Peritonsillar abscess with rapid progression to complete airway obstruction in a toddler

Emerging findings for the assessment and treatment of pediatric deep neck abscesses

PURPOSE OF REVIEW

The purpose of this review is to summarize new literature regarding the description, diagnosis, and treatment of pediatric deep neck abscesses.

RECENT FINDINGS

Providers should include multi-inflammatory syndrome in children (MIS-C) in a differential diagnosis in children suspected of having a retropharyngeal abscess. MRI may guide the proper management of children with deep neck abscesses by more accurately detecting free fluid compared to computed tomography imaging. Factors that may predict the need for surgical management include elevations in white blood cell counts and abscess size more than 3 cm. However, future investigation is necessary to establish consistent guidelines. Medical management is effective in many children, with a new study indicating success using a combination of cefotaxime and rifampicin.

SUMMARY

Anatomical and age-related risk factors predispose children to the development of deep neck abscesses. Findings from recent studies may aid providers in making an accurate diagnosis and providing proper medical or surgical management of children with these infections.

Complications of peritonsillar abscess

Background

The vast majority of patients with peritonsillar abscess (PTA) recover uneventfully on abscess drainage and antibiotic therapy. However, occasionally patient´s condition deteriorates as the infection spread in the upper airway mucosa, through cervical tissues, or hematogenously. The bacterial etiology of PTA is unclarified and the preferred antimicrobial regimen remains controversial. The current narrative review was carried out with an aim to (1) describe the spectrum of complications previously recognized in patients with peritonsillar abscess (PTA), (2) describe the bacterial findings in PTA-associated complications, and (3) describe the time relation between PTA and complications.

Methods

Systematic searches in the Medline and EMBASE databases were conducted and data on cases with PTA and one or more complications were elicited.

Results

Seventeen different complications of PTA were reported. The most frequently described complications were descending mediastinitis (n = 113), para- and retropharyngeal abscess (n = 96), necrotizing fasciitis (n = 38), and Lemierre´s syndrome (n = 35). Males constituted 70% of cases and 49% of patients were > 40 years of age. The overall mortality rate was 10%. The most prevalent bacteria were viridans group streptococci (n = 41, 25%), beta-hemolytic streptococci (n = 32, 20%), F. necrophorum (n = 21, 13%), S. aureus (n = 18, 11%), Prevotella species (n = 17, 10%), and Bacteroides species (n = 14, 9%). Simultaneous diagnosis of PTA and complication was more common (59%) than development of complication after PTA treatment (36%) or recognition of complication prior to PTA (6%).

Conclusion

Clinicians involved in the management of PTA patients should be aware of the wide range of complications, which may arise in association with PTA development. Especially males and patients  > 40 years of age seem to be at an increased risk of complicated disease. In addition to Group A streptococci and F. necrophorum, the current findings suggest that viridans group streptococci, S. aureus, Prevotella, and Bacteroides may also play occasional roles in the development of PTA as well as spread of infection. Complications occasionally develop in PTA patients, who are treated with antibiotics and surgical drainage.

The role of bacteriological studies in the management of peritonsillar abscess

OBJECTIVE

Since most patients with peritonsillar abscess (PTA) can be successfully treated with surgical drainage and empirical antibiotic therapy, routine bacteriologic studies for all patients with PTA may be unnecessary. This study tried to evaluate which patients with PTA should certainly undergo bacteriologic studies.

METHODS

Hundred consecutive patients with PTA were treated and underwent culture tests of purulent contents obtained by surgical drainage between April 2008 and December 2013.

RESULTS

In 62 of the 100 patients, 71 pathogenic bacteria were identified; 61 (86%) were Gram-positive cocci (GPC), 8 (11%) were Gram-negative rods (GNR), and 6 (8%) were anaerobes. Normal flora were isolated in 27 patients, and culture results were negative in 11 patients. Although not significant, primary (without prior antibiotic therapy) case (odds ratio (OR)=2.19; 95% CI, 0.95-5.05) and laryngeal edema (OR=2.04; 95% CI, 0.82-5.03) showed a tendency of associations with detection of pathogenic bacteria. After taking into account interactions between smoking habit and laryngeal edema, the covariate-adjusted OR for non-smokers with laryngeal edema was significant and showed a strong relationship (OR=7.43; 95% confidence interval, 1.05-52.73) compared to non-smokers without laryngeal edema.

CONCLUSION

Although empirical antibiotic therapy was effective for most of the PTA patients, bacteriologic studies might be indispensable for the patients with laryngeal edema considering the failure of the first treatments. Particularly, the culture tests may be useful for non-smokers with laryngeal edema.