Pediatric deep space neck infections in U.S. children, 2000-2009

Extensive Parapharyngeal Abscess in a 4-Month-Old Infant

Parapharyngeal abscess in an infant is a very rare condition. We present the case of a 4-month-old girl with large masses on the neck's left side. Computed tomography showed an extensive parapharyngeal abscess. Left tonsillectomy was performed under general anesthesia from a transoral approach, followed by an incision and evacuation of the abscess from the parapharyngeal space. Microbiological analysis identified a massive occurrence of Streptococcus intermedius.

Parapharyngeal and retropharyngeal infections in children: Kawasaki disease needs vigilance

OBJECTIVE

Kawasaki Disease (KD) may mimic Parapharyngeal (PPI) and Retropharyngeal Infections (RPI), leading to misdiagnosis as Deep Neck Infections (DNIs). The treatment plans for the two diseases are different, and delayed treatment can lead to serious complications. Therefore, prompt diagnosis and management are necessary. This study was performed to evaluate the clinical features of KD mimicking DNIs and explore the treatment options.

METHODS

Children with cellulitis or abscess in parapharyngeal or retropharyngeal space in neck CT were included in this study. The medical records of enrolled children were retrospectively reviewed.

RESULTS

In total, 56 children were diagnosed with PPI or/and RPI. Twenty-two (39.3%) participants were eventually diagnosed with KD, and 34 (60.7%) were diagnosed with DNIs. Compared with the DNIs group, the KD group had a higher body temperature (p=0.007), and higher levels of AST (p=0.040), ALT (p=0.027), and ESR (p=0.030). Deep cervical cellulitis (p=0.005) were more common in the KD group. However, deep neck abscess often occurred in the DNIs group (p=0.002), with parapharyngeal abscess being the most common type of abscess (p=0.004). The KD mimicking DNIs cases did not respond to antibiotic treatment, but symptoms significantly improved after the use of Immunoglobulin (IVIG) and aspirin.

CONCLUSION

Children with KD may exhibit retropharyngeal or parapharyngeal inflammation in the early stages. KD should be considered a differential diagnosis for children with DNIs, high fever, and no response to antibiotic therapy. Surgery in KD mimicking deep neck abscess requires caution.

LEVEL OF EVIDENCE

I.

Ultrasound in Causes of Stridor in Children

Airway ultrasound (US) is an easily available, portable, radiation-free imaging modality for quick, non-invasive, dynamic evaluation of the airway without sedation. This is useful in children with stridor, which is an emergency due to upper airway obstruction requiring immediate management. Several causes of stridor including laryngomalacia, laryngeal cyst, subglottic hemangioma, vocal cord palsy, and lymphatic malformations can be evaluated accurately. Thin musculature and unossified cartilages in children provide a good acoustic window. Thus, airway US is valuable, but underutilized for the evaluation of children with stridor. In this case-based review, we describe the technique, indications, anatomy, and pathologies on airway US.

Disparities in the Presentation and Management of Pediatric Retropharyngeal Abscess

OBJECTIVES

Differences in management and outcomes of otolaryngologic diseases may reflect inequities driven by social determinants of health. This study aimed to investigate disparities in presentation and outcomes of retropharyngeal abscess (RPA) among 231 pediatric patients.

METHODS

Medical records were searched for pediatric patients with RPA from 2010 to 2021. Charts were reviewed for demographics, clinical features, and treatment decisions. Area deprivation index (ADI) scores for patient zip codes were determined. Chi-square analysis independent samples t-test, and regression analyses were used to investigate associations between variables.

RESULTS

Among patients presenting for RPA, Black patients were less likely to undergo surgical management than non-Black patients (53.2% vs. 71.6%, p = 0.009). Black patients had a lower rate of treatment with antibiotics prior to hospital admission (19.4% vs. 54.4%, p < 0.001). Among patients who received surgery, Black patients had higher cross-sectional abscess area on CT (6.4 ± 8.4 cm2  > vs. 3.8 ± 3.3 cm2 , p = 0.014), longer length of stay (5.4 ± 3.3 days vs. 3.2 ± 1.5, p < 0.001), and longer time between admission and surgery (2.3 ± 2.1 vs. 0.83 ± 1.1, p < 0.001). Increased ADI was correlated with increased rate of trismus.

CONCLUSIONS

Lower rates of pre-admission antibiotics and larger abscess area on CT imaging among Black patients may suggest disparities in access to primary care, resulting in presentation to tertiary care at later stages of disease and higher rates of medical management trial prior to surgical intervention.

LEVEL OF EVIDENCE

3 (retrospective cohort study) Laryngoscope, 134:1907-1912, 2024.

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.

Nasal Endoscopic Incision and Drainage Transnasal Retropterygoid Approach to Upper Parapharyngeal Abscess: A Novel Technique

Parapharyngeal infection is a well-known disease of otorhinolaryngologists. Rapid onset, short duration, severe symptoms, and manifestations such as sore throat and dysphagia are common characteristics treated primarily by surgical incision and drainage. Traditional surgical approaches encompass endoscopic transoral/nasal, transparotid, transcervical, or a combination thereof. We report a novel technique of nasal endoscopic incision and drainage transnasal retropterygoid approach to an upper parapharyngeal abscess. This report presents a case of a 14-year-old man presented with severe right neck and head pain, who was found to have an upper parapharyngeal abscess during a nasal endoscopic parapharyngeal exploration via a retropterygoid approach. The intraoperative frozen section revealed chronic mucosal inflammation and mild to moderate dysplasia of the squamous epithelium, but no carcinoma.

Surgical management of lateral neck abscesses in children: a retrospective analysis of 100 cases

Cervical abscesses are relatively common infections in pediatric patients. There is an ongoing debate about the necessity and time point of surgical drainage. The identification of a focus of infection might play an important role in facilitating a therapeutic decision. In a retrospective study, 100 pediatric patients aged 1-18 years who underwent incision and drainage of a lateral cervical abscess at our institution were analyzed. Patients were divided into two groups based on whether a focus of infection could be identified or not. Data collection included patient characteristics, microbiological results, antibiotic regimen, and clinical course. A focus of infection was found in 29% (29/100) of the patients, most frequently in the tonsils. A causative microorganism was found in 75% (75/100) of all patients, with Staphylococcus aureus and Streptococcus pyogenes being the most common pathogens. All patients received an empiric antibiotic therapy in addition to surgery. Antibiotic medication was changed in 31% in both groups (9/29 with a focus of infection and 22/71 without a focus of infection) during therapy. Children without an identified focus of infection generally were younger and had more comorbidities reducing immune response while also showing differences in the pathogens involved. There were no complications associated to surgery or antibiotic therapy in any of the patients involved.

CONCLUSION

Children with an identified focus of infection show several differences compared to those with isolated lateral abscesses, especially regarding the microorganisms involved. But the focus of infection seems not to have an impact on patient's outcome.

WHAT IS KNOWN

• Neck abscesses are a relatively common disease in the pediatric population and may cause serious complications. • Therapy in general consists of intravenous antibiotics with or without surgery.

WHAT IS NEW

• The focus identification has no impact on patient's outcome. • Children with an identified focus of infection show several differences compared to those with isolated lateral abscesses, especially regarding their medical history, age, and the microorganisms involved.

Failure factors in pediatric deep neck space abscess surgical management

INTRODUCTION

Deep neck space infections (DNSI) in pediatric otolaryngology are a common occurrence in the inpatient setting. A subset of DNSI patients will fail medical and surgical management. It is difficult to predict which patients will fail. There are no studies that effectively evaluate variables associated with readmission and reoperation for DNSI abscesses. The purpose of this study was to evaluate the specific perioperative decisions that may lead to combined therapy failure and necessitate reoperation.

METHODS

A case-control study was performed at a single center academic tertiary care hospital. Patients <18 years old treated from January 2015 to April 2020 with a surgically treated DNSI were reviewed. The single incision and drainage group (SOp) and reoperation group (ReOp) were evaluated with reoperation performed within a 30-day period. Intravenous antibiotic administration timing, drain management and type (gauze or latex), diagnostic, and postoperative factors were evaluated.

RESULTS

The SOp group consisted of 275 patients and the ReOp group of 21 patients. The average preoperative intravenous antibiotic time showed no statistical difference (p = 0.884) and no increased risk for reoperation (p = 0.470; OR = 0.993). Timing of drain removal showed a significant difference (p < 0.005; 41.1 SOp vs 46.5 h ReOp). Abscess location (p = 0.855) and complications rate did not vary (p = 0.450). Gauze drains were used in 131 (44.3%), latex in 80 (27%), and no drain in 84 (28.4%) with no difference regarding reoperation (p = 0.124). Length of stay was longer in the ReOp group (8 vs 4 days; p < 0.001). The average measured dimension for each group did not significantly vary (p = 0.633).

CONCLUSIONS

The duration of antibiotics in the preoperative period showed no statistical role in the need for reoperation in DNSI abscess patients. Drain type and duration also had a potentially clinically relevant association with the need for reoperation. Extensive unknown abscess pockets or inadequate technique may be the main contributors to the need for reoperation.

Clinical features of Kawasaki disease initially mimicking retropharyngeal abscess: a retrospective analysis

OBJECTIVE

Incomplete Kawasaki disease (IKD) initially presenting as retropharyngeal abnormality is very rare and is prone to misdiagnosis and missed diagnosis, often leading to poor prognosis. Most patients were misdiagnosed with retropharyngeal abscesses. Here, we describe and compare IKD patients initially presenting with retropharyngeal abnormalities, typical KD patients without retropharyngeal abnormalities and retropharyngeal abscess patients.

METHODS

We performed a retrospective case-control study comparing IKD patients initially presenting with retropharyngeal abnormalities to both KD patients without retropharyngeal abnormalities and retropharyngeal abscess patients admitted to Shenzhen Children's Hospital between January 2016 and December 2021.

RESULTS

We evaluated data from 10 IKD patients initially presenting with retropharyngeal abnormalities (Group A), 20 typical KD patients (Group B) and 16 surgical drainage confirmed retropharyngeal abscess patients (Group C). Compared to Group B, we observed that Group A was older and had a more intense inflammatory response. On the day of admission, Groups A and C had similar early clinical presentations, and there were no significant differences in any major signs or symptoms. Close observation for the development of new KD signs and symptoms and unresponsiveness to empirical antibiotic therapy after 3 days is extremely important. The CRP (p = 0.011), AST (p = 0.002) and ALT (p = 0.013) levels were significantly higher and the WBC (P = 0.040) levels were significantly lower in Group A than in Group C. Neck radiological findings, such as the presence of ring enhancement (p = 0.001) and mass effects on the airway, are also useful tools for distinguishing these two diseases.

CONCLUSION

The careful observation of the signs and symptoms of this disease and the comprehensive analysis of the laboratory tests and neck radiological findings may help clinicians become aware of retropharyngeal abnormality as an atypical presentation of KD. Then, unnecessary treatments could be reduced, and the occurrence of serious complications can be avoided.

Role of steroids in conservative treatment of parapharyngeal and retropharyngeal abscess in children

Purpose

To characterize the clinical features and outcomes of pediatric patients with retropharyngeal (RPA) or parapharyngeal abscesses (PPA) managed only with medical treatment and showing the importance of early symptoms and imaging studies in the diagnosis of deep neck space infections (DNIs) in children.

Methods

A retrospective analysis of all patients diagnosed with RPA and PPA between 2007 and 2017 was performed in Hospital Universitario Central de Asturias.

Results

30 children were identified, with 11 RPA and 19 PPA. 23 children (76.7%) were under 5 years old, and all were treated with intravenous amoxicillin/clavulanic acid and corticosteroids. Torticollis and fever were present in all patients. The mean length of hospital stay was 7.5 days. There were no complications associated.

Conclusion

DNIs can be treated in a conservative way, reserving the surgical drainage for cases with a complication associated (airway compromise, lack of response to antibiotic therapy, immunocompromised patients). Treatment with intravenous antibiotics and corticosteroids is a safe option, reducing the duration of symptoms and the length of hospital stay.

Paediatric Deep Neck Infection—The Risk of Needing Intensive Care

Deep neck infections are potentially dangerous complications of upper respiratory tract or odontogenic infections. The pathophysiology, clinical presentation, and potential spreading depend on the complex anatomy of the neck fascia. These infections can lead to severe pathological conditions, such as mediastinitis, sepsis, and especially airway impairment with difficult management. Because of the risk of life-threatening emergency situations and the possible impacts on the overall health status of affected children, their early recognition is of utmost importance. Torticollis, drooling, and stridor are the most common signs of advancing disease. Children presenting with these symptoms should be admitted to the paediatric intensive care unit for vital function monitoring, where the airway could be readily secured if function is compromised.

[Differential diagnosis of parapharyngeal abscess with multisystem inflammatory syndrome in children associated with COVID-19]

The pandemic of the new coronavirus infection (COVID-19) has identified new diagnostic and medical tasks before different doctors. As observations show, children have the flow of infection easier than adults. However, in some cases, COVID-19 in children proceeds extremely difficult, with fever and multisystem inflammation, possibly requiring treatment in the resuscitation department. In domestic practice, the term "Multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19" is used to indicate the disease. Among the local symptoms of MIS are inflammations of the skin and mucous membranes, as well as various lymphadenopathy. The article presents the results of our clinic's observation of 205 patients with MIS for the period from May 2020 to May 2021. In some patients, the clinical manifestations of MIS-C required differential diagnosis with parapharyngeal abscesses (PPA). For this purpose, the children were consulted by an otorhinolaryngologist and a CT scan of the neck with contrast enhancement was performed. Despite the striking clinical manifestations similar to PPA, in no case was a pharyngeal abscess revealed. Both of these diseases are potentially fatal if treatment is not started on time, and therefore we believe that the awareness of otorhinolaryngologists about the manifestations of MIS-C will be useful in modern clinical practice.

Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses

Deep neck infections (DNIs) include all the infections sited in the potential spaces and fascial planes of the neck within the limits of the deep layer of the cervical fascia. Parapharyngeal and retropharyngeal infections leading to parapharyngeal abscess (PPA) and retropharyngeal abscess (RPA) are the most common. DNIs remain an important health problem, especially in children. The aim of this narrative review is to describe the management of peritonsillar, retropharyngeal and parapharyngeal abscesses in pediatric age. Despite relatively uncommon, pediatric DNIs deserve particular attention as they can have a very severe course and lead to hospitalization, admission to the intensive care unit and, although very rarely, death. They generally follow a mild upper respiratory infection and can initially present with signs and symptoms that could be underestimated. A definite diagnosis can be made using imaging techniques. Pus collection from the site of infection, when possible, is strongly recommended for definition of diseases etiology. Blood tests that measure the inflammatory response of the patient may contribute to monitor disease evolution. The therapeutic approach should be targeted toward the individual patient. Regardless of the surgical treatment, antibiotics are critical for pediatric DNI prognosis. The diagnostic-therapeutic procedure to be followed in the individual patient is not universally shared because it has not been established which is the most valid radiological approach and which are the criteria to be followed for the differentiation of cases to be treated only with antibiotics and those in which surgery is mandatory. Further studies are needed to ensure the best possible care for all children with DNIs, especially in this era of increased antimicrobial resistance.

Variability in advanced imaging of pediatric neck infections in US emergency departments

OBJECTIVES

To describe the use of computed tomography (CT) and ultrasound (US) imaging for the evaluation of neck infections in pediatric patients in United States emergency departments (EDs).

METHODS

This is a cross-sectional analysis, using the National Emergency Department Sample database, of pediatric patients evaluated for common neck infections between 2012 and 2018. We used bivariable analysis to assess for differences in US and CT use by ED type. We performed multivariable logistic regression to adjust for potential confounding factors including patient characteristics (sex, age, insurance status, discharge diagnosis) and ED characteristics (metropolitan statistical area, pediatric center). Results are reported as odds ratios and adjusted odds ratios with 95% confidence intervals.

RESULTS

There were 19,363 ED visits for pediatric neck infections in the database over the study period, representing 84,439 national visits. Of those imaged, 80.8% were imaged with CT and 19.2% were imaged with US. Pediatric patients evaluated in general EDs as compared to pediatric EDs (aOR 5.32, 95% CI 3.06, 9.24) and patients with a diagnosis of peritonsillar abscess (aOR 2.11, 95% CI 1.34, 3.33) and retropharyngeal abscess (aOR 6.12, 95% CI 2.14, 17.53) were more likely to be imaged with CT scan.

CONCLUSIONS

Children with neck infections evaluated in general EDs are significantly more likely to undergo CT scans when compared to those evaluated in pediatric EDs. To reduce exposure to radiation in children, we propose the dissemination of US-first protocols in general EDs for the evaluation of pediatric neck infections.

Deep Neck Abscesses in Children: An Italian Retrospective Study

BACKGROUND

Retropharyngeal and parapharyngeal abscesses (RPAs, PPAs) usually affect young children. Surgical drainage and/or antibiotic therapy are treatment of choice, but no specific guidelines exist. In order to reduce the risk of severe complications, appropriate diagnosis and therapy are necessary. The aims of the study were to review diagnosis and management of children with RPAs/PPAs and to compare surgical versus medical approach.

METHODS

This is a multicenter retrospective study including all patients younger than 15 years admitted at 4 Italian pediatric hospitals of Florence, Padua, Rome, and Treviso, with International Classification of Diseases, Ninth Revision discharge diagnosis code of RPAs and PPAs, from January 1, 2008, to December 31, 2016.

RESULTS

One hundred fifty-three children were included. The median age was 4.4 years, with overall male predominance. Heterogeneous signs and symptoms (fever, neck cervical, lymphadenopathy, pain, and stiff neck most frequently) and a large mixture of bacteria from pus cultures were detected. Computer tomography (66.7%) and magnetic resonance imaging (27.5%) were performed to confirm the presence of abscess. Fifty-one percent of abscesses were greater than 3 cm. Eighty-seven patients (56.9%) underwent surgery, and 66 (43.1%) were treated with antibiotics alone (mostly ceftriaxone, metronidazole, amikacin, and clindamycin) with median days of therapy of 26.5 days and length of therapy of 16.0 days of median. Median length of stay was 11 days. None had severe complications. Multivariate analysis indicated as independent predictive factors of surgery abscess of 3 cm or greater, high white blood cell count, and-most of all-the hospital of admission.

CONCLUSIONS

Deep neck abscesses mostly affect patients in early childhood, with a combination of nonspecific signs and symptoms, and it still emerges as a heterogeneous approach in diagnosis and management of these infections. Thus, common shared protocols represent an essential tool in order to standardize care and improve patients' outcomes.

Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses

BACKGROUND AND OBJECTIVES

Treatment of retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs) includes antibiotics, with possible surgical drainage. Although corticosteroids may decrease inflammation, their role in the management of RPAs and PPAs is unclear. We evaluated the association of corticosteroid administration as part of initial medical management on drainage rates and length of stay for children admitted with RPAs and PPAs.

METHODS

We conducted a retrospective study using administrative data of children aged 2 months to 8 years discharged with RPAs and PPAs from 2016 to 2019. Exposure was defined as systemic corticosteroids administered as part of initial management. Primary outcome was surgical drainage. Bivariate comparisons were made between patients in the corticosteroid and noncorticosteroid groups by using Wilcoxon rank or χ² tests. Outcomes were modeled by using generalized linear mixed-effects models.

RESULTS

Of the 2259 patients with RPAs and PPAs, 1677 (74.2%) were in the noncorticosteroid group and 582 (25.8%) were in the corticosteroid group. There were no significant differences in age, sex, or insurance status. There was a lower rate of drainage in the corticosteroid cohort (odds ratio: 0.28; confidence interval: 0.22-0.36). Patients in this group were more likely to have repeat computed tomography imaging performed, had lower hospital costs, and were less likely to have opioid medications administered. The corticosteroid cohort had a higher 7-day emergency department revisit rate, but there was no difference in length of stay (rate ratio 0.97; confidence interval: 0.92-1.02).

CONCLUSIONS

Corticosteroids were associated with lower odds of surgical drainage among children with RPAs and PPAs.

A case of intracranial vasospasm in a patient with extensive retropharyngeal cellulitis

Retropharyngeal cellulitis/abscesses are deep neck infections that may become life-threatening if airway compromise occurs. This condition is more common in children than in adults, and associated intracranial vessel narrowing has been reported. We report an adult patient with extensive retropharyngeal cellulitis and intracranial vasospasm. The patient was a 62-year-old woman who presented with fever, sore throat, and neck pain. She also had uncontrolled type 2 diabetes mellitus. Leukocytosis, prolonged erythrocyte sedimentation rate, elevated C-reactive protein, and hyperglycemia were present on admission. Computed tomography and contrast-enhanced magnetic resonance imaging revealed severe swelling in the nasopharyngeal, retropharyngeal, prevertebral, and bilateral carotid spaces. Gadolinium enhancement extended to the middle cranial fossa and visceral space. Multiple stenoses in several intracranial vessels was also identified. Intravenous antibiotic therapy was initiated, the patient's symptoms resolved, and repeat imaging confirmed improvement. Intracranial vasospasm should be considered in patients with retropharyngeal cellulitis.

The treatment of streptococcal tonsillitis/pharyngitis in young children

Pharyngitis is common in children, accounting for nearly 12 million visits annually in the United States. Streptococcus pyogenes or group A streptococcus (GAS) is the most common bacterial cause of pharyngitis for which antibiotics are indicated. Antibiotic treatment of streptococcal pharyngitis virtually eliminates the presence of bacteria from the pharynx and thus removes the risk of subsequent rheumatic fever. GAS is spread from person to person via respiratory droplets with a short incubation period of 2∼5 days. GAS pharyngitis peaks in the late winter and early spring months when children are predominately indoors for school and sports. Colonization is also higher in winter months, and while up to 20% of school age children are colonized with GAS in their throat during this time, colonization has not been shown to contribute to the spread of disease. In low- and middle-income countries and other situations in which crowding is common (e.g., schools), outbreaks of pharyngitis are common. GAS pharyngitis can occur at all ages and it is most common in school-aged children with a peak at 7∼8 years of age. Pharyngitis caused by GAS is rare in children <3 years of age and becomes much less common in late adolescence through adulthood.

Variation in the Management of Children With Deep Neck Infections

BACKGROUND AND OBJECTIVES

Children with deep neck infections (DNIs) are increasingly being managed nonsurgically with intravenous antibiotics. Our objective was to examine variation in the management of children with DNIs across US children's hospitals.

METHODS

We conducted a retrospective cohort study using the Pediatric Health Information System database. Children ≤12 years of age hospitalized for retropharyngeal or parapharyngeal abscesses from 2010 to 2018 were included. Hospital variation in management modality and imaging use was described. Temporal trends in management modality were assessed by using logistic regression. Medical management alone versus a combination of medical and surgical management was assessed, and the characteristics of children in these 2 groups were compared. The relationship between hospital rates of initial medical management and failed medical management was assessed by using linear regression.

RESULTS

Hospitals varied widely in their rates of surgical management from 17% to 70%. The overall rate of surgical management decreased from 42.0% to 33.5% over the study period. Children managed surgically had higher rates of ICU admission (11.5% vs 3.2%; P < .001) and higher hospital charges ($25 241 vs $15 088; P < .001) compared with those managed medically alone. Seventy-three percent of children underwent initial medical management, of whom 17.9% went on to undergo surgery. Hospitals with higher rates of initial medical management had lower rates of failed medical management (β = -.43).

CONCLUSIONS

Although rates of surgical management of pediatric DNI are decreasing over time, there remains considerable variation in management across US children's hospitals. Children managed surgically have higher rates of resource use and costs.

Resource utilization of intraoperative cultures for pediatric deep neck space abscesses

INTRODUCTION

Peritonsillar (PT), parapharyngeal (PP), and retropharyngeal (RP) abscesses are common pediatric deep neck space infections (DNSI). Despite established literature on DNSI microbiology, obtaining intraoperative cultures remains commonplace. The objective was to evaluate the resource utilization of intraoperative cultures when draining PT, PP, and RP abscesses.

METHODS

Pediatric patients (age <18.0 years) who underwent surgical drainage of a PT, PP, or RP abscess between January 2013 and June 2018 were retrospectively reviewed. Changes in antimicrobials based on intraoperative culture results were assessed by use of Fisher's exact tests or Wilcoxon rank-sum tests, as appropriate. Multivariable linear regression was used to model the association between factors of interest and number of cultures obtained.

RESULTS

Eighty-eight patients underwent surgical drainage, of which 80 patients (median age 6.96 years) had intraoperative bacterial cultures (32 PT, 21 PP, and 27 RP). There were no positive fungal or acid-fast bacilli cultures. Seven patients had culture-directed changes in treatment; none of these patients had a PT abscess. Age was inversely associated with culture-directed changes (p = 0.006) while the use of blood cultures (p = 0.012) was positively associated with culture-directed treatment changes. Hospital length of stay (p < 0.001) and history of prior DNSI (p = 0.001) were associated with number of cultures obtained.

CONCLUSIONS

Younger children with PP and RP abscesses are most likely to benefit from intraoperative bacterial cultures. Cultures of PT abscesses are unlikely to change clinical management. Fungal and acid-fast bacilli cultures are unlikely to yield clinically useful information. Prudent use of intraoperative cultures may decrease the use of hospital resources and admission-related costs.

Utility of Soft Tissue Lateral Neck Radiographs in the Emergency Department: The 5-Year Experience of a Large Tertiary Care Pediatric Hospital

INTRODUCTION

Although retropharyngeal infection (RPI) may present with voice change, drooling, fever, and a toxic appearance, diagnosis based on symptoms alone is unreliable. As incidence is increasing in children and drug-resistant bacterial strains such as methicillin-resistant Staphylococcus aureus are becoming more common, we decided to assess the clinical utility of lateral neck radiography.

OBJECTIVE

The aim of this study was to review the experience of a large tertiary care pediatric emergency department (ED) in using lateral soft tissue neck radiographs in the diagnosis of suspected RPI.

METHODS

A retrospective analysis of all lateral soft tissue neck radiograph reports from 2011 to 2015 in conjunction with a review of patients' charts to describe clinical and laboratory findings, disposition, and final diagnosis was performed. Patients aged 31 days to 18 years who presented to the ED with suspicion of RPI were included.

RESULTS

Review of 366 radiographic reports revealed that 46 were positive for RPI, 286 were negative, and 34 indeterminate. A final discharge diagnosis of RPI was made in 38 patients. Lateral neck radiographs had a sensitivity of 84.3% and a specificity of 93.7% for diagnosing RPI. In triage, most patients had no fever (264, 72.1%), stridor (356, 97%), drooling (348, 95%), or voice change (342, 93%). Surgical intervention occurred in 15 patients (39.5%) with a final diagnosis of RPI.

CONCLUSIONS

Lateral neck radiography is useful for diagnosis of RPI in the ED with good sensitivity and specificity. Additional imaging is to be considered at the behest of physician's clinical judgment.

Clinical characteristics for conservative therapy of pediatric parapharyngeal abscesses

Introduction

The role of surgical drainage versus conservative therapy in treating patients with parapharyngeal abscesses is still a theme of debate.

Objectives

This study aimed to investigate the characteristics associated with good outcomes in pediatric patients with parapharyngeal abscesses treated with conservative therapy.

Methods

This 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.

Results

A 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).

Conclusion

The 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.

Management of pediatric peritonsillar and deep neck infections- cross- sectional retrospective analysis

Objective

Deep neck infections (DNI) are responsible for significant morbidity in children and healthcare expenditures. Few studies exist specifically addressing the clinical and epidemiologic characterization and management of DNI's in the pediatric population. Our goal was to analyse the demographic characteristics, clinical presentation, diagnostic and therapeutic approaches of peritonsillar and DNI in pediatric patients.

Methods

The medical records of patients, aged up to 18 years, admitted for peritonsillar and DNI at our department, from 2011 to 2016, were retrospectively reviewed and compared with the literature available. Ninety-eight patients were enrolled.

Results

The mean age was higher in patients with peritonsillar abscess and lower in patients with retropharyngeal and parapharyngeal infections. Admissions have significantly increased from 2011. There was a seasonal variation for DNI incidence, with a peak incidence in Summer and Spring. All patients included were treated as inpatient and received empirical intravenous antibiotic therapy and steroids regardless of drainage procedures. Incision and drainage was performed in 72 patients. The hospital length of stay was higher among patients with retropharyngeal abscess and in the group with complications. Only 2 patients developed complications during hospital stay. The most common microbiological pattern was monomicrobial and the most commonly isolated pathogens were Streptococcus Pyogenes, Streptococcus Mitis and anaerobic bacteria.

Conclusions

Surgical incision and drainage followed by intravenous antibiotic and steroids proved to be successfull with low morbidity related to surgical approach. However, in selected cases, medical therapy may be an alternative to surgical management in uncomplicated infections.

Trends in the management of peritonsillar abscess in children: A nationwide population-based study in Taiwan

OBJECTIVE

Population-based studies analyzing peritonsillar abscess in children are lacking. In this study, a population-based survey of the epidemiology of pediatric peritonsillar abscess in Taiwan was conducted.

METHODS

This cross-sectional study was conducted using the Taiwan National Health Insurance Research Database. All cases of inpatient pediatric peritonsillar abscess (age < 18 years) in Taiwan between 2000 and 2012 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification. Incidence rates of inpatient peritonsillar abscess in children were calculated. Characteristics such as age, gender, hospital level, treatment modalities, imaging studies, drug administration, and length of hospital stays during the study period were analyzed.

RESULTS

A total of 12,965 children with peritonsillar abscess were included (mean age, 6.6 years [standard deviation, 4.8 years]; 56.5% boys). The overall incidence was 18 per 100,000 children. Incidence rates decreased from 2000 to 2012 (19.1/100,000 to 8.3/100,000 children) (p_trend < 0.001). During the study period, the proportion of peritonsillar abscess treatments at medical centers increased from 4.6% to 15.0%. The proportion of treatments involving incision and drainage or needle aspiration increased significantly (1.3%-4.1% and 49.4%-65.6%, respectively), whereas treatments with antibiotics only decreased significantly (48.9%-29.0%). The use of computed tomography (CT) increased (1.4%-12%, p_trend < 0.001). The use of nonsteroidal anti-inflammatory drugs, steroids, and penicillin increased during the study period. The mean length of hospital stays increased from 3.78 to 4.67 days.

CONCLUSIONS

The incidence of peritonsillar abscess in children decreased between 2000 and 2012 in Taiwan. Moreover, increasing trends were observed in the use of CT, the rates of incision and drainage and needle aspiration procedures, and the length of hospital stay in this study cohort.

Wisdom Tooth's Revenge: Retropharyngeal Abscess and Mediastinitis after Molar Tooth Extraction

Retropharyngeal abscess is potentially associated with high morbidity and mortality as a result of its direct anatomical connection with the mediastinum. Therefore, knowledge of the relevant anatomy is essential for recognizing the presence and extent of disease in a timely manner. In this case report, we aim to review the pertinent anatomy and patterns of spread of infection from a full blown deep neck space infection to result in mediastinitis and empyema.

Is vessel narrowing secondary to pediatric deep neck space infections of clinical significance?

INTRODUCTION

Pediatric deep neck space infections (DNSI) may cause internal jugular vein and/or carotid artery narrowing. Radiologists and otolaryngologists are often queried by emergency room providers and pediatricians with regards to the clinical significance when this radiographic finding is noted. There are often questions raised about need for further imaging, anticoagulation and overall management strategy. There is limited data to support our answers to these questions. This study investigated the clinical significance of vessel narrowing of the internal jugular vein and carotid artery in the setting of DNSI in children.

METHODS

208 patients over a 10 year period were reviewed in retrospective fashion. CT scans reports were evaluated for vessel narrowing, and clinical outcomes were analyzed.

RESULTS

This study found that nearly half (44.7%, 93 of 208) of pediatric DNSIs reviewed showed evidence of either carotid and/or internal jugular vein narrowing. There was no significant difference in vascular complications in those with vessel narrowing and those without (p = 0.09). There were no observed neurologic complications in either group.

CONCLUSIONS

Vessel narrowing is a very common finding in pediatric DNSI. Vascular complications are very rare, and importantly no patients had neurologic complications in either group (vessel narrowing or not). We found no evidence to support more aggressive surgical management, getting further imaging, starting anticoagulation, nor changing overall management strategy for patients based solely to the finding of vessel narrowing in DNSI.

Comparison of inpatient versus outpatient management of pediatric peritonsillar abscess outcomes

INTRODUCTION

Peritonsillar abscess (PTA) in pediatric patients is a challenging condition to diagnose and treat, and recurrence can occur in up to 15% of patients. This condition can be managed in various settings and there may be outcome differences depending on the choice of inpatient/outpatient management. The objective of this study was to evaluate immediate and long-term outcomes, specifically recurrence, after PTA management in the inpatient versus outpatient setting as well as specific patient characteristics leading to hospital management decisions.

METHODS

We conducted a retrospective cohort study of all suspected cases of PTA seen at a tertiary pediatric hospital from 2008 to 2017, and 566 confirmed cases of PTA were included in this study. Demographics, PTA management, recurrence, and subsequent tonsillectomy (immediate or within 1 year of diagnosis) were ascertained from patient medical records. We compared characteristics of patients seen in the inpatient and outpatient setting using Chi-squared and Wilcoxon-Mann-Whitney tests.

RESULTS

Patients treated in the outpatient setting were more likely to be older and have a lower rate of recurrent ear infections (p < 0.0001 and p = 0.01 respectively). Additionally, no differences in gender, Down Syndrome, or autism were found. Patients who were admitted were more likely to undergo immediate tonsillectomy within a month or tonsillectomy within one year (p < 0.0001 and p = 0.02 respectively), whereas patients in the outpatient setting were more likely to receive antibiotics alone (p < 0.0001). Outpatient management was associated with no differences in recurrence rate within 30 days (p = 0.56). However, recurrence was associated with older age, a history of recurrent tonsillitis, but not a history of ear infections (p = 0.005, p < 0.0001, and p = 0.49 respectively). A history of recurrent ear infections, recurrent tonsillitis and recurrent PTAs were associated with the decision to pursue a tonsillectomy (p = 0.003, p = 0.03, and p < 0.0001 respectively).

CONCLUSIONS

Patients seen in the outpatient setting are more likely to receive antibiotics alone as their initial treatment, likely a result of certain clinical characteristics and presenting features as well as uncertain diagnosis. Inpatient status was associated with a younger age and a history of ear infections while recurrence was associated with a history of recurrent tonsillitis and older age. The recurrence rates for outpatient management were not statistically different than inpatient, suggesting that triaging and treatment of patients was occurring appropriately. The association of tonsillectomies in the inpatient group within 12 months is likely due to the higher rate of preexisting tonsil issues considering that recurrent tonsillitis, ear infections and a higher rate of PTA recurrence were all statistically correlated.

The increasing cost of pediatric otolaryngology care

INTRODUCTION

Defining the costs associated with healthcare is vital to determining and understanding ways to reduce costs and improve quality of healthcare delivery. The objective of the present study was to identify the current public health burden of inpatient admissions for conditions commonly treated by pediatric otolaryngologists and compare trends in healthcare utilization with other common surgical diagnoses.

METHODS

A retrospective cohort study using the Kids' Inpatient Database for pediatric discharges in the United States from 2000 to 2012. A list of the top 500 admission diagnoses was identified and subsequently grouped into surgical diagnoses typically managed by otolaryngologists and those managed by any other surgical discipline with the top 10 in each category included. Database analyses generated national estimates of summary statistics and comparison of trends over the twelve-year period.

RESULTS

Of the top pediatric admission diagnoses, the most common conditions managed by surgical specialties involved inflammatory or infectious causes. Hospital charges significantly increased during this time across all diagnoses. On average, the charges for otolaryngologic diagnoses increased by 37.13% while costs increased by almost 12%. In comparison, the charges for non-otolaryngologic diagnoses increased by 35.87% and the costs by 10.43%.

CONCLUSIONS

The public health impact and rising costs of healthcare are substantial. It is of critical significance that the healthcare system be aware of opportunities and lessons that may be learned across specialties to identify the primary drivers of healthcare cost while maintaining high quality standards for patient care.

What Are the Primary Cost Drivers of Anterior Cruciate Ligament Reconstruction in the United States? A Cost-Minimization Analysis of 14,713 Patients

PURPOSE

To analyze the individual costs associated with anterior crucial ligament reconstruction (ACLR), accounting for patient demographics, perioperative decision making, and location of the surgical procedure (hospital vs ambulatory surgery center), utilizing a cost-minimization analysis in a large national database.

METHODS

Univariate analysis and multiple linear regression were performed to determine which patient and surgical variables were the largest cost drivers for ACLR in the United States according to the State Ambulatory Surgery and Services Database.

RESULTS

The average cost for ACLR (n = 14,713) was $24,707 (standard deviation, $15,644). When patient variables were considered, younger age (P < .001), male sex (P < .001), Hispanic ethnicity (P < .001), number of chronic medical conditions (P < .001), Medicare insurance (P < .001), and quartile of household income (P < .001) were all associated with higher costs after ACLR. For operative variables, time spent in the operating room (P < .001), meniscal repair (P < .001), and use of general anesthesia alone (P < .001) were all associated with higher costs for ACLR. There was no significant difference between cost of surgery performed at a private surgery center and cost at a hospital-owned center. In the multivariate regression, the 3 variables with the greatest influence on cost of ACLR were use of isolated general anesthesia (associated with an increase of $2,049), Hispanic ethnicity ($1,828), and >1 chronic medical condition ($1,749). Male sex, time in operating room, and older age also significantly increased ACLR cost.

CONCLUSIONS

The greatest contributor to cost of ACLR was the use of general anesthesia alone. Time spent in the operating room increased ACLR cost by $108 per minute. Patient factors included greater age, male sex, Hispanic ethnicity, number of chronic medical conditions, Medicare insurance, and annual income. Meniscal repair and regional nerve block did not significantly affect cost as determined by multivariate regression.

Defining the role of surgical drainage in paediatric deep neck space infections

OBJECTIVES

Surgical drainage is the traditional mainstay of treatment of paediatric deep neck space infection (DNSI), but recently non-operative management in selected cases has been advocated. We sought to identify any characteristics predictive of requirement for surgical intervention.

DESIGN

Retrospective cohort study using receiver operating characteristics analyses.

SETTING

Tertiary referral paediatric hospital.

PARTICIPANTS

Children (≤16 years) with a radiologically confirmed diagnosis of retro- or parapharyngeal abscess over a ten-year period.

MAIN OUTCOME MEASURES

Predictive value of clinical and radiological variables in determining the requirement for surgical intervention. Length of hospital stay (LoS) was also examined.

RESULTS

Ninety-three children were studied, 15 (16.1%) of whom underwent immediate surgery, 42 (45.2%) of whom underwent delayed surgery following an initial period of conservative management, and 36 (38.7%) of whom were managed conservatively. Age, WCC and CRP were not predictive of the need for surgical drainage. Radiological abscess diameter, however, was predictive of requirement surgery (AUC = 0.85 [95% CI ± 0.09] P = 0.02), with a cut-off value of 2.5 cm determined assuming equal weight to sensitivity and specificity. All DNSIs were successfully treated with no adverse outcomes, and there was no significant difference in LoS between groups. In those managed surgically, outcome and LoS did not depend on yield of pus.

CONCLUSIONS

Selected paediatric DNSIs can be successfully managed conservatively, with abscess diameter >2.5 cm a significant predictor of need for surgical intervention. Any benefit of surgery does not appear to depend on intra-operative yield of pus.

Infant Midnasal Stenosis: Reliability of Nasal Metrics

BACKGROUND AND PURPOSE

Midnasal stenosis is a poorly defined entity that may be a component of other conditions of nasal obstruction contributing to respiratory distress in infants. We sought to establish whether midnasal vault narrowing is a component of well-defined syndromes of nasal narrowing, such as bilateral choanal atresia and pyriform aperture stenosis, and to characterize the nasal anatomy of patients with syndromic craniosynostosis.

MATERIALS AND METHODS

A convenience sample of patients with pyriform aperture stenosis, bilateral choanal atresia, and Apert and Crouzon syndromes with maxillofacial CT scans was identified. Patients with Pierre Robin Sequence were used as controls. Nasal measurements were performed at the pyriform aperture, choana, and defined midnasal points on axial and coronal CT scans. Intra- and interrater reliability was quantified with the intraclass correlation coefficient. T tests with Bonferroni adjustment were used to assess differences from controls.

RESULTS

The study included 50 patients: Eleven had pyriform aperture stenosis, 10 had Apert and Crouzon syndromes, 9 had choanal atresia, and 20 were controls. Measurements in patients with pyriform aperture stenosis and Apert and Crouzon syndromes were narrower than those of controls at all measured points (P < .001). Measurements in patients with choanal atresia were only narrow in the posterior half of the nose (P < .001). The intra- and interrater reliability of midnasal and pyriform measurements was very good to excellent (intraclass correlation coefficient > 0.87). The choanal measurement was good (intraclass correlation coefficient = 0.76-0.77).

CONCLUSIONS

Pyriform aperture stenosis, Apert and Crouzon patients were narrower at all measured points compared to controls. Bilateral choanal atresia patients were only narrower in the posterior half of the nose. More research is needed to evaluate the clinical implications of these radiographic findings.

Utilization of emergency department computed tomography and otolaryngology consultation in the diagnosis of pediatric peritonsillar abscess

OBJECTIVES

To determine whether obtaining a computed tomography (CT) scan in the emergency department (ED) is predictive of peritonsillar abscess (PTA) in the pediatric population, and to evaluate for clinical characteristics that may suggest whether a CT is beneficial in the diagnosis of pediatric PTA.

METHODS

Single-institution retrospective chart review at Rush University Hospitals. Study included pediatric patients, aged 17 or younger, who presented to the ED with suspected PTA over a 6-year period. Patients received a neck CT and/or an official otolaryngology consultation. Relevant demographic and study parameters were collected and statistically analyzed using SPSS.

RESULTS

A total of 36 pediatric patients with suspected PTA. Of these, 47.2% (17/36) received a diagnosis of PTA while 52.8% (19/36) received an alternative diagnosis. Patients with PTA were more likely to have trismus (41.2% vs 5.3%; p < .01), uvular deviation (94.1% vs 15.8%; p < .01), and palatal edema (52.9% vs 10.5%; p < .01), compared to patients without PTA. Fewer CT scans were ordered when comparing PTA positive versus negative cohorts (35% vs 63.2%; p = .10), however this was not statistically significant. An otolaryngology consult prior to imaging did significantly reduce the frequency of ordered CT scans (12.5% vs 63.6%; p < .01).

CONCLUSION

This is the first study to investigate the benefit of CT imaging in the diagnosis of pediatric PTA and impact of an otolaryngology consult on the frequency of CT scans. Pediatric patients at high risk for PTA based on clinical findings may not require CT imaging for diagnosis. Patients at lower risk may benefit from imaging based on the availability of an otolaryngology consult or expertise of the examiner.

An analysis of perioperative outcomes following cervical abscess drainage in children under 2 years

OBJECTIVE

To identify risk factors and determine perioperative morbidity of children under 2 years of age undergoing cervical abscess drainage.

METHODS

Patients who underwent cervical abscess drainage 1-18 years of age were queried via the ACS-National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database (2012-2015). Analyzed outcomes include length of stay, operative time, readmission/reoperation rate, and postoperative complications.

RESULTS

A total of 2181 children were identified, 858 were <2 (51.5% male) and 1323 were >2 years (57.1% male) (p = 0.011). The younger cohort was found to undergo more lateral approaches for cervical abscess drainage whereas the older cohort was found to undergo more intraoral approaches for pharyngeal abscess drainage (p < 0.001), suggesting a difference in abscess location related to age at clinical presentation. The younger cohort was also found to have a higher preoperative white blood cell count (20.7 vs. 17.5, p < 0.001) but no significant difference in preoperative fulminant sepsis was observed. Younger children were found to have both a longer wait-time until surgery (1.4 vs. 1.1 days, p = 0.003) and a prolonged length of stay (LOS) (4.3 vs. 3.4 days, p < 0.001). Operative time was found to be lower in the younger cohort (18.4 vs. 21.5 min, p = 0.003), Finally, the younger cohort was found to have an increased incidence and duration of postoperative mechanical ventilation (63 vs. 41, and 0.4 vs. 0.1 days, respectively, p < 0.001.). There were no differences in post-op complications (wound infection, dehiscence, pneumonia, reintubation, and reoperation/readmission). Linear regression for LOS showed that major contributors were operative time, days of postop ventilation, and days from admission to surgery with R = 0.700.

CONCLUSION

Children under 2 years of age have longer LOS that may in part be due to a greater likelihood of postoperative ventilation and a delay in operative intervention, despite having surgical approaches associated with a shorter LOS. They are no more prone to complications than are older children. Recognition of these critical factors plays a role in optimizing perioperative risk assessment and procedural planning within this patient population.

Acute Infections That Produce Upper Airway Obstruction

This chapter discusses the common and potentially serious infective causes of acute upper airway obstruction in children. The laryngeal anatomy of young children makes them particularly susceptible to upper airway obstruction, and during acute infections this is exacerbated by inflammation and edema of the airway mucosa. The most common cause of infective upper airway obstruction in children is viral laryngotracheobronchitis, or croup, which is usually a mild and self-limiting illness, but management with corticosteroids may still be necessary. Bacterial causes of upper airway obstruction have fortunately become rare since the introduction of the Haemophilus influenzae B (HiB) immunization, but a few cases of epiglottitis do still occur due to nonimmunization, vaccine failure, and infection with non-HiB organisms. These cases constitute a medical emergency due to the risk of rapid progression to complete airway obstruction. Other rare conditions are discussed including bacterial tracheitis, diphtheria, retropharyngeal, and peritonsillar abscesses. Key learning points in this chapter include the main discriminating factors of the various causes of infective upper airway obstruction, the importance of a calm and minimally distressing approach to the child presenting with stridor, and the need for early anesthetic team involvement in cases with a suspected bacterial etiology or signs of impending airway obstruction.

Geographic health disparities in the Los Angeles pediatric neck abscess population

OBJECTIVE

To assess geographical sociodemographic differences in neck abscesses that require surgical drainage in Los Angeles.

STUDY DESIGN

retrospective review.

METHODS

We reviewed the medical records of 119 consecutive pediatric patients at Children's Hospital Los Angeles (CHLA) from 2014 to 2017 with a diagnosis of a neck abscess requiring incision and drainage. Sociodemographic information including zip code of residence was extracted and analyzed with Chi-square, Fisher's exact test, and multivariate logistic regression.

RESULTS

The average age of patients with a neck abscess in this study was 3.4 years old, 53.8% were female, 54.6% were Hispanic, and 82.5% had public health insurance. 79% of patients had an abscess located in the superficial neck, and 10.1% had an abscess located in the retropharyngeal space. There were no significant differences in gender, race, type of health insurance, or income between patients that lived within 10 miles of CHLA versus those that lived farther than 10 miles. On multivariate analysis, zip codes with a high volume of neck abscesses were more likely to be lower income neighborhoods. Gender, race, type of health insurance, and distance from CHLA were not associated with zip codes with a high volume of neck abscesses.

CONCLUSION

Geographic areas in the greater Los Angeles community with a high volume of neck abscesses requiring incision and drainage at our institution were associated with lower income neighborhoods.

LEVEL OF EVIDENCE

IV.

Confluent Retropharyngeal, Lateral Pharyngeal, and Peritonsilar MRSA Abscess in an Infant

Neck abscesses such as retropharyngeal, peritonsilar, and lateral pharyngeal are well described, typically cause a characteristic illness, and have a known epidemiology. We present a rare occurrence of case of confluent, mixed retropharyngeal, lateral pharyngeal, and peritonsilar abscess in a 9-month-old female infant. The symptoms at presentation were very mild and not expected in association with this extensive an abscess. The causative organism was methicillin-resistant Staphylococcus aureus.

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.

Red Flags in Torticollis: A Historical Cohort Study

OBJECTIVE

This study aimed to assess the spectrum of pathologies responsible for torticollis in children presenting to the emergency department and to evaluate the associated symptoms to determine clinical red flags for hospitalization.

METHODS

This was a historical retrospective cohort study. Medical records of children evaluated in our emergency department for torticollis from 2008 to 2013 were reviewed.

RESULTS

Among 392 identified patients, 61% had postural torticollis,19.4% infection related, 16.3% traumatic, and 3.5% other. Twenty-five patients (6.4%) were hospitalized. Four variables were strongly and independently related to the severe outcome: fever, sore throat, headache, and age.

CONCLUSIONS

The association of 2 or 3 of these 4 features carried a risk of 32% and 58%, respectively, of having a severe illness.

The Association of External Transfer Status with Adverse Outcomes in Otolaryngology

Objective To compare rates of morbidity and mortality in patients treated by otolaryngologists who undergo interhospital transfers vs those who do not and to quantify conditions requiring interhospital transfers in this population. Study Design Cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program. Subjects and Methods We identified patients requiring surgery by otolaryngologists in the National Surgical Quality Improvement Program database from 2006 to 2013. We compared patients who were transferred from an outside institution to those admitted from home. Multivariate regression was used to adjust for patient characteristics, comorbidities, and case mix. The primary outcome was overall morbidity and mortality within 30 days of surgery. Results We identified 60,498 patients; 488 (0.8%) were transferred from another institution. Operations that were more common in the transferred group were incision and drainage (24.0% vs 1.2%), facial trauma repair (9.0% vs 3.1%), and oropharyngeal hemorrhage control (3.9% vs 0.4%). External transfer patients had significantly longer hospital stays (44.1% vs 4.4% >7 days, P < .05). On unadjusted analysis, transferred patients had a significantly higher rate of morbidity and mortality (odds ratio [OR], 11.3; 95% confidence interval [CI], 9.4-13.5). On multivariate analysis, transferred patients had a significantly greater rate of morbidity and mortality (OR, 3.1; 95% CI, 2.4-4.0). Conclusion Transfer from another institution is associated with worse outcomes independent of case mix, demographics, and preoperative comorbidities in acute otolaryngology conditions requiring surgery. Practitioners should be aware of this when caring for transfer patients, and transfer status should be considered when measuring hospital quality.

Clinical and bacteriological differences of deep neck infection in pediatric and adult patients: Review of 123 cases

OBJECTIVES

Deep neck infections (DNIs) can lead to life-threatening disease. However, the detailed pathophysiology remains unclear due to its rarity and only a few reports have directly compared DNIs in children and adults. This study aimed to reveal the clinical differences between DNIs in children and adults.

METHODS

We retrospectively reviewed 123 patients who suffered from DNIs at Tohoku University Hospital from August 2005 to July 2015. We extracted data on patient sex, age, antecedent illness, extension of infections, operative procedures, and bacteriology results. The patients were categorized into pediatric (≤18 years) and adult (>18 years) groups. Fisher's exact test was performed to determine significant differences between the two groups.

RESULTS

Fifteen children (6 males and 9 females) and 108 adults (71 males and 37 females) were identified. The most common antecedent illness in pediatric patients was lymphadenitis, which was the least common in adult patients (73% vs 7%, p < 0.0001). The incidence of DNIs extending below the hyoid bone was significantly lower in pediatric patients than in adult patients (20% vs 53%, p < 0.05). Regarding bacterial culture analysis, Staphylococcus species was the most common pathogen in children (60%), whereas only 9% of adults were positive for Staphylococcus (p < 0.001). Streptococcus species were significantly less common in children than in adults (27% vs 56%, p = 0.05). Anaerobes were also significantly less common in children than in adults (13% vs 45%, p < 0.01). Concerning surgical intervention, 53% of pediatric patients underwent external incision compared with 70% of adults. Specifically, tracheostomy was significantly less frequently performed in children than in adults (7% vs 54%, p < 0.01).

CONCLUSION

DNIs in children feature different characteristics from those in adults regarding severity, antecedent illness, bacteriology, and clinical management.

Increasing rates of surgical treatment for paediatric diaphyseal forearm fractures: a National Database Study from 2000 to 2012

FOREARM

Purpose fractures are one of the most commonly sustained injuries in children and are often treated non-operatively. The purpose of this study was to estimate the rate of inpatient surgical treatment of paediatric forearm fractures over time using a large, publicly available, national database.

METHODS

The Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) was evaluated between 2000 and 2012. Forearm fractures and surgeries were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) diagnosis and procedure codes. Univariable and multivariable logistic regression were used to determine variables associated with greater proportion of surgical treatment. All statistical analyses were performed using SAS statistical software v.9.4 (SAS Institute Inc., Cary, NC, USA). Statistical significance was set at p < 0.05.

RESULTS

The database identified 30 936 forearm fracture admissions. Overall, 19 837 of these patients were treated surgically (64.12%). The percentage of patients treated with surgery increased from 59.3% in 2000 to 70.0% in 2012 (p < 0.001). Multivariable regression analysis found increased age (p < 0.001), more recent year (p < 0.001), male gender (p = 0.003) and admission to a children's hospital (p < 0.001) were associated with an increased proportion of patients receiving surgical treatment. Medicaid payer status was associated with a lower proportion of surgical treatment (p < 0.001).

CONCLUSIONS

The rate of operative treatment for paediatric forearm fractures admitted to the hospital increased over time. Increased surgical rates were associated with older age, male gender, treatment at a children's hospital and non-Medicaid insurance status.