Conservative Treatment of Retropharyngeal and Parapharyngeal Abscess in Children

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.

Granulicatella adiacens Causing a Parapharyngeal Abscess in a 10-Month-Old Infant: A Rare-Case Report and Literature Review of Deep Neck Infections (DNIs) in Children

Granulicatella adiacens is a rare variant of the Streptococcus bacteria. When isolated, G. adiacens has been described in cases of endocarditis and bacteremia, but less commonly seen in isolated pyogenic infections. We report a case of a parapharyngeal abscess caused by G. adiacens in an otherwise healthy 10-month-old infant, which was successfully treated with antibiotics and surgical drainage. To the best of our knowledge, this is the first described case of a pediatric deep soft tissue neck infection caused by G. adiacens with one other report in an adult. Additionally, of all localized infections from this bacteria, this is only the second reported case in the pediatric population. We also include an evidence-based literature review of the clinical presentation, microbiology, imaging modalities, and management approach to deep neck infections (DNIs).

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.

Pediatric deep neck infections: Clinical description and analysis of therapeutic management

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.

Deep Neck Abscesses in Children: An Italian Retrospective Study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Retropharyngeal abscess and mediastinitis as an uncommon complication of varicella infection

Varicella infection is one of the most common and contagious infection in children and could course with severe complications. We report the case of a 4-year-old patient derived to our hospital for suspicion of suppurative complication in the context of a varicella infection. A computerized tomographic scanning was performed, showing a large retropharyngeal abscess with mediastinitis. Complications of varicella are up to 2% of patients, but this is the first report of a retropharyngeal and mediastinal abscess in this context. In the face of clinical suspicion, early intervention is important through imaging, intravenous antibiotics and surgical drainage in necessary cases.

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.

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

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

Risk factors for transcervical incision and drainage of pediatric deep neck infections

OBJECTIVES

The aim of this study was to identify risk factors for transcervical approaches in the treatment of pediatric deep neck infections (DNIs).

METHODS

We performed a retrospective analysis of data from patients who were diagnosed with DNIs. All medical records were reviewed for demographic characteristics, presenting signs and symptoms, duration of symptoms, size of abscess, laboratory results, duration of intravenous (IV) antibiotic administration, duration of hospitalization, medical treatment, and type of surgical drainage (oral or transcervical approach). We divided 126 patients into three groups according to the approach used to treat the DNI: non-surgical, intraoral surgical and external transcervical surgical.

RESULTS

The average ages of the non-surgical, intraoral, and transcervical groups were 10.46±5.27, 12.75±4.82 and 5.54±5.15years, respectively. The transcervical approach was used to treat younger patients (p<0.001). Abscess size was significantly larger for the transcervical group compared to the other groups (5.72±8.93, 13.51±14.74, 18.36±16.05mm, non-surgical, intraoral, and transcervical group, respectively, p=0.009). The average duration of IV antibiotic administration for the transcervical group was 9.77±3.27days, which was significantly higher than those for the other groups (5.49±3.28 for non-surgical and 6.13±2.85 for intraoral, p<0.001). Multivariate analysis revealed that submandibular abscesses (Exp (B)=5.254, p=0.012) were the only significant risk factor for the transcervical approach in surgical treatment of DNIs.

CONCLUSION

Submandibular space abscesses were the only significant risk factor for the transcervical approach in the treatment of pediatric DNI patients.

LEVEL OF EVIDENCE

III.

The effectiveness of conservative management for retropharyngeal abscesses greater than 2 cm

Objectives

Conservative management for retropharyngeal abscesses <2 cm is now a first line option. It is unclear if conservative management can be used to manage larger abscesses without increased morbidity and mortality.

Study design

A prospective case series was performed from 2012 to 2015 by the Otolaryngology department of the San Fernando General Hospital involving pediatric patients who presented with retropharyngeal abscesses. All patients were initially treated with antibiotics alone.

Methods

Patients with clinical features and CT scan confirmation of a retropharyngeal abscess were included in the study. Those who improved clinically and biochemically within 48 h continued to be treated conservatively and those who deteriorated had surgical intervention.

Results

Sixteen patients fulfilled the inclusion criteria. Most patients were Afro Trinidadian males between the ages of two and five who were also found to be iron deficient. Drooling was a sensitive predictor for the presence of an abscess but did not indicate the need for drainage. Hoarseness was the clinical feature that prompted surgical intervention. Sixty three percent of patients had an abscess >2 cm of which 90% improved within 48 h. One patient required surgical drainage with no increase in morbidity or mortality.

Conclusion

Conservative management of retropharyngeal abscesses >2 cm can be offered to patients during the first 48 h. If the patient demonstrates clinical and biochemical improvement, antibiotics alone can be continued. If the patient deteriorates, surgical drainage can be subsequently performed with no increase in morbidity and mortality.

•

The retropharyngeal abscess is a deep neck space infection commonly seen in the pediatric population.

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Drainage of these abscesses is associated with multiple complications.

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Patient presenting with hoarseness requires surgical intervention.

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Conservative management can be successfully performed in patients who have abscesses that are greater than 2 cm.

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Patients treated with antibiotic alone need to be closely followed up for lack of improvement or deterioration.

Acute cervical lymphadenitis and infections of the retropharyngeal and parapharyngeal spaces in children

Background

Acute cervical adenitis can evolve into suppurative cervical lymphadenitis and may sometimes be associated with infection of the retropharyngeal and parapharyngeal spaces (i.e., retropharyngeal and poststyloid parapharyngeal abscesses). This study aimed to describe the clinical presentation of acute cervical lymphadenitis and infections of the retropharyngeal and parapharyngeal spaces in children and examine the management of these conditions.

Methods

This was a retrospective study including children from 3 months to 18 years old who were hospitalized in the Pediatric Department of the Centre-Intercommunal-de-Créteil between January 2003 and May 2010. Selected cases were based on the diagnosis of acute cervical lymphadenitis, suppurative cervical lymphadenitis, or infections of the retropharyngeal or parapharyngeal spaces. Case history, clinical signs, laboratory tests, imaging, treatment and clinical course were collected from patient charts.

Results

We included 75 children (54 males [72%]); 62 (83%) were < 6 years old. Diagnoses were acute cervical lymphadenitis in 43 patients (57%), suppurative cervical lymphadenitis in 13 (17%), retropharyngeal or poststyloid parapharyngeal abscess in 18 (24%) and cervical necrotizing fasciitis in 1 (1%). In total, 72 patients (96%) presented fever and 34 (45%) had torticollis. Suppurative cervical lymphadenitis or abscesses of the retropharyngeal or poststyloid parapharyngeal spaces was significantly higher for children with than without torticollis (52.9% vs. 4.8%, p < 0.001). In all, 21 patients among the 44 > 3 years old (48%) underwent a rapid antigen detection test (RADT) for group A beta-hemolytic Streptococcus pyogenes; results for 10 were positive (48%). Contrast-enhanced CT scan of the neck in children with torticollis (n = 31) demonstrated an abscess in 21 (68%). Fine-needle aspiration was performed in 8 patients (11%) and 8 (11%) required surgical drainage. Bacteriology was positive in 8 patients (11%), with a predominance of Staphylococcus aureus and S. pyogenes. All patients received intravenous antibiotics and the outcome was favorable regardless of surgery. Recurrence was observed in only 1 case among the 34 patients with a follow-up visit after discharge.

Conclusion

Our data suggest that presentation with cervical lymphadenitis associated with fever and torticollis requires evaluation by contrast-enhanced CT scan. Furthermore, abscess drainage should be restricted to the most severely affected patients who do not respond to antibiotic therapy.

Parapharyngeal abscess is frequently associated with concomitant peritonsillar abscess

To characterize patients with parapharyngeal abscess admitted to a Danish tertiary care centre and evaluate our management. This is a retrospective chart review. All records of patients with parapharyngeal abscess admitted to the Ear-Nose-Throat Department at Aarhus University Hospital, Denmark, from January 2001 through December 2011 were reviewed. In total, 63 patients (41 males), aged 4-89 years (median, 45 years) were included in the study. The mean annual incidence of parapharyngeal abscess was 0.9 cases/100,000 population. Thirty-three (52%) patients had concomitant peritonsillar abscess. In two patients the parapharyngeal abscess was accompanied by necrotizing fasciitis. The most frequent surgical approach used was intrapharyngeal incision in combination with tonsillectomy. The most commonly used antibiotic regimen was benzylpenicillin plus metronidazole. Seven (13%) patients returned to the operating theatre due to post-tonsillectomy haemorrhage or insufficient abscess drainage. Tonsillectomy and internal incision of the abscess in combination with a narrow-spectrum intravenous penicillin and metronidazole is a safe and efficient approach for managing parapharyngeal abscesses. This approach, however, carries a relatively high complication rate, requiring close surveillance in the early post-operative period. This is especially true for parapharyngeal abscess patients without peritonsillar abscess. In our series, these patients were more ill, more likely to experience complications, require intensive care, intubation, and tracheotomy, than parapharyngeal abscess patients with concurrent peritonsillar abscess. The frequent co-existence of parapharyngeal abscess and peritonsillar abscess favours careful consideration of addition of tonsillectomy to intrapharyngeal incision.

Children with Deep Space Neck Infections

Objective

To identify clinical features associated with unsuccessful medical therapy in children with deep space neck infections (DSNIs).

Study Design

Consecutive case series with chart review.

Setting

Tertiary-care, academic children’s hospital.

Subjects and Methods

One hundred seventy-eight pediatric patients treated for retropharyngeal or parapharyngeal infections between July 1, 2007, and May 23, 2012.

Results

Median age was 34.5 months (2.9 years; range, 2-142 months); two-thirds were male. Increased surgical drainage was found in children age ≤15 months ( P = .002) and for abscesses >2.2 cm ( P = .0001). Risk factors associated with increased likelihood of medical therapy failure included age ≤51 months, intensive care unit admission, and computed tomography findings consistent with abscess size >2.2 cm. Methicillin-resistant Staphylococcus aureus infections were found more often in younger children, with the highest incidence in those ≤15 months of age ( P = .001). All children had resolution of infection.

Conclusion

Deep space neck infections in children can often be successfully managed with medical therapy alone, but life-threatening complications may occur. We recommend that young patients be managed cautiously.

Antibiotic therapy for pediatric deep neck abscesses: a systematic review

OBJECTIVE

To evaluate the current evidence regarding the safety and efficacy of medical management for deep neck abscesses in children.

DATA SOURCES

Pubmed and Embase databases accessed 3/27/2012.

REVIEW METHODS

An a priori protocol defining inclusion and exclusion criteria was developed to identify all articles addressing medical therapy of pediatric deep neck abscesses where details regarding diagnostic criteria, specifics of medical therapy and definitions of failure were presented. The search included electronic databases to identify candidate articles as well as a manual crosscheck of references. The level of evidence was assessed and data extracted by three authors independently. Data were pooled using a random effects model due to significant study heterogeneity.

RESULTS

Eight articles met inclusion criteria. The overall level of evidence was grade C. There was significant heterogeneity among the studies (I(2)=98.8%; p<.001). However, each article uniformly presented cases suggesting that medical therapy may be a viable alternative to surgical drainage in some patients. The pooled success rate of medical therapy in avoiding surgical drainage in children with deep neck infections was 0.517 (95%CI: 0.335, 0.700). When patients taken immediately to surgery were excluded and patients were placed on author defined medical protocols, the success rate increased to 0.951 (95%CI: 0.851, 1.051). Subgroup analysis by duration of intravenous antibiotic trial greater than 48h demonstrated a pooled success rate of 0.740 (95%CI: 0.527, 0.953).

CONCLUSION

The current literature suggests medical management may be a safe alternative to surgical drainage of deep neck abscesses in children. However, the level of evidence lacks strength and further investigation is warranted.

A pain in the neck: non-traumatic adult retropharyngeal abscess

BACKGROUND

We present the case of a 47-year-old man who presented to the Emergency Department (ED) with complaint of left-sided neck pain. He was thought to have a musculoskeletal sprain on his initial visit. However, he returned the following evening with worsening symptoms. On further investigation, he was found to have a non-traumatic retropharyngeal abscess (RPA), a rare infection in the adult patient population.

OBJECTIVES

This infection has been studied primarily in the pediatric population, and extrapolation of their studies demonstrates the importance of airway stabilization, antibiotic use targeting polymicrobial organisms, and conservative medical management vs. surgical drainage. We aim to summarize this case and review the literature on retropharyngeal abscess.

CASE REPORT

This patient presented to the ED with complaints of left-sided neck pain. There was no history of trauma or injury to the affected area. He was evaluated and discharged but returned with a deteriorating clinical picture. On further evaluation, he was found to have a non-traumatic RPA. He was admitted to the Otolaryngology service and managed conservatively with intravenous (IV) antibiotics. His condition resolved and he was subsequently discharged from the hospital.

CONCLUSIONS

The majority of data on diagnosis and treatment of adult RPA have come from the pediatric population. However, the same essential treatment principles apply: airway stabilization, resuscitation, initiation of IV antibiotics, and consultation with an otolaryngology specialist.

Grisel's syndrome as a sequela of a complicated acute mastoiditis

Grisel's syndrome is a rare complication of ENT area infections. It consists of a non-traumatic atlantoaxial subluxation after an infectious process. Its characteristic symptom is persistent torticollis despite a resolved infection. The knowledge of this condition helps early diagnosis and treatment. We therefore present the case of a patient with Grisel's syndrome as a sequela of an acute mastoiditis complicated by a Bezold's abscess.

Immediate tonsillectomy: indications for use as first-line surgical management of peritonsillar abscess (quinsy) and parapharyngeal abscess

Objectives:

This study was designed to evaluate the efficacy and morbidity of immediate tonsillectomy used to treat peritonsillar abscess (quinsy) and parapharyngeal abscess.

Subjects and method:

This four-year, retrospective study was based on 31 patients hospitalised in a university hospital ENT and head and neck surgery department for peritonsillar and/or parapharyngeal abscess. All patients underwent immediate, bilateral tonsillectomy. The length of hospital stay, duration of antibiotic therapy, microbiological findings, complications, and the time to complete recovery and oropharyngeal healing were recorded.

Results:

The patients' mean post-tonsillectomy hospital stay was 2.84 days (median: 3 days). No post-operative haemorrhage was observed. All patients were considered to be cured at the day 10 follow-up visit, and complete oropharyngeal healing was observed at the day 21 visit. The duration of antibiotic therapy ranged from 10 to 15 days (mean: 11.5 days; median: 10 days).

Discussion and conclusion:

Immediate tonsillectomy appears to be a safe and effective surgical technique for the management of peritonsillar and parapharyngeal abscess; in particular, it markedly reduces patients' hospital stay (when performed early in the course of the disease) and duration of antibiotic therapy. Immediate tonsillectomy has become the first-line treatment for parapharyngeal abscess and several types of peritonsillar abscess in our department.