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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Mehmed M, Walters B, Keys H, Hnynn Si PE, Athavale N, Abdelhafiz AH. Spontaneous retropharyngeal abscess presenting as delirium in a frail older woman: a case-based review. Hosp Pract (1995) 2024; 52:39-45. [PMID: 38466020 DOI: 10.1080/21548331.2024.2329043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 03/07/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Retropharyngeal abscess (RPA) is an uncommon infection in older people, which usually presents with localized upper airway symptoms. CASE PRESENTATION We present a case of RPA in a 69-year-old frail woman with co-morbidities, who presented atypically with delirium. She initially complained of general symptoms of malaise, body aches and general decline. Her symptoms progressed to hypoactive delirium before she started to localize her complaints to the upper airway. The delirium presentation of RPA is not commonly reported in the literature. Co-morbidities and frailty are likely to be the underlying risk factors for delirium presentation in this case. Most of the RPA cases reported in older people in the literature presented typically with localized symptoms, however these cases had lower burden of morbidities and reported no frailty. In our case report, poor mouth hygiene and dental caries were thought to be the source of infection. Early intervention with antibiotic treatment for total of four weeks resulted in a full recovery. CONCLUSION RPA may present with delirium in older people with frailty and co-morbidities. Poor oral hygiene and dental caries, if left untreated, may progress into serious deep space neck infection.
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Affiliation(s)
- Melisa Mehmed
- Department of Internal Medicine, Rotherham General Hospital, Rotherham, UK
| | - Ben Walters
- Department of Internal Medicine, Rotherham General Hospital, Rotherham, UK
| | - Heather Keys
- Department of Internal Medicine, Rotherham General Hospital, Rotherham, UK
| | - Pann Ei Hnynn Si
- Department of Internal Medicine, Rotherham General Hospital, Rotherham, UK
| | | | - Ahmed H Abdelhafiz
- Department of Internal Medicine, Rotherham General Hospital, Rotherham, UK
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Hankey PB, Tracy M, Arganbright JM. Emerging findings for the assessment and treatment of pediatric deep neck abscesses. Curr Opin Otolaryngol Head Neck Surg 2023; 31:407-411. [PMID: 37820224 DOI: 10.1097/moo.0000000000000937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
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.
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Affiliation(s)
- Paul Bryan Hankey
- West Virginia University, Department of Otolaryngology-Head and Neck Surgery, Morgantown, West Virginia
| | - Meghan Tracy
- Children's Mercy Hospital, Division of Otolaryngology
| | - Jill M Arganbright
- Children's Mercy Hospital, Division of Otolaryngology
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
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Nurminen J, Heikkinen J, Happonen T, Nyman M, Sirén A, Vierula JP, Velhonoja J, Irjala H, Soukka T, Ivaska L, Mattila K, Hirvonen J. Pictorial Review of MRI Findings in Acute Neck Infections in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:967. [PMID: 37371199 DOI: 10.3390/children10060967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023]
Abstract
Pediatric neck infections and their complications, such as abscesses extending to deep neck compartments, are potentially life-threatening acute conditions. Medical imaging aims to verify abscesses and their extensions and exclude other complications. Magnetic resonance imaging (MRI) has proven to be a useful and highly accurate imaging method in acute neck infections in children. Children and adults differ in terms of the types of acute infections and the anatomy and function of the neck. This pictorial review summarizes typical findings in pediatric patients with neck infections and discusses some difficulties related to image interpretation.
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Affiliation(s)
- Janne Nurminen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jaakko Heikkinen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Tatu Happonen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Mikko Nyman
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Aapo Sirén
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jari-Pekka Vierula
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jarno Velhonoja
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Heikki Irjala
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Tero Soukka
- Department of Oral and Maxillofacial Surgery, University of Turku, 20014 Turku, Finland
| | - Lauri Ivaska
- Department of Paediatrics and Adolescent Medicine, InFLAMES Research Flagship Center, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Kimmo Mattila
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
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Fadel MA, McCoy JL, Obuekwe F, Kitsko D. COVID-19 Impact on Operative Management of Pediatric Neck Abscesses. Int Arch Otorhinolaryngol 2023; 27:e152-e157. [PMID: 36714909 PMCID: PMC9879651 DOI: 10.1055/s-0042-1758718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 09/04/2022] [Indexed: 01/28/2023] Open
Abstract
Introduction For multiple reasons, elective pediatric otolaryngology surgical procedures have declined during the COVID-19 pandemic. Objective The purpose of the present study was to assess whether the prevalence of pediatric neck abscesses managed with operative drainage decreased compared with previous years. Methods Medical records of all pediatric cases at a tertiary care children's hospital diagnosed with abscess of the neck and treated with incision and drainage were evaluated between the dates of April 1 and November 30 from 2015 to 2020. Outcomes were compared for each year from 2015 to 2019 to 2020, which included location, abscess size, duration of antibiotic treatment, microbiology, and the number of cases per year. Results A total of 201 cases were included. The mean ± standard deviation (SD) presenting age in the 2015 to 2019 group was 5.05 ± 5.03 years old and 2.24 ± 1.91 years old in the 2020 group. The mean number of cases between 2015 and 2019 was 35.6 ± 4.2, whereas the number of cases in 2020 was 23 ( p = 0.002). Of those patients who underwent IV antibiotic therapy prior to presentation ( n = 43), the mean number of days before admission was 1.98 ± 2.95 ( n = 40) from 2015 to 2019 and 12.00 ± 10.39 ( n = 3) in 2020 ( p = 0.008). The percent of cases with multiple strains cultured between 2015 and 2019 was 13.4% versus 18.2% in 2020 ( p = 0.007). Conclusion There was a decrease in the number of operative neck abscesses in 2020 compared with the mean number per year from 2015 to 2019. COVID-19 mitigation strategies leading to reduced transmission of other viral and bacterial illnesses and a tendency toward prolonged medical management to avoid surgery are two possible explanations.
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Affiliation(s)
- Mark A. Fadel
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Jennifer L. McCoy
- Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Fendi Obuekwe
- School of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Dennis Kitsko
- Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States,Address for correspondence Dennis Kitsko, DO Department of Otolaryngology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center4401 Penn Ave, Faculty Pavilion, 7123 Pittsburgh, PA 15213-2583United States
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Hosokawa T, Tanami Y, Sato Y, Deguchi K, Takei H, Oguma E. Role of ultrasound in the treatment of pediatric infectious diseases: case series and narrative review. World J Pediatr 2023; 19:20-34. [PMID: 36129633 PMCID: PMC9490683 DOI: 10.1007/s12519-022-00606-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 08/05/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Infectious diseases are common in pediatric patients. In these patients, ultrasound is a useful imaging modality that involves no irradiation or sedation and can be performed repeatedly at the patient's bedside. The purpose of this review was to show pediatric cases with infectious disease that used ultrasound to decide the methods of treatment. DATA SOURCES Literature review was performed using Pubmed as the medical database source. No year-of-publication restriction was placed. The mesh terms used were: "ultrasound", "sonography", "infectious disease", "treatment", "antibiotics", "surgical intervention", "pediatric", "children", "deep neck abscess", "pyothorax", "empyema", "pneumonia", "urinary tract infection", "intra-abdominal abscess", "soft tissue infection", "septic arthritis", "osteomyelitis", and "surgical site infection". RESULTS We presented pediatric case series with infectious diseases, including deep neck abscess, pyothorax and empyema, pneumonia, urinary tract infection, intra-abdominal abscess, soft tissue infection, septic arthritis and osteomyelitis, and surgical-site infection. Ultrasound was useful for evaluating the extent and location of inflammation and abscess and for decision-making concerning surgical intervention. CONCLUSION Knowledge of these sonographic findings is important for sonographers during examinations and for physicians when determining the treatment plan and period of antibiotic therapy for infected lesions.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku, Saitama, 330-8777, Japan.
| | - Yutaka Tanami
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku, Saitama, 330-8777 Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku, Saitama, 330-8777 Japan
| | - Kuntaro Deguchi
- Department of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
| | - Haruka Takei
- Department of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku, Saitama, 330-8777 Japan
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Tecle NE, Hackenberg S, Scheich M, Scherzad A, Hagen R, Gehrke T. Surgical management of lateral neck abscesses in children: a retrospective analysis of 100 cases. Eur J Pediatr 2023; 182:431-438. [PMID: 36378330 PMCID: PMC9829626 DOI: 10.1007/s00431-022-04676-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/09/2022] [Accepted: 10/22/2022] [Indexed: 11/16/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Nyat-Eyob Tecle
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany.
| | - Stephan Hackenberg
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany ,Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Matthias Scheich
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Agmal Scherzad
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Rudolf Hagen
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Thomas Gehrke
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany
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Hagelberg J, Pape B, Heikkinen J, Nurminen J, Mattila K, Hirvonen J. Diagnostic accuracy of contrast-enhanced CT for neck abscesses: A systematic review and meta-analysis of positive predictive value. PLoS One 2022; 17:e0276544. [PMID: 36288374 PMCID: PMC9604924 DOI: 10.1371/journal.pone.0276544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/08/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Jon Hagelberg
- Department of Radiology, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere University, Tampere, Finland
| | - Bernd Pape
- Turku Clinical Research Center, Turku University Hospital, Turku, Finland
- School of Technology and Innovations, University of Vaasa, Vaasa, Finland
| | - Jaakko Heikkinen
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Janne Nurminen
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Kimmo Mattila
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere University, Tampere, Finland
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
- * E-mail:
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Perina V, Szaraz D, Harazim H, Urik M, Klabusayova E. Paediatric Deep Neck Infection—The Risk of Needing Intensive Care. CHILDREN 2022; 9:children9070979. [PMID: 35883963 PMCID: PMC9315740 DOI: 10.3390/children9070979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/19/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Vojtech Perina
- Department of Oral and Maxillofacial Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Jihlavska 20, 625 00 Brno, Czech Republic; (V.P.); (D.S.)
| | - David Szaraz
- Department of Oral and Maxillofacial Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Jihlavska 20, 625 00 Brno, Czech Republic; (V.P.); (D.S.)
| | - Hana Harazim
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic;
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Milan Urik
- Department of Paediatric Otorhinolaryngology, University Hospital Brno, Faculty of Medicine, Masaryk University, Cernopolni 9, 662 63 Brno, Czech Republic;
| | - Eva Klabusayova
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic;
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Correspondence: ; Tel.: +420-532-234-693
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Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses. CHILDREN 2022; 9:children9050618. [PMID: 35626793 PMCID: PMC9139861 DOI: 10.3390/children9050618] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022]
Abstract
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.
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12
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Guri A, Scheier E. A 10-year-old child with acute torticollis due to polymicrobial deep neck infection. BMJ Case Rep 2022; 15:e244331. [PMID: 34992062 PMCID: PMC8739054 DOI: 10.1136/bcr-2021-244331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 11/04/2022] Open
Abstract
Torticollis in children can be a sign of a potentially dangerous disease; the correct diagnosis is not always obvious on history and physical examination. The use of point-of-care ultrasound (POCUS) helps to limit the differential diagnosis and direct appropriate further laboratory and radiology-performed evaluation. We present a case of a 10-year-old child whose deep neck infection (DNI) was timely diagnosed in the paediatric emergency department by early use of POCUS and drained under POCUS guidance after admission to the hospital. The culture from the fluid grew Eikenella corrodens, Streptococcus constellatus and Prevotella buccae This case demonstrates that DNIs occur in children with acute acquired torticollis, even without fever and demonstrates the importance of early use of POCUS in cases where DNI is a potential diagnosis. Moreover, this case emphasises the importance of microbiological identification of DNIs that can be the key to successful treatment.
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Affiliation(s)
- Alex Guri
- Pediatrics, Kaplan Medical Center, Rehovot, Israel
- The School of Medicine, The Hebrew University and Hadassah Medical Centre, Jerusalem, Israel
| | - Eric Scheier
- Pediatrics, Kaplan Medical Center, Rehovot, Israel
- The School of Medicine, The Hebrew University and Hadassah Medical Centre, Jerusalem, Israel
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Nurminen J, Heikkinen J, Happonen T, Velhonoja J, Irjala H, Soukka T, Ivaska L, Mattila K, Hirvonen J. Magnetic resonance imaging findings in pediatric neck infections-a comparison with adult patients. Pediatr Radiol 2022; 52:1158-1166. [PMID: 35184213 PMCID: PMC9107440 DOI: 10.1007/s00247-021-05275-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 12/08/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Janne Nurminen
- Diagnostic Radiology, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Jaakko Heikkinen
- Diagnostic Radiology, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
| | - Tatu Happonen
- Diagnostic Radiology, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
| | - Jarno Velhonoja
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Heikki Irjala
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Tero Soukka
- Department of Oral and Maxillofacial Surgery, University of Turku, Turku, Finland
| | - Lauri Ivaska
- Department of Paediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Kimmo Mattila
- Diagnostic Radiology, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
| | - Jussi Hirvonen
- Diagnostic Radiology, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
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Demongeot N, Akkari M, Blanchet C, Godreuil S, Prodhomme O, Leboucq N, Mondain M, Jeziorski E. Pediatric deep neck infections: Clinical description and analysis of therapeutic management. Arch Pediatr 2021; 29:128-132. [PMID: 34955300 DOI: 10.1016/j.arcped.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 10/20/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of our study was to describe clinical presentations, bacteriological results, and therapeutic management in a pediatric population presenting with acute pharyngeal suppuration. A further aim was to identify clinical, bacteriological, and radiological predictors of success associated with exclusive medical treatment. METHOD A retrospective study was carried out including patients under 18 years of age hospitalized between January 1, 2015 and December 31, 2017 in our center for acute pharyngeal suppuration. We identified three groups of patients: group A, treated with exclusive intravenous antibiotics; group B, surgically treated after 48 h of appropriate antibiotic therapy, due to persistent fever and/or clinical worsening and/or persistence of a collection on follow-up imaging; group C, surgically treated as first-line therapy in association with intravenous antibiotics. A total of 83 patients were included: 36 in group A, 12 in group B, and 35 in group C. These three groups were compared for several variables: age of the patients, polynuclear neutrophil counts, diameter of the collections (the largest diameter found on imaging), duration of antibiotic therapy, delay before return to apyrexia, and hospitalization duration. RESULTS A neck mass and torticollis were present, respectively, in 48.8 and 47.6% of cases. No breathing difficulties were reported. Streptococcus pyogenes was the most frequently identified microorganism. The average diameter of the collections from patients treated surgically as first-line therapy (group C) was significantly larger than that of the patients treated with antibiotics (group A) (27.89 mm vs. 18.73 mm, respectively, p = 0.0006). All the patients who required surgery despite 48 h of appropriate antibiotic therapy (group B) had collections with diameters greater than or equal to 15 mm. There was no significant difference between the groups concerning hospitalization duration. CONCLUSION Exclusive medical treatment is associated with a high cure rate, mainly for collections with small diameter. We recommend special attention to patients treated with first-line exclusive intravenous antibiotic therapy and with a collection diameter greater than or equal to 15 mm.
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Affiliation(s)
- N Demongeot
- Department of Pediatrics, University Hospital Arnaud de Villeneuve, University of Montpellier, France
| | - M Akkari
- Department of Ear Nose and Throat and Head and Neck surgery, University Hospital Gui de Chauliac, 80 avenue Augustin Fliche, University of Montpellier, Montpellier 34295 Cedex 5, France.
| | - C Blanchet
- Department of Ear Nose and Throat and Head and Neck surgery, University Hospital Gui de Chauliac, 80 avenue Augustin Fliche, University of Montpellier, Montpellier 34295 Cedex 5, France
| | - S Godreuil
- Department of Bacteriology, University Hospital Arnaud de Villeneuve, UMR MIVEGEC, UMR IRD 224-CNRS INSERM 1058, University of Montpellier, Montpellier, France
| | - O Prodhomme
- Department of Pediatric imaging, University Hospital Arnaud de Villeneuve, University of Montpellier, France
| | - N Leboucq
- Department of Bacteriology, University Hospital Arnaud de Villeneuve, UMR MIVEGEC, UMR IRD 224-CNRS INSERM 1058, University of Montpellier, Montpellier, France
| | - M Mondain
- Department of Ear Nose and Throat and Head and Neck surgery, University Hospital Gui de Chauliac, 80 avenue Augustin Fliche, University of Montpellier, Montpellier 34295 Cedex 5, France
| | - E Jeziorski
- Department of Pediatrics, University Hospital Arnaud de Villeneuve, University of Montpellier, France; Pathogenesis and Control of Chronic Infections, INSERM, University of Montpellier, Montpellier, France
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Goenka PK, Hall M, Shah SS, Florin TA, Leone N, Narayanan S, Ishman S, Gill P, Liewehr S, Palumbo N, McGeechan S, Mestre M, Parikh K. Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses. Pediatrics 2021; 148:peds.2020-037010. [PMID: 34697219 DOI: 10.1542/peds.2020-037010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Pratichi K Goenka
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Cohen Children's Medical Center-Northwell Health and Zucker School of Medicine at Hofstra/Northwell, Hofstra University, New Hyde Park, New York
| | - Matthew Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Samir S Shah
- Division of Hospital Medicine and Department of Pediatrics
| | - Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Nicole Leone
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Cohen Children's Medical Center-Northwell Health and Zucker School of Medicine at Hofstra/Northwell, Hofstra University, New Hyde Park, New York
| | - Sridaran Narayanan
- Division of Hospital Medicine, Department of Pediatrics, Children's National Medical Center and School of Medicine, George Washington University, Washington, District of Columbia
| | - Stacey Ishman
- Division of Pediatric Otolaryngology-Head and Neck Surgery, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Peter Gill
- Division of Paediatric Medicine, The Hospital for Sick Children and University of Toronto, Toronto, Ontario
| | - Sheila Liewehr
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Cohen Children's Medical Center-Northwell Health and Zucker School of Medicine at Hofstra/Northwell, Hofstra University, New Hyde Park, New York
| | - Nancy Palumbo
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Cohen Children's Medical Center-Northwell Health and Zucker School of Medicine at Hofstra/Northwell, Hofstra University, New Hyde Park, New York
| | - Stacy McGeechan
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Cohen Children's Medical Center-Northwell Health and Zucker School of Medicine at Hofstra/Northwell, Hofstra University, New Hyde Park, New York
| | - Marcos Mestre
- Division of Pediatric Hospital Medicine, Nicklaus Children's Hospital, Miami, Florida
| | - Kavita Parikh
- Division of Hospital Medicine, Department of Pediatrics, Children's National Medical Center and School of Medicine, George Washington University, Washington, District of Columbia
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Velhonoja J, Lääveri M, Soukka T, Hirvonen J, Kinnunen I, Irjala H. Early surgical intervention enhances recovery of severe pediatric deep neck infection patients. Int J Pediatr Otorhinolaryngol 2021; 144:110694. [PMID: 33799100 DOI: 10.1016/j.ijporl.2021.110694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Pediatric deep neck space infection (DNI) is a relatively rare but potentially life-threatening condition and requires prompt and accurate management. This study retrospectively reviews our experience in a tertiary referral hospital from 2004 to 2019. METHODS Systematic data collection from medical records using ICD10 codes between 2004 and 2019. INCLUSION CRITERIA age ≤16 years, DNI requiring hospitalization and/or surgery. EXCLUSION: peritonsillar abscess without complications. RESULTS We identified 42 patients, 21 boys and 21 girls, with a median age of 4.9 years. Most of the patients had severe symptoms, the most common of which were neck swelling (n = 39; 92.9%), neck pain (n = 39; 92.9%) and fever (n = 32; 76.2%). Twenty-two (52.4%) had torticollis, and the mean duration of symptoms before hospitalization was 4.95 days. Diagnosis was confirmed by MRI (n = 24), contrast-enhanced CT (n = 11) or ultrasonography (n = 6), except in one case. Twenty-three (54.8%) required an open neck incision, ten (23.8%) patients had intraoral surgery and nine were treated conservatively. Twelve (28.6%) patients were admitted to the pediatric ICU. Median hospitalization duration was six days. The infection most commonly had tonsillopharyngeal etiology (n = 18) and a retropharyngeal location (n = 17). Staphylococcus Aureus (n = 7) and Streptococcus pyogenes (n = 7) were the most frequent pathogens. We compared the early surgical intervention group (<2 days of intravenous antibiotics; n = 18; 42.9%) to the late surgery group (n = 15; 35.7%) and the conservatively treated groups (n = 9; 21.4%). The overall length of stay (LOS) was lower in the shorter preoperative medication group (mean 4.4 vs. 7.2; p = 0.009). The size of the abscess did not differ between the groups (mean 28 mm; 30 mm; 21 mm; p = 0.075) and the neck incision rate was similar in the operated groups. CONCLUSION Early surgical intervention is associated with decreased LOS among severe pediatric DNI patients.
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Affiliation(s)
- Jarno Velhonoja
- Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - Meira Lääveri
- Department of Oral and Maxillofacial Surgery, Turku University Hospital and University of Turku, Lemminkäisenkatu 2, 20520, Turku, Finland.
| | - Tero Soukka
- Department of Oral and Maxillofacial Surgery, Turku University Hospital and University of Turku, Lemminkäisenkatu 2, 20520, Turku, Finland.
| | - Jussi Hirvonen
- Department of Radiology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - Ilpo Kinnunen
- Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - Heikki Irjala
- Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
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Klug TE, Greve T, Hentze M. Complications of peritonsillar abscess. Ann Clin Microbiol Antimicrob 2020; 19:32. [PMID: 32731900 PMCID: PMC7391705 DOI: 10.1186/s12941-020-00375-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Tejs Ehlers Klug
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 Aarhus N, Aarhus, 8200, Denmark.
| | - Thomas Greve
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Malene Hentze
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 Aarhus N, Aarhus, 8200, Denmark
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18
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Ahuja V, Chachra A, Singh M, Gupta N, Singh P. Awake tracheostomy in a child with respiratory distress due to retropharyngeal abscess. Anaesth Rep 2020; 8:e12047. [PMID: 32743557 DOI: 10.1002/anr3.12047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2020] [Indexed: 11/09/2022] Open
Abstract
Awake tracheostomy in a child with respiratory distress is an emergency life-saving procedure when risk of airway loss after induction of general anaesthesia is greater due to difficult anatomy. A 10-year-old boy presented three days after removal of a foreign body in the throat under general anaesthesia. Over the subsequent days, the patient had a progressively increasing visible swelling in the neck, stridor and respiratory distress. An urgent X-ray and computed tomography scan of the neck revealed a retropharyngeal abscess compressing the trachea. Due to anticipated difficulty in airway management under general anaesthesia, we decided to perform an awake tracheostomy. The child and the parents were counselled regarding steps of awake tracheostomy, as well as the benefits and possible risks associated with it. Topicalisation was achieved by administering glycopyrrolate, nebulisation with lidocaine 4%, and the skin was prepared with lidocaine 2% with 1:200,000 adrenaline. After the awake tracheostomy was successfully performed, general anaesthesia was induced and the retropharyngeal abscess was drained. Effective communication and building rapport is essential for safe awake tracheostomy in a child with respiratory distress when impending airway loss may occur at any moment.
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Affiliation(s)
- V Ahuja
- Government Medical College and Hospital Chandigarh India
| | - A Chachra
- Government Medical College and Hospital Chandigarh India
| | - M Singh
- Government Medical College and Hospital Chandigarh India
| | - N Gupta
- Government Medical College and Hospital Chandigarh India
| | - P Singh
- Government Medical College and Hospital Chandigarh India
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Matos R, Martins S, Marques P, Santos M. Unilateral acute cervical lymphadenitis in children: can we predict the need for surgery? Int J Pediatr Otorhinolaryngol 2019; 127:109655. [PMID: 31470203 DOI: 10.1016/j.ijporl.2019.109655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/20/2019] [Accepted: 08/20/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Paediatric acute cervical lymphadenitis is a frequent diagnosis in the emergency department. Traditionally, suppurative cervical lymphadenitis (SCL) is associated with a higher need of surgical drainage. However, a great variability in the management of this suppurative infections can be observed. Moreover, the clinical distinction between non-suppurative cervical lymphadenitis (NSCL) and SCL is not an easy task and there are, currently, no guidelines defining which patients are eligible for imaging study. OBJECTIVES To assess the determinants and benefits in the surgical management of SCL in children. As secondary outcome, to determine differences in epidemiological characteristics, clinical, biochemical and radiological features between NSCL and SCL. MATERIAL AND METHODS A retrospective survey was carried out in a tertiary university hospital between January 2007 and December 2016. Forty-two children with a diagnosis of acute cervical lymphadenitis (ACL) were included and categorized according to the presence of suppuration, resulting in two groups: NSCL and SCL. The latter group was further categorized into surgical and non-surgical groups, according to the need of surgical drainage. RESULTS No significant differences were found between SCL and NSCL groups in gender, age and previous antibiotics intake (p > 0.05). According to clinical presentation, odynophagia was significantly more frequent in NSCL patients (p = 0.01), with no differences found in other clinical parameters (p > 0.05). Patients presenting acute cervical lymphadenitis involving the submandibular region have 16 times the odds of a suppurative process (p = 0.029). In a SCL subgroup analysis, no association was observed between lymphadenitis size or location and the need for surgical drainage (p > 0.05). Children included in the SCL surgical group presented a trend to an increased in the hospitalization length (p = 0.01), when comparing to those in which treatment was limited to intravenous antibiotics. One death was observed in the SCL non-surgical group. CONCLUSIONS Predictive factors for the need of surgery were not found. Furthermore, surgical drainage was not associated with better outcomes. Surgery could be considered in selected stable patients, when alternative medical treatments do not seem to work, in a case-to-case basis.
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Affiliation(s)
- Ricardo Matos
- Department of Otorhinolaryngology, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal; Department of Surgery and Physiology/Otorhinolaryngology, University of Porto Medical School, Portugal.
| | - Sónia Martins
- Department of Otorhinolaryngology, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal; Department of Surgery and Physiology/Otorhinolaryngology, University of Porto Medical School, Portugal
| | - Pedro Marques
- Department of Otorhinolaryngology, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal; Department of Surgery and Physiology/Otorhinolaryngology, University of Porto Medical School, Portugal
| | - Margarida Santos
- Department of Otorhinolaryngology, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal
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Sousa Menezes A, Ribeiro DC, Guimarães JR, Lima AF, Dias L. Management of pediatric peritonsillar and deep neck infections- cross- sectional retrospective analysis. World J Otorhinolaryngol Head Neck Surg 2019; 5:207-214. [PMID: 32083248 PMCID: PMC7015866 DOI: 10.1016/j.wjorl.2019.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/08/2019] [Accepted: 04/11/2019] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Ana Sousa Menezes
- Department of Otorhinolaryngology-Head and Neck Surgery, Hospital De Braga, Portugal
| | | | - Joana Rocha Guimarães
- Department of Otorhinolaryngology, Instituto Português de Oncologia Francisco Gentil do Porto, Portugal
| | - António Fontes Lima
- Department of Otorhinolaryngology-Head and Neck Surgery, Hospital De Braga, Portugal
| | - Luís Dias
- Department of Otorhinolaryngology-Head and Neck Surgery, Hospital De Braga, Portugal
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Asakura M, Tanaka T, Shoji K, Karakawa S, Ishiguro A, Miyairi I. Chronic Neutropenia in Children With Abscess Forming Cervical Lymphadenitis Caused by Staphylococcus aureus. Pediatr Infect Dis J 2019; 38:293-296. [PMID: 29613972 DOI: 10.1097/inf.0000000000002059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Suppurative cervical lymphadenitis is rare in children with limited information about the frequency of neutropenia in any series. METHODS We conducted a retrospective review of pediatric patients in whom suppurative cervical lymphadenitis was diagnosed between April 2011 and March 2016 at a tertiary children's hospital in Tokyo, Japan. Microbiologically confirmed cases of cervical lymphadenitis with abscess formation were included in the analysis. RESULTS Twenty-five patients (median age, 1 yr old; 64% female) with abscess formation caused by Staphylococcus aureus were identified. Among these 25 patients, 5 (20%) met the criteria for chronic neutropenia and 4 (80%) received the final diagnosis of autoimmune neutropenia based on the identification of the serum anti-CD16 antibodies. CONCLUSIONS Chronic neutropenia and autoimmune neutropenia were relatively common among infants with suppurative cervical lymphadenitis caused by S. aureus.
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Affiliation(s)
- Mari Asakura
- From the Department of Postgraduate Education and Training
| | | | - Kensuke Shoji
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Shuhei Karakawa
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, Hiroshima, Japan
| | - Akira Ishiguro
- From the Department of Postgraduate Education and Training
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.,Department of Microbiology, Immunology, and Biochemistry, University of Tennessee Health Science Center, Memphis, Tennessee
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Abstract
Recognizing and acting early on airway compromise reduces morbidity and mortality in patients with airway obstruction. Causes include foreign bodies, toxic/hot fumes, difficult intubation, laryngeal spasm, and tumors. Before definitive control of the airway is possible, provide 100% oxygen with a tightly fitting mask to optimize body oxygen stores. Pulse oximetry is a poor indicator of airway compromise; a decreasing arterial hemoglobin oxygen saturation is a late sign of impending hypoxemia. Basic airway maneuvers improve the patency of an obstructed airway. Getting help from an anesthetist early is a priority.
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