer when compared with single CT detection. CECT-TNCA improves the accuracy of CT and diagnostic confidence in assessing mural enhancement in patients with suspected gastric cancer.

A New Trend in the Management of Pediatric Deep Neck Abscess: Achievement of the Medical Treatment Alone

Objective

Albeit the traditional opinion that advocates a routine surgical drainage for the treatment of an abscess, the case series presenting high success rates of the medical therapy alone is increasing in deep neck abscesses of childhood. This research focuses on children whose deep neck abscess fully disappeared after only medical treatment.

Methods

In a retrospective study, we evaluated medical records of 12 pediatric (<18 years old) cases diagnosed with deep neck abscess or abscess containing suppurative lymphadenitis and treated with only medical therapy between 2010 and 2015 for age, gender, treatment modality, parameters related to antimicrobial agents, location of the infection, etiology, symptoms, duration of hospital stay, characteristics of the radiological and biochemical examination findings, and complications.

Results

The mean age of 10 male and two female children was 5.9 years (range, 1-17 years). Baseline and the last control's mean values of white blood cell (WBC), C-reactive protein, and erythrocyte sedimentation rate were 18,050/μL, 99.8 mg/L, 73.1 mm/h, and 8,166/μL, 34.1 mg/L, 35.3 mm/h, respectively. Contrast-enhanced neck computed tomography demonstrated an abscess in seven cases and an abscess containing suppurative lymphadenitis in five cases. The largest diameter of the abscess was 41 mm. All cases were given broad-spectrum empirical antibiotherapy (penicillin+metronidazole, ceftriaxone+metronidazole, or clindamycin). No medical treatment failure was experienced.

Conclusion

Independent of age and abscess size, if the baseline WBC is ≤25.200/μL, if only two or less than two cervical compartments are involved, if there are no complications in the admission, and if the etiological reason is not a previous history of trauma, surgery, foreign body, and malignancy, pediatric deep neck abscess can be treated successfully with parenteral empirical wide-spectrum antibiotherapy.

Difficult Cases of Odontogenic Deep Neck Infections: A Report of Three Patients

BACKGROUND

Deep neck infections are important otolaryngologic emergencies due to serious complications and the risk of airway compromise, which can lead to mortality. Although the most common causes among pediatric patients are tonsillitis and pharyngeal infections, odontogenic infections are an important cause in adults.

CASE REPORT

We present three patients with multiple deep neck space abscess formation due to odontogenic infection. Two of them required tracheotomy due to airway compromise, and one had mediastinitis.

CONCLUSION

An underestimated tooth infection can cause hazardous complications such as mediastinitis and respiratory distress requiring tracheotomy.

Neck abscess: 79 cases

OBJECTIVE

Neck abscess is a disease that might cause mortality and severe morbidity, if it is not treated urgently. In our study, patients with diagnosis of neck abscess in our clinic were analyzed retrospectively and presented in the light of the literature.

METHODS

In our clinic, age distribution, source of infection, systemic disease, imaging methods that were used in diagnosis, preferred anaesthesia during drainage, abscess sites, culture results of abscess material, complications during treatment procedure, any antibiotherapy before admission and duration of hospitalization of 79 cases with neck abscess who were treated in the hospital between January 2008 and January 2015 were assessed.

RESULTS

Cases in our study were aged between 1-79 (mean 28.3) years and 43 of them were female and 36 were male patients. Systemic diseases were determined in 19 of the cases. The most common systemic disease was diabetes mellitus. Abscesses were localized mostly at peritonsillar region and 13 of the cases were operated when abscess were in multipl localizations. In 74 of the cases, drainage was performed under local anaesthesia and in 5 cases under general anaesthesia. Four of these 5 cases, abscesses were localized within retropharyngeal region and 1 of them had multiple abscesses at various regions. Staphylococcus aereus was the most detected microorganism based on culture results. Three adult cases were followed up in the intensive care unit because of development of mediastinitis. One of these 3 cases exited because of sepsis. Hospitalization periods of 79 cases ranged between 2-21 days (mean 7.64 days). Hospitalization period of 19 cases with systemic diseases were 9.47 days (p<0.05) and statistically which were statistically significantly longer when compared with those without any systemic disease.

CONCLUSION

Neck abscess must be diagnosed early and treated with surgical drainage and parenteral therapy because it might cause severe complications.

The effectiveness of conservative management for retropharyngeal abscesses greater than 2 cm

Objectives

Conservative management for retropharyngeal abscesses <2 cm is now a first line option. It is unclear if conservative management can be used to manage larger abscesses without increased morbidity and mortality.

Study design

A prospective case series was performed from 2012 to 2015 by the Otolaryngology department of the San Fernando General Hospital involving pediatric patients who presented with retropharyngeal abscesses. All patients were initially treated with antibiotics alone.

Methods

Patients with clinical features and CT scan confirmation of a retropharyngeal abscess were included in the study. Those who improved clinically and biochemically within 48 h continued to be treated conservatively and those who deteriorated had surgical intervention.

Results

Sixteen patients fulfilled the inclusion criteria. Most patients were Afro Trinidadian males between the ages of two and five who were also found to be iron deficient. Drooling was a sensitive predictor for the presence of an abscess but did not indicate the need for drainage. Hoarseness was the clinical feature that prompted surgical intervention. Sixty three percent of patients had an abscess >2 cm of which 90% improved within 48 h. One patient required surgical drainage with no increase in morbidity or mortality.

Conclusion

Conservative management of retropharyngeal abscesses >2 cm can be offered to patients during the first 48 h. If the patient demonstrates clinical and biochemical improvement, antibiotics alone can be continued. If the patient deteriorates, surgical drainage can be subsequently performed with no increase in morbidity and mortality.

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The retropharyngeal abscess is a deep neck space infection commonly seen in the pediatric population.

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Drainage of these abscesses is associated with multiple complications.

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Patient presenting with hoarseness requires surgical intervention.

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Conservative management can be successfully performed in patients who have abscesses that are greater than 2 cm.

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Patients treated with antibiotic alone need to be closely followed up for lack of improvement or deterioration.

Minimally invasive transnasal approach to infratemporal fossa abscess

Background:

Infratemporal fossa abscess following odontogenic infection is not rare, and usually occurs as a sequela of dental disease. Infratemporal fossa abscess was previously treated with the combination of buccal incision and temporal incision, or via a transoral approach.

Method:

This paper reports a case of infratemporal fossa abscess in a 51-year-old female.

Results:

The abscess was drained transnasally via an endoscopic modified medial maxillectomy approach, preserving the inferior turbinate and nasolacrimal duct. The pain remitted the next day and trismus had diminished in one week.

Conclusion:

The transnasal approach with endoscopic modified medial maxillectomy is a direct, minimally invasive method that provides a direct field of view for drainage of infratemporal fossa abscess. This approach is recommended for infratemporal fossa abscess.

Periapical lucency around the tooth: radiologic evaluation and differential diagnosis

Periapical lucencies are often seen incidentally at head and neck imaging studies performed for indications not related to the teeth. These lesions are, however, occasionally manifestations of diseases that have a wide range of effects and may at times represent the source of symptoms that prompted the study. The vast majority of periapical lucencies are the result of apical periodontal or pulpal disease. If found in an advanced state or left untreated, disease related to the tooth may spread to adjacent tissues, including the sinuses, orbits, deep fascial spaces of the neck, and intracranial structures, and result in a significant increase in patient morbidity and mortality. Although the majority of periapical lucencies seen on radiographs and computed tomographic images occur secondary to apical periodontal or pulpal disease, not all lucencies near the tooth root are due to infection. Lucency near the tooth root may be seen in the setting of other diseases of odontogenic and non-odontogenic origin, including neoplasms. Although imaging findings for these lesions can include periapical lucent components, awareness of the varied secondary imaging features can aid the radiologist in developing an accurate differential diagnosis. Familiarity with the imaging features and differential diagnoses of diseases or conditions that cause lucency around the tooth root results in appropriate referral and prompt diagnosis, management, and treatment, and can prevent unnecessary additional imaging or intervention. In addition, early recognition and appropriate treatment of infectious processes will result in improved clinical outcomes and a decrease in morbidity and mortality.

CT differentiation of abscess and non-infected fluid in the postoperative neck

BACKGROUND

Differentiation of postoperative neck abscess from non-infected fluid is important because the treatment is different.

PURPOSE

To determine specific CT findings that might help to differentiate abscesses from non-infected fluid collections in the postoperative neck.

MATERIAL AND METHODS

We retrospectively reviewed CT scans of 50 patients (43 men and 7 women; mean age, 62.5 ± 8.9 years) who had postoperative fluid collections in the neck (26 abscesses and 24 non-infected fluid collections). Diagnosis of an abscess was determined by a positive bacteria culture from the fluid collection. Diagnoses were correlated with the following CT findings: anatomic spaces involved, the maximum transverse diameter, margin, attenuation, rim enhancement, gas bubbles, and manifestations of soft tissue adjacent to a fluid collection.

RESULTS

Rim enhancement pattern and soft tissue manifestations showed significant differences between abscess and non-infected fluid. The reliable CT findings for abscess were: (i) rim enhancement > 50% of the circumference, 54% sensitive, 71% specific, and 62% accurate; and (ii) severe soft tissue manifestations, 39% sensitive, 92% specific, and 64% accurate. There were no significant differences in the anatomic spaces involved, the maximum transverse diameter, margin, attenuation, and gas bubbles between abscess and non-infected fluid.

CONCLUSION

CT findings that may help differentiate postoperative neck abscess from non-infected fluid were rim enhancement > 50% of the circumference and severe soft tissue manifestations.

Emergency imaging assessment of deep neck space infections

Deep neck space infection may lead to severe and potentially life-threatening complications, such as airway obstruction, mediastinitis, septic embolization, dural sinus thrombosis, and intracranial abscess. The clinical presentation is widely variable, and often early symptoms do not reflect the disease severity. The complication risk depends on the extent and anatomical site: diseases that transgress fascial boundaries and spread along vertically oriented spaces (parapharyngeal, retropharyngeal, and paravertebral space) have a higher risk of complications and require a more aggressive treatment compared with those confined within a nonvertically oriented space (peritonsillar, sublingual, submandibular, parotid, and masticator space). Imaging has 5 crucial roles: (1) confirm the suspected clinical diagnosis, (2) define the precise extent of the disease, (3) identify complications, (4) distinguish between drainable abscesses and cellulitis, and (5) monitor deep neck space infection progression. Ultrasonography is the gold standard to differentiate abscesses from cellulitis, for the diagnosis of lymphadenitis. and to identify internal jugular thrombophlebitis in the infrahyoid neck. However, field-of-view limitation and poor anatomical information confine the use of ultrasonography to the evaluation of superficial lesions and to image-guided aspiration or drainage. Computed tomography (CT) combines fast image acquisition and precise anatomical information without field-of-view limitations. For these reasons, it is the most reliable technique for the evaluation of deep and multicompartment lesions and for the identification of mediastinal and intracranial complications. Contrast agent administration enhances the capability to differentiate fluid collections from cellulitis and allows the detection of vascular complications. Magnetic resonance imaging is more time-consuming than CT, limiting its use to selected indications. It is the technique of choice for assessing the epidural space involvement in pre- and paravertebral space infections and complements CT in the evaluation of the infections reaching the skull base.

[Peritonsillar infections: prospective study of 100 consecutive cases]

INTRODUCTION

Peritonsillar infection is the most frequent complication of acute tonsillitis. Peritonsillar infections are collections of purulent material, usually located between the tonsillar capsule and the superior constrictor of the pharynx. Peritonsillar infection can be divided into abscess and cellulitis.

MATERIAL AND METHODS

We prospectively analysed the clinical data from 100 patients with peritonsillar infection from 2008 to 2010. The diagnosis of abscess or peritonsillar cellulitis was primarily based on obtaining pus through fine-needle aspiration.

RESULTS

Seventy-seven per cent of patients had no history of recurrent tonsillitis and 55% were receiving antibiotic treatment. Sixty-two cases were peritonsillar abscess and the rest were cellulitis. Trismus, uvular deviation and anterior pillar bulging were statistically associated with peritonsillar abscess (P<.005). All patients were admitted to hospital and treated with puncture-drainage, intravenous antibiotics (amoxicillin/clavulanate in 83% of cases) and a single dose of steroids. All patients were discharged on oral antibiotic therapy. The mean length of hospital stay was 3 days and the recurrence rate was 5%.

CONCLUSIONS

Due to the absence of clinical practice guidelines, there are different therapeutic protocols. According to our experience, puncture-aspiration and administration of intravenous antibiotics is a safe, effective way to treat these patients. To determine the efficacy and safety of outpatient management, controlled studies would be needed.

Retropharyngeal infections in children. Treatment strategies and outcomes

OBJECTIVE

To optimize the treatment of retropharyngeal infections in children.

METHODS

Retrospective chart review of 101 consecutive pediatric cases of retropharyngeal infections referred to our center from January 2006 to July 2009.

RESULTS

Two-thirds of patients were males. Their mean age was 52 months (range: 6-163). Upper airway obstruction was observed in three patients. In another child, the infection evolved towards a diffuse cervical cellulitis. Medical treatment was initially planned in 44% of patients. Failures requiring surgical drainage occurred in 18% of them. In 56% of cases, surgical treatment was immediately instigated. It failed in 16% of patients, requiring a second surgical drainage. There was no difference in the duration of fever and of hospital stay between patients initially treated medically or surgically. Both medical and surgical treatment failures were associated with longer durations of fever (p=0.002, and p<0.0001, respectively) and of hospital stay (p=0.0006, and p=0.0005, respectively). Some characteristics of CT-scan anomalies were correlated with treatment failure. A hypodense core surrounded by rim enhancement, with a largest long axis ≥ 20 mm, was more frequent in case of medical failure (p=0.02). Surgical failure was associated with the same feature, but with a largest long axis ≥ 30 mm (p=0.05).

CONCLUSIONS

The present study suggests that severe complications are rare in pediatric retropharyngeal adenitis, and that CT-scan is a useful tool to choose between medical and surgical treatment.

Head and neck cancers manifested as deep neck infection

The incidence of head and neck cancers in patients with an initial presentation of deep neck infection is unclear and may be underestimated. Thus, the aim of this study was to assess the incidence of head and neck cancers initially manifested as deep neck infection. Also, the possible risk factors and pathophysiology are discussed. This study was a retrospective medical chart review in a tertiary referral center. A total of 81 consecutive patients admitted with a diagnosis of deep neck infection over a 46-month period were analyzed. The demographic data, physical examinations, laboratory findings, radiographic studies, and pathology report were analyzed. Among the 81 deep neck infection patients, head and neck cancers were histologically demonstrated in four patients (4.9%) with the initial symptom of a painful neck mass. The incidence of head and neck cancer initially manifested as deep neck infection was found to increase in patients aged over 40 years (6.7%; 3/45 vs. 2.8%; 1/36). A detailed history of all patients with deep neck infection should be taken. Furthermore, endoscopic examination, thyroid examination and routine pathological examination should be performed, especially in those aged over 40. Also, careful explanation to the patient and his/her family about the possibility of underlying head and neck cancer (incidence 1-5%) may be needed. If the neck swelling diminishes, but does not disappear completely after full course of antibiotics, repeated fine needle aspiration, endoscopy, or image study should be considered.