Head and Neck Space Infections in Infants and Children

Deep neck infections mortal complications: Intrathoracic complications and necrotising fasciitis

BACKGROUND

We planned this study considering that complications of deep neck infections can be seriously life threatening.

AIM

To raise awareness that introthoracic complications and necrotizing fasciitis are causes of serious mortality and morbidity.

METHODS

This study was carried out with the participation of 188 patients who were treated at Mersin University Department of Otorhinolaryngology and Head and Neck Surgery at January 1, 2024. When the patient files were retrospectively examined, 16 of 188 patients (8.5%) were included in the study because they were observed to have necrotizing fasciitis and/or intrathoracic complications.

RESULTS

There were a total of 16 patients in this study, 9 males (56.25%) and 7 females (43.75%). All patients were adults (> 18 years) and the mean age was 50.37 years ± 15.37 years. Female patients had a mean age of 40.42 years ±13.38 years, whereas for male patients was 58.11 years ± 12.44 years.

CONCLUSION

Patients with necrotizing fasciitis and/or intrathoracic complications require more complicated and serious surgeries, intensive care unit monitoring, and mechanical ventilator support. Higher rates of morbidity and mortality should be expected in these patients who are hospitalized for longer periods of time.

Pediatric head and neck emergencies

PURPOSE

Head and neck emergencies in children are frequent cause of visits to the hospital. Imaging plays a critical role in the management of these patients. This review article aims to familiarize radiologists with the common clinical presentations encountered, imaging characteristics of nontraumatic pediatric head and neck emergencies, and improve their ability to recognize associated complications as well as be aware of common mimics.

METHODS

We researched our database for commonly encountered nontraumatic head and neck emergencies in children. A literature search was done to compare and complete the list of conditions to be discussed in this review.

RESULTS

The review was organized according to anatomical location of the emergent condition. Relevant anatomy has been discussed along with clinical presentation, imaging characteristics and complications. We have presented common mimics with each set of disorders. Key imaging characteristics have been delineated using radiology images.

CONCLUSION

Familiarity with the known complications of head and neck emergencies allows the radiologist to actively search for such findings, encourage early institution of appropriate therapy, and improve outcomes.

Conscious sedation for the management of peritonsillar abscess in pediatric patients: A prospective case series and literature review

OBJECTIVE

Peritonsillar abscess (PTA) is a common pediatric infection requiring drainage. Conscious Sedation (CS) can facilitate drainage in uncooperative children. However, it carries risks, especially if the airway is compromised. Moreover, evidence on its safety and efficacy is limited. This study examined the safety, pain reduction, and anxiety management of hospitalized pediatric patients treated for PTA under CS.

MATERIALS AND METHODS

We performed a prospective observational case series of 118 children aged 2-15 years with 155 PTA episodes, managed from 2016 to 2023. Conscious sedation was used in 42 episodes. Outcomes were compared among CS and non-CS (local anesthesia only). Complications assessed safety. Efficacy was evaluated by the amount of pus, hospitalization parameters, pain scores, and recurrence.

RESULTS

No significant differences were found regarding the demographic and presentation parameters except for younger age among the CS group (9 vs 11 years p = 0.001). One minor oxygen desaturation (2 %) event occurred with CS. Abscess drainage amount was greater with CS than non-CS, 4.9±4 mL vs. 3.2±2 mL, respectively (p = 0.03). Hospitalization stays were similar among groups. Maximum pain scores were lower with CS than non-CS, 1.4 ± 2 vs 4.2 ± 3 (p < 0.001); similarly, IV pain medication was used less frequently, 0.9 ± 1 vs. 1.6 ± 3 (p = 0.045), and the need for re-aspiration was less common 14 % vs. 28 % (p = 0.04), with CS than non-CS, respectively. The three-month recurrence rate was numerically lower with CS (5 % vs. 14 % non-CS).

CONCLUSIONS

Conscious sedation facilitates PTA drainage with excellent safety and improved efficacy compared to local anesthesia in children. Pain scores are reduced both during drainage and hospitalization. Our prospective data add to the limited evidence supporting CS as a viable option for abscess drainage in uncooperative pediatric patients. Further study is warranted to confirm potential long-term reductions in recurrence.

Veillonella atypica causing retropharyngeal abscess: A rare case presentation

Veillonella species are obligate anaerobes which are part of the human oral, gut and vaginal microbiota. The genus Veillonella consists of 16 characterized species. Very few infections due to Veillonella atypica have been reported till date. Here we present a case of retropharyngeal abscess due to this organism in a 55-year-old lady.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Conscious Sedation for Pediatric Peritonsillar Abscess: Comparison of Anesthetic Approaches

Objective

To compare the efficacy, safety, and cost of incision and drainage (I&D) for pediatric patients with peritonsillar abscesses (PTAs) under conscious sedation (CS) versus unsedated (awake) and general anesthesia (GA).

Study Design

Case series with chart review.

Setting

Tertiary pediatric hospital.

Subjects and Methods

Records for all pediatric patients (<18 years) treated for PTAs in the emergency department from 2005 to 2015 were reviewed and stratified into awake, CS, and GA groups for comparison. The primary outcome measure was procedure tolerance, with secondary measures including return to the emergency department within 15 days, complications, and facility costs associated with treatment.

Results

A total of 188 patients were identified. The median age was 14 years (interquartile range, 9-16). Awake drainage with injected local anesthetic was used in 115 children; 62 underwent CS; and 11 underwent GA. Over 92% of the children tolerated I&D regardless of anesthesia, with no difference among groups ( P = .60). None of those who underwent I&D via CS returned to the emergency department within 15 days of the procedure, as compared with 5.2% for the awake group and 9.1% for the GA group ( P = .06). None in the GA or awake group had a complication associated with the procedure, as opposed to 9.6% in the CS group ( P = .02). Complications included apnea and dental trauma (2 children each) and transient hypotension and desaturation (1 each). Cost was highest in the GA group and lowest for the awake group ( P < .0001).

Conclusion

CS for PTA I&D is a viable treatment option with tolerance and success similar to that of the awake and GA groups. Complications were observed for those who underwent CS, but they were manageable.

Establishing the Need for an Evidence-Based Treatment Algorithm for Peritonsillar Abscess in Children

In this retrospective case series, we report clinical factors associated with pediatric peritonsillar abscess (PTA), with hopes of contributing to the design of an evidenced-based, economic treatment approach. Charts were examined for presenting symptoms and signs. Each of these were analyzed for association with the presence of PTA and for association with treatment. We found that, with the exception of leukocytosis, the signs/symptoms that prompted treatment correlate with those that indicate the presence of PTA. However, there are several signs/symptoms, namely, referred otalgia, cervical lymphadenopathy, and decreased oral intake, that were associated with PTA but unassociated with treatment. Treatment can be aided by establishing an algorithm that accounts for the symptoms/signs most correlated with true, drainable abscess.

Image-Guided Surgical Drainage of Medial Parapharyngeal Abscesses in Children: A Novel Adjuvant to a Difficult Approach

Surgical drainage of localized infections in deep neck spaces in children is often completed without a high degree of technical difficulty. However, abscess drainage within the superior parapharyngeal space medial to the great vessels is particularly challenging for otolaryngologists. Drawbacks to both the intraoral and external approaches to this area have led us to develop a new adjunctive technique that utilizes intraoperative image-guided technology to augment the intraoral approach. Here we present a case series of 12 children in whom this technique was successfully used.

The Rising Incidence of Methicillin-Resistant Staphylococcus Aureus in Pediatric Neck Abscesses

OBJECTIVES: To examine the incidence of methicillin-resistant Staphylococcus aureus (MRSA) in pediatric neck abscesses and compare these with abscesses caused by methicillin-susceptible Staphylococcus aureus (MSSA) and other organisms (non-SA).

STUDY DESIGN: Retrospective review of 245 children who underwent incision and drainage of neck abscesses from January 1, 2001, to December 1, 2005.

RESULTS: The yearly incidence of MRSA increased from 9 percent to 40 percent during the study period. Abscesses in medial locations were less common in the MRSA group ( P < 0.01) and MSSA group ( P < 0.001) compared with the non-SA group. Average patient ages were MRSA 18.9 months, MSSA 18.7 months, and non-SA 47.6 months. Complication rates were MRSA 8 percent, MSSA 5 percent, and non-SA 5 percent.

CONCLUSIONS: The incidence of MRSA in pediatric neck abscesses is increasing dramatically. MRSA and MSSA usually infect younger patients in the lateral locations. Clinical courses were similar in all groups.

Dentigerous Cysts Presenting as Head and Neck Infections

OBJECTIVE: To describe dentigerous cysts presenting as head and neck infections.

STUDY DESIGN AND SETTING: Retrospective analysis of 327 charts with an admitting diagnosis of head and neck infection, deep neck space infection, and dentigerous cysts treated at a tertiary care hospital between 1975 and 2004. RESULTS: Seven patients were identified who had dentigerous cysts that presented as head and neck infections. Six of these patients had recurrent infections at the same site and one was diagnosed with a submasseteric space abscess. The incidence of head and neck infections with dentigerous cysts as the underlying causative pathology was 2.1%.

CONCLUSION: Head and neck infections with dentigerous cysts as underlying pathology are more common than perceived.

SIGNIFICANCE: Typically not considered as sources of infection, dentigerous cysts must be considered in cases of head and neck infection.

Symptom duration and CT findings in pediatric deep neck infection

Objective: To investigate whether children with less than 48 hours of localized symptoms of deep neck infection are less likely to have an abscess on CT scan.

Study Design: Case series.

Subjects and Methods: The charts of children seen in a tertiary children's hospital for deep neck infections between 2000 and 2007 were reviewed.

Results: Of 179 children identified, 167 (93.3%) underwent a CT scan of the neck of which 102 (61.1%) were positive for abscess. There was no significant difference in the rate of abscess on CT between children with less than 48 hours of localizing symptoms and 48 or more hours of symptoms at 58.1 percent and 58.3 percent, respectively ( P = 0.98). Furthermore, there was no significant difference in age, gender, C-reactive protein levels, disease location, or length of stay between children with and without abscess on CT. White blood cell counts were significantly higher in the abscess group ( P = 0.01); however, the median white blood cell count in both groups was above normal.

Conclusion: Because duration of symptoms does not predict finding of abscess on CT, it is appropriate to obtain a CT scan upon presentation in all children with symptoms concerning for neck abscess.

Spectrum and management of deep neck space infections: an 8-year experience of 234 cases

OBJECTIVE

To study the clinical course and outcome of deep neck infections (DNI), with special emphasis on microbiology and histopathology.

STUDY DESIGN

Two hundred thirty-four patients with DNIs were included in this study. Patients with peritonsillar or dental infections, infections arising from salivary glands, as well as subjects with abscesses caused by neck trauma were excluded.

METHODS

Clinical analysis of all patients with DNIs who were treated between January 1, 1997 and May 31, 2005 in a single center.

RESULTS

In 13 patients, the DNI was the first manifestation of a malignant tumor. In 17 cases, the DNI was associated with cat-scratch disease (CSD). Six patients suffered from tuberculosis, and in another 7, an infected lateral cleft cyst was found. In 176 patients, the origin of DNI remained unclear.

CONCLUSIONS

Our results demonstrate that CSD, tuberculosis, and malignant tumors must be considered as possible causes of DNIs. The current study represents one of the largest series of DNIs in the modern medical literature.

EBM RATING

C.

Retropharyngeal abscess management in children: current practices

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

Prospective application of a protocol for selective nonsurgical management of suspected orbital subperiosteal abscesses in children

Goodwin et al (1982) and Souliere et al (1990) have proposed a protocol for the selective nonsurgical management of suspected orbital subperiosteal abscesses. This protocol has been routinely applied by the Temple Pediatric Otolaryngology and Ophthalmology services since 1990. During this period, children with computed tomography and physical examination findings consistent with orbital subperiosteal abscesses and visual acuity better than 20/60 were treated with intravenous antibiotics rather than immediate surgery. They were followed with frequent ophthalmologic examinations and operated upon if vision deteriorated or they failed to improve clinically within 48 hours. A review of patients admitted to St Christopher's Hospital for Children, the site of Temple University's pediatric activities in the years from 1991 to 1997, revealed 14 patients with clinical evidence of orbital subperiosteal abscesses. Twelve patients were treated in accordance with the Goodwin-Souliere protocol. All recovered completely without surgical intervention and without any adverse sequelae. Selective nonsurgical treatment of clinically diagnosed orbital subperiosteal abscesses in children is relatively safe and effective.

Computed tomography in the evaluation of pediatric neck infections

In children, infections involving both the superficial and deep neck spaces are common. Children so affected typically present with fever, neck mass, neck stiffness, and, occasionally, airway compromise. Radiologic modalities used in the evaluation of neck infections include plain lateral neck radiography, ultrasound, computed tomography, and magnetic resonance imaging. All these modalities have proved useful in the treatment of such infections, specifically the decision to perform incision and drainage. The charts of 66 patients-33 with superficial and 33 with deep neck infections-were analyzed with respect to symptoms, signs, computed tomography findings, and need for surgical intervention. Computed tomography was not particularly helpful in superficial neck infections with regard to the decision to perform surgical drainage; however, it did localize and demonstrate the extent of infection. In deep neck infections we found a 92% correlation between computed tomographic evidence of an abscess and surgical confirmation of one. Contrast-enhanced computed tomography remains an excellent tool in the treatment of neck infections in children.

Contemporary Management of Deep Neck Space Infections

Deep neck infections continue to be seen despite the wide use of antibiotics. These infections follow along fascial planes to create deep neck space abscesses. The clinical presentation often points to the space involved. Understanding the regional anatomy gives the surgeon the ability to treat these grave infections. The records of 24 patients with a diagnosis of deep neck space abscess admitted to Hermann Hospital between 1988 and 1993 were reviewed. Fifty percent of the patients had received antibiotics for an infection of the ear, nose, or throat before the development of a neck space abscess. Ten patients had parapharyngeal abscesses, seven had retropharyngeal abscesses, six had submandibular space abscesses, and one had parotid space abscess. Thirty-five organisms were isolated in 18 cases (1.9 isolates per patient). The most common organism cultured was Streptococcus (13 of 18), followed by Staphylococcus (6 of 18), Bacteroides (5 of 18), Micrococcus (2 of 18), and Neisseria (2 of 18). One case each of Candida, Enterobacter, Enterococcus, Peptostreptococcus, Proteus, Proprionobacter, and Pseudomonas was cultured. Six patients had no growth on culture but did have organisms found on Gram's stain. The operative techniques and antibiotics used are discussed. The main complications of jugular vein thrombosis, carotid artery rupture, and mediastinitis are described, as well as an unusual case of meningitis from a large retropharyngeal-parapharyngeal abscess.