Retropharyngeal and Parapharyngeal Abscesses Among Children and Adolescents in the United States: Epidemiology and Management Trends, 2003-2012

Retropharyngeal and parapharyngeal infections in children: A retrospective analysis

OBJECTIVES

To describe presentations, management and outcomes of retropharyngeal and parapharyngeal infections in children presenting to a tertiary care pediatric emergency department.

METHODS

A retrospective chart review of children with deep neck infections such as retropharyngeal or parapharyngeal infection from January 2008 to December 2018 was conducted at a pediatric hospital.

RESULTS

There were 176 retropharyngeal, 18 parapharyngeal and 6 with both retropharyngeal and parapharyngeal infections treated during the 10-year study period. Males were 60% of the cohort and the mean age was 4.3 (SD: 3.2) years. No significant differences in age or sex ratio or presentations were seen in children with retropharyngeal infections compared with parapharyngeal infections. All received parenteral antibiotics; 42% (84/200) of children underwent surgery and four of them had more than one surgical drainage. Age <12 months and the diagnosis of parapharyngeal infections were associated with significantly higher rates of surgical treatment. Children under 12 months of age were sicker at presentation and had a high complication rate of 23% compared with 1% in the older children (p = 0.002). Seven children had co-existence of Kawasaki disease with deep neck infections.

CONCLUSIONS

Early diagnosis of retropharyngeal and parapharyngeal infections especially in infants under a year of age is important as they are more likely to have complications and need surgical management. Most paediatric patients with retropharyngeal and parapharyngeal infections have a phlegmon or very small abscesses and are treated non-operatively with parenteral antibiotics.

Challenges in Diagnosis and Management of Infantile Deep Neck Abscess: A Case Report and Literature Review

A deep neck abscess is a relatively rare bacterial infection in infants that can rapidly progress to life-threatening complications. Mostly, the patients present with fever and neck pain. Some may present with dysphonia, sore throat, torticollis, trismus, or neck swelling. Early diagnosis and management can prevent life-threatening complications, such as airway obstruction, mediastinitis, and tracheitis. In this report, we present a case of a six-month-old infant presenting with retropharyngeal and parapharyngeal abscesses with prompt diagnosis leading to complete recovery of the patient.

The role of adjuvant systemic corticosteroid in pediatric retropharyngeal and parapharyngeal abscess

OBJECTIVES

To evaluate the potential benefits of systemic corticosteroids as an adjuvant treatment for pediatric retropharyngeal abscess (RPA) and parapharyngeal abscess (PPA).

METHODS

We retrospectively reviewed medical records of patients diagnosed with RPA and PPA who were admitted to Shenzhen Children's Hospital between January 2010 and January 2023. Data on demographic characteristics, clinical presentation, physical examination, laboratory data, use of corticosteroids, management, duration of hospital stay, need for surgical drainage, and complications were collected. Patients were divided into two groups: non-corticosteroid group (antibiotic only) and corticosteroid group (corticosteroid and antibiotic).

RESULTS

A total of 111 patients were enrolled. There were 51 cases in non-corticosteroid group and 60 cases in corticosteroid group (10 cases received methylprednisolone and 50 cases received dexamethasone). There was no significant difference in sex, age, location of abscess, size of abscess and laboratory parameters at admission and discharge between the two groups. The surgical drainage rate was significantly lower in the corticosteroid group than in the non-corticosteroid group (p = 0.008). The hospital duration was also shorter in the corticosteroid group than in the non-corticosteroid group (p = 0.026). The hospitalization cost was significantly lower in the corticosteroid group than in the non-corticosteroid group (p = 0.000).

CONCLUSION

The use of systemic corticosteroids along with antibiotics in children with RPA and PPA may reduce the need for surgical drainage, shorten hospital duration, and decrease hospitalization cost. Further studies are needed to confirm these findings and determine the optimal timing, duration, and route of administration of corticosteroids.

Demographic disparities in children with retropharyngeal and parapharyngeal abscesses

PURPOSE

To explore the impact that demographic and socioeconomic factors such as age, gender, race, and insurance status have on the diagnosis of retropharyngeal (RPA) and parapharyngeal abscesses (PPA) in the pediatric population.

METHODS

The 2016 HCUP KID was searched for all RPA/PPA discharges using the joint ICD-10 code J39.0. Descriptive statistics, univariate, and multivariate analyses were performed to assess the relationship between demographic factors and their impact on RPA/PPA diagnosis. Results were reported with their corresponding odds ratio with a 95 % confidence interval and p-value.

RESULTS

56.4 per 100,000 weighted discharges were discharged with a diagnosis of a RPA/PPA, the average age was 5.7 years old, with a male predominance. Pediatric discharges diagnosed with a RPA/PPA were less likely to identify as Hispanic or Asian/Island Pacific. They were also less likely to be insured by Medicaid and reside in zip codes with a lower median income.

CONCLUSION

The analysis of this national pediatric database demonstrated significant demographic differences in children diagnosed with RPA/PPAs. Following the multivariate analysis, children from a higher socioeconomic background and those with private insurance were more likely to be diagnosed with a RPA/PPAs. However, disparities in children's overall hospital course and complications is a potential area for future research.

Spontaneous retropharyngeal abscess presenting as delirium in a frail older woman: a case-based review

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.

Life-threatening complication of retropharyngeal abscess in an infant: a case report

BACKGROUND

Deep neck space infections are uncommon in infants. Retropharyngeal abscess (RPA) is a deep space neck infection that can present with subtle signs and symptoms. Delay in diagnosis can lead to life-threatening complications. Here we describe life-threatening complication of retropharyngeal abscess.

CASE PRESENTATION

We report a life-threatening complication of retropharyngeal abscess in 10-month old Asian infant weighing 8.2 kg. The patient presented with fever, right-sided neck swelling, hoarseness of voice, and respiratory distress. The clinical and radiological findings were suggestive of airway obstruction complicated by retropharyngeal abscess. The patient was urgently taken to the operating room and underwent (grade 3) intubation. After stabilization, the patient underwent endoscopic trans-oral incision and drainage, during which 5 cc pus was aspirated. Antibiotics were prescribed for 2 weeks following the procedure based on the sensitivity result of the pus culture.

CONCLUSION

In retropharyngeal abscess, a delay in diagnosis can result in life-threatening complications. This report highlights the importance of prompt recognition of a threatened airway and the management of retropharyngeal abscess by emergency physicians. If an emergency physician suspects RPA with airway obstructions, the airway should be immediately secured in a secure environment by otolaryngologist and an anesthesiologist.

Pictorial Review of MRI Findings in Acute Neck Infections in Children

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.

Treatments and outcomes of adult parapharyngeal and retropharyngeal abscess: 1882 cases from a Japanese nationwide database

PURPOSE

Although parapharyngeal and retropharyngeal abscesses are potentially fatal deep neck abscesses, there is limited evidence for the treatment courses for adult patients with these abscesses. We aimed to describe the practice patterns and clinical outcomes of adult patients undergoing an emergency surgery for parapharyngeal or retropharyngeal abscesses using a nationwide database.

MATERIALS AND METHODS

We identified patients aged ≥18 years who underwent emergency surgery for parapharyngeal (para group, n = 1148) or retropharyngeal (retro group, n = 734) abscesses from July 2010 to March 2020, using a nationwide inpatient database. We performed between-group comparisons of the baseline characteristics, treatment course, and outcomes.

RESULTS

Compared with the retro group, the para group was more likely to be older (median, 66 vs. 60 years; P < 0.001) and have several comorbidities, such as diabetes (21 % vs 16 %; P = 0.010) and epiglottitis (33 % vs. 26 %; P = 0.002), except for peritonsillar abscess (14 % vs. 22 %; P < 0.001) and tonsillitis (2.1 % vs. 13 %; P < 0.001). Regarding intravenous drugs administered within 2 days of admission, approximately half of the patients received steroids, non-antipseudomonal penicillins, and lincomycins. The para group received more comprehensive treatments, such as tracheostomy, intensive care unit admissions, and swallowing rehabilitation, within total hospitalization than the retro group. Moreover, it demonstrated higher in-hospital mortality (2.7 % vs. 1.1 %; P = 0.017) and morbidity (16 % vs. 9.7 %; P < 0.001), and longer length of hospitalization than the retro group.

CONCLUSION

The current nationwide study provided an overview of the characteristics, treatments, and outcomes for patients who underwent an emergency surgery for parapharyngeal or retropharyngeal abscess.

Predictive value of serum interleukin-6 to determine surgical drainage of deep neck space infection in adults

PURPOSE

The aim of this study was to determine whether interleukin-6 (IL-6) could be used as a predictor for surgical drainage in deep neck space infection (DNSI).

METHODS

A retrospective study was conducted to analyze 69 adult patients newly diagnosed as DNSI from January 2017 to December 2021 at a single center. The patients were treated with either surgical drainage or not. The following clinical data including age, gender, maximum diameter of abscess (MDA), laboratory data, therapeutic modalities, comorbidities, duration of hospitalization and complications were collected and evaluated.

RESULTS

Patients in drained group had significantly elevated MDA, IL-6, procalcitonin, C-reactive protein and neutrophil to lymphocyte ratio compared to patients in non-drained group (all P < 0.01). Significant predictors for surgical drainage were IL-6 and MDA as independent factors, with the optimum cutoff values of 52.5 pg/mL and 14.4 mm, respectively. Moreover, the IL-6 had a wider area under the curve than MDA for prediction of surgical drainage in DNSI.

CONCLUSIONS

IL-6 as a promising predictor of the need for surgical drainage can be effectively used for routine assessment in the early stage of DNSI to determine the optimal treatments.

Acute Retropharyngeal Abscess in Libyan Children: Case Series and Literature Review

Background A retropharyngeal abscess (RPA) is a deep neck infection that considers a medical emergency because of the possibility of serious complications including life-threatening upper airway obstruction, mediastinitis, and sepsis.

Materials and Methods We present our experience in Benghazi Children's Hospital, describing the clinical presentations, diagnostic workup, management, and the outcome of four children presented during the time period between November 2017 and November 2021 as cases of RPA secondary to penetrating trauma to the posterior pharyngeal wall either due to ingestion of a foreign body or due to manipulation of tonsils by the traditional therapist.

Results All cases presented with fever, poor feeding, and hyperextension of the neck. All were diagnosed by ultrasound and they needed surgical drainage of RPA, as they did not improve with medical treatment alone.

Conclusion A high index of suspicion is necessary for the early diagnosis and treatment of RPA. Two of our cases were presented following the manipulation of tonsils by a traditional therapist, so we attempted to emphasize this life-threatening consequence after traditional therapy, as well as the unnecessary morbidity and mortality associated with this ongoing traditional treatment in our country.

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.

Magnetic resonance imaging accuracy before surgery in children with retropharyngeal abscesses

AIMS

Retropharyngeal abscess (RPA) is a deep neck infection occurring in childhood. The gold standard technique for diagnosis is computerised tomography (CT) with a contrast medium. The aim of this study is to answer the question of whether magnetic resonance imaging (MRI) can be an alternative in diagnosing RPA and predicting pus drainage at surgery.

METHODS

This is a retrospective study conducted at the paediatric emergency department of a tertiary level children hospital. The medical records of 31 children admitted to the Otorhinolaryngology and Paediatric ward, with a suspected diagnosis of RPA, were reviewed. The primary study outcome was the diagnostic accuracy of CT and MRI in predicting the amount of pus during surgery.

RESULTS

Twenty-two patients (71%) underwent surgery. Among them, 18 had imaging before surgery. Eleven patients evaluated with CT scan underwent surgery: four had non-significant purulent drainage, three of them were reported to have a significant fluid collection (negative predictive value 66% and positive predictive value of 55%). Nine patients evaluated with MRI underwent surgery: four cases had non-significant purulent drainage, three of them showed a significant fluid collection at MRI (negative predictive value of 60%; positive predictive value of 56%).

CONCLUSION

MRI and CT scans showed similar accuracy in predicting successful pus drainage during surgery; therefore, it could be a valid alternative in the diagnosis of RPA in children.

Not Just a Sore Throat: A Case of a Retropharyngeal Abscess Causing Midline Shift of the Nasopharynx

A retropharyngeal abscess (RPA) is a deep neck space infection that can present with subtle symptoms. Although it is an uncommon diagnosis, an RPA can be life-threatening as it can result in airway compromise if not treated promptly. In this article, we report a case of a 21-month-old infant with a retropharyngeal abscess that required prompt recognition and treatment.

Retropharyngeal Abscess in a Fourteen-Month-Old Child Presenting with Dysphagia and Obstructive Sleep Apnea: A Case Report

Retropharyngeal abscess is a relatively uncommon midline deep neck space infection that extends from the base of the skull to the posterior mediastinum, situated between the buccopharyngeal and alar fascias. In this case report, we present a 14-month-old previously healthy female patient who had a high-grade fever for 7 days, associated with neck stiffness and restriction of neck movements to the right side. Her parents noticed decreased oral intake associated with dysphagia, muffled quality of voice, and obstructive sleep apnea. However, the patient had no clinical signs of mechanical obstruction on examination. A contrast-enhanced computed tomography scan of the neck showed a large retropharyngeal septated fluid collection measuring 8 × 3 × 6 cm, which was categorized as a large retropharyngeal abscess that was complicated by descending mediastinitis. The patient was taken immediately to the operation theater for incision and drainage under general anesthesia, after which she was started on intravenous antibiotics.

Infantile leukocytoclastic vasculitis caused by enterotoxin-producing methicillin-sensitive Staphylococcus aureus

Staphylococcus aureus infections are known to cause leukocytoclastic vasculitis (LCV). Herein, we describe a case of an 18-month-old with LCV caused by enterotoxin-producing methicillin-sensitive Staphylococcus aureus (MSSA) emanating from an unrecognized pharyngeal abscess. It is critical to consider the possibility of extracutaneous sources of MSSA infection when investigating an infant with vasculitis. Prompt diagnosis and appropriate treatment are vital in preventing potentially life-threatening complications.

Clinical evaluation of antibiotic regimens in patients with surgically verified parapharyngeal abscess: a prospective observational study

PURPOSE

We aimed to evaluate the effectiveness of different antibiotic regimens for the treatment of parapharyngeal abscess (PPA) and characterize patients, who suffered potentially preventable complications (defined as death, abscess recurrence, spread of infection, or altered antibiotic treatment because of insufficient progress).

METHODS

Sixty adult patients with surgically verified PPA were prospectively enrolled at five Danish Ear-nose-throat departments.

RESULTS

Surgical treatment included internal incision (100%), external incision (13%), and tonsillectomy (88%). Patients were treated with penicillin G ± metronidazole (n = 39), cefuroxime ± metronidazole (n = 16), or other antibiotics (n = 5). Compared to penicillin-treated patients, cefuroxime-treated patients were hospitalized for longer (4.5 vs 3.0 days, p = 0.007), were more frequently admitted to intensive care (56 vs 15%, p = 0.006), underwent external incision more frequently (31 vs 5%, p = 0.018), and suffered more complications (50 vs 18%, p = 0.022), including re-operation because of abscess recurrence (44 vs 3%, p < 0.001). Nine patients suffered potentially preventable complications. These patients displayed significantly higher C-reactive protein levels, received antibiotics prior to admission more frequently, underwent external incision more commonly, and were admitted to intensive care more frequently compared to other patients.

CONCLUSION

The majority of patients with PPA were effectively managed by abscess incision, tonsillectomy, and penicillin G ± metronidazole. Cefuroxime-treated patients were more severely ill at time of admission and had worse outcome compared to penicillin-treated patients. We recommend penicillin G + metronidazole as standard treatment for patients with PPA, but in cases with more risk factors for potentially preventable complications, we recommend aggressive surgical and broadened antibiotic therapy, e.g. piperacillin-tazobactam.

Retropharyngeal Abscess in an Adult With Pneumonia During COVID-19 Outbreak

BACKGROUND

Retropharyngeal abscesses are rarely reported in adults and occur mostly in patients with immunocompromised or as a foreign body complication. Admittedly, the treatment of retropharyngeal abscesses frequently involves surgical drainage to achieve the best results. However, when retropharyngeal abscesses occurred in a highly suspected patient with COVID-19, the managements and treatments should be caution to prevent the spread of the virus.

CLINICAL PRESENTATION

On February 13, a 40-year-old male with retropharyngeal abscesses turned to our department complaining dyspnea and dysphagia. In addition, his chest CT scan shows a suspected COVID-19 infection, thus making out Multiple Disciplinary Team determine to perform percutaneous drainage and catheterization through left anterior cervical approach under the guidance of B-ultrasound. Finally, the patient recovered and was discharged from the hospital on February 27 after 14 days of isolation. There was no recurrence after half a year follow-up.

CONCLUSIONS

By presenting this case, we aim at raising awareness of different surgical drainage methods and summarizing our experience in the management of retropharyngeal abscesses during the outbreak of COVID-19.

Early surgical intervention enhances recovery of severe pediatric deep neck infection patients

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.

Transoral versus Transcervical Drainage of Pharyngeal Abscesses in Children: Post-Operative Complications

INTRODUCTION

The objective of this study was to compare complications and other perioperative outcomes between intraoral and transcervical drainage of both retropharyngeal and parapharyngeal abscesses.

MATERIALS AND METHODS

This was a retrospective study that analyzed data from the 2012 to 2016 National Surgical Quality Improvement Program (NSQIP)-Pediatric public use files. Baseline characteristics and perioperative outcomes including postoperative complications and length of hospital stay (LOS) were compared between intraoral and transcervical drainage groups. Multivariable logistic regression was performed to inspect predictors of having an extended LOS, defined as LOS greater than 3 days.

RESULTS

A total of 1174 patients were included. Mean age was 5.1 ± 3.8 years in the intraoral group (N = 1063) and 4.2 ± 4.3 years in the transcervical group (N = 111, P < .001). There was no significant difference in the rate of post-operative complications between groups (5.7% intraoral vs 8.1% transcervical, P = .316). LOS was significantly longer in the transcervical group (>3 days in 36.2% of intraoral vs 49.5% of transcervical, P = .006). Patients in the transcervical group had 1.59 times the odds of extended LOS, after adjusting for age, pre-operative ventilator support, asthma, structural pulmonary disease, hematologic disorders, and all post-operative complications (P = .024).

CONCLUSION

There does not appear to be a significant difference in the rate of post-operative complications after intraoral versus transcervical drainage for pharyngeal abscesses in children. However, transcervical drainage was associated with an extended hospital stay. Further prospective studies will be needed to determine the reasons for this.

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.

Tongue protrusion as the presenting symptom of parapharyngeal abscess

Deep neck space infections are commonly seen in the pediatric population. The diagnosis, however, can be challenging to make and requires a high degree of suspicion because of developmental and age-related factors in children and non-specific presenting symptoms. Diagnosis becomes further complicated in patients whose comorbid conditions mask some of the more severe systemic symptoms. We present a case of a 2-year-old female with Trisomy 21 who presented with a chief concern of "tongue swelling" per parents. After initially failing treatment for presumed angioedema caused by an angiotensin-converting enzyme inhibitor, she was ultimately diagnosed with a parapharyngeal abscess with extension and mass effect causing tongue protrusion. This case represents a novel early presentation of a common infection and highlights the challenges of diagnosing deep neck space infections in children.

A Nationwide Population-Based Study on the Incidence of Parapharyngeal and Retropharyngeal Abscess-A 10-Year Study

This study aimed to investigate the annual incidence of parapharyngeal and retropharyngeal abscess (PRPA) based on 10-year population-based data. Patients with PRPA were identified from the Taiwan Health Insurance Research Database, a database of all medical claims of a randomly selected, population-representative sample of over two million enrollees of the National Health Insurance system that covers over 99% of Taiwan’s citizens. During 2007–2016, 5779 patients received a diagnosis of PRPA. We calculated the population-wide incidence rates of PRPA by sex and age group (20–44, 45–64, and >64) as well as in-hospital mortality. The annual incidence rate of PRPA was 2.64 per 100,000 people. The gender-specific incidence rates per 100,000 people were 3.34 for males and 1.94 for females with a male:female gender ratio of 1.72. A slight increase in incidence rates among both genders over the study period was noted. Age-specific rates were lowest in the 20–44 age group with a mean annual incidence of 2.00 per 100,000 people, and the highest rates were noted in the age groups of 45–64 and >64 years with mean annual incidences of 3.21 and 3.20, respectively. We found that PRPA is common in Taiwan, males and older individuals are more susceptible to it, and incidence has increased in recent years.

[Features of the clinic, diagnosis and treatment of parapharyngeal abscesses in children: analysis of 121 observations]

Parapharyngeal and retropharyngeal abscesses (PPA) in children are a rare pathology, for the diagnosis of which it is necessary to use additional instrumental examination methods. The tactics of treating patients remains a subject of discussion.

OBJECTIVE

To analyze the features of the clinic, diagnosis and treatment of PPA in children.

MATERIAL AND METHODS

According to the hospital database, a retrospective analysis of the medical histories of children discharged from the clinic with a diagnosis of "J39.0 Retropharyngeal and parapharyngeal abscess" was carried out in the period from 01.01.14 to 31.12.19. In all cases, the diagnosis was confirmed by computed tomography (CT) data with contrast enhancement. Complaints at the time of treatment, anamnesis and instrumental diagnosis data, clinical features of the course of the disease and the effectiveness of treatment were analyzed.

RESULTS

121 children were treated for PPA (average age 73±41 months; Me=52.5 months), which is 0.4% of all hospitalized in the otorhinolaryngological department, 0.7% of the number of emergency hospitalizations, 0.8% of the number of hospitalized children with pharyngeal diseases, and 8.3% of the number of patients with pharyngeal abscess. Abscesses were more often localized in the upper pharynx, at the level of the I-II cervical vertebrae (49.6% of all observations); abscesses were found least often in the pharyngeal space (5.8%), there was no statistically significant difference between the right-sided and left-sided location: 47.9% and 46.2%, respectively. Surgical treatment was performed in 98 (81%) patients in the presence of an abscess capsule or an abscess diameter of more than 2 cm according to CT; the remaining 23 (19%) children were treated conservatively. The opening of the abscess was performed endopharyngeal, in the case of a pronounced deep lateral location of the abscess and its proximity to large blood vessels - with access through the tonsillar niche after preliminary tonsillectomy (19.4% of those operated).

CONCLUSION

The final diagnosis of parapharyngeal and retropharyngeal abscess can be established by contrast-enhanced computed tomography. Conservative treatment is indicated for a limited group of patients at the initial stages of the disease, most patients need surgical treatment.

Multisystem Inflammatory Syndrome in Children in a 15-Year-Old Male with a Retropharyngeal Phlegmon

This is a case of a 15-year-old male with an initial diagnosis of a retropharyngeal phlegmon who ultimately developed new symptoms and laboratory findings consistent with MIS-C. This case report demonstrates an atypical initial presentation for MIS-C that has not been reported in the literature.

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.

An intubated 7-month-old infant with a retropharyngeal abscess and multidrug-resistant Streptococcus mitis

The profile of antimicrobial resistance (ie, antibiogram) may be disparate between children and adults. An infant developed severe deep neck infection with a multidrug-resistant microbe. The microbe was more drug-resistant in children than in adults, in our hospital. Treatment of a child should be guided by the antibiogram obtained from children.

Deep Neck Space Involvement of Kawasaki Disease in the US: A Population-Based Study

OBJECTIVES

To describe the rate and risk factors of deep neck space involvement of Kawasaki disease.

STUDY DESIGN

We performed a retrospective analysis using the Kids' Inpatient Database from 2006, 2009, 2012, and 2016. Kawasaki disease and deep neck space involvement cases were identified using International Classification of Diseases codes among children aged <12 years. Demographic and outcome data of Kawasaki disease cases with and without deep neck space involvement were compared.

RESULTS

Of 20 787 patients with Kawasaki disease, 0.6% (130 cases) had deep neck space involvement. On multivariable analysis, children aged ≥4 years (OR 8.41; 95% CI 3.79-18.7 in those aged 6-11 years), Asian or Pacific Islanders (OR 3.72; 95% CI 1.90-7.27), non-Hispanic black children (OR 2.39; 95% CI 1.34-4.28), and Northeast hospital region (OR 2.32; 95% CI 1.21-4.46) were associated with deep neck space involvement. Surgical drainage was performed in 21.7% of patients with deep neck space involvement. Deep neck space involvement was associated with longer hospital stay and greater costs.

CONCLUSIONS

Approximately 0.6% of patients with Kawasaki disease present with deep neck space involvement in the US. Deep neck space involvement of Kawasaki disease occurs primarily in older (≥4 years old), non-white, non-Hispanic children. Deep neck space involvement is associated with operative procedures for presumed abscess, longer hospital stay, and greater costs. In caring for children with suspected deep neck space abscess, particularly when they are not responding to antibiotics, clinicians should evaluate them for the possibility of Kawasaki disease.

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.

Otolaryngology in Critical Care

Diseases affecting the ear, nose, and throat are prevalent in intensive care settings and often require combined medical and surgical management. Upper airway occlusion can occur as a result of malignant tumor growth, allergic reactions, and bleeding events and may require close monitoring and interventions by intensivists, sometimes necessitating surgical management. With the increased prevalence of immunocompromised patients, aggressive infections of the head and neck likewise require prompt recognition and treatment. In addition, procedure-specific complications of major otolaryngologic procedures can be highly morbid, necessitating vigilant postoperative monitoring. For optimal outcomes, intensivists need a broad understanding of the pathophysiology and management of life-threatening otolaryngologic disease.

Spontaneous retropharyngeal and mediastinal thoracic duct cyst in an infant with respiratory distress

Thoracic duct cysts (TDC) within the retropharyngeal space and mediastinum are exceedingly rare lesions, with the majority related to trauma or neoplasm. We describe a case of an otherwise healthy 8-month-old boy who presented with severe respiratory distress, which was found to be caused by a large, spontaneous TDC occupying most the retropharyngeal and mediastinal space. To our knowledge, this is the youngest patient to date presenting with TDC. Ultimately, his TDC was completely resolved with sclerotherapy, however the patient's age and size presented unique challenges to his medical management, which we describe below.

Paediatric Virology: A rapidly increasing educational challenge

The '2nd Workshop on Paediatric Virology', which took place on Saturday the 8th of October 2016 in Athens, Greece, provided an overview on recent views and advances on Paediatric Virology. Emphasis was given to HIV-1 management in Greece, a country under continuous financial crisis, hepatitis B vaccination in Africa, treatment options for hepatitis C virus in childhood, Zika virus in pregnancy and infancy, the burden of influenza on childhood, hand-foot-mouth disease and myocarditis associated with Coxsackie viruses. Other general topics covered included a critical evaluation of Paediatric Accident and Emergency viral infections, multimodality imaging of viral infections in children, surgical approaches of otolaryngologists to complex viral infections, new advances in the diagnosis and treatment of viral conjunctivitis and novel molecular diagnostic methods for HPV in childhood. A brief historical overview of the anti-vaccination movement was also provided, as well as presentations on the educational challenge of Paediatric Virology as a new subspecialty of Paediatrics. This review highlights selected lectures and discussions of the workshop.