Magnetic resonance imaging accuracy before surgery in children with retropharyngeal abscesses

Suppurative Cervicomediastinitis From the Perspective of the Head and Neck Surgeon in a Tertiary Treatment Unit

Introduction Cervical suppurations represent an emergency pathology, with a dramatic evolution in the absence of adequate treatment. It frequently affects young people, hence the medico-legal implications of these cases. The anatomical substrate for the development of these deep cervical suppurations is represented by the cervical fascia and spaces. A distinct and extremely serious sub-chapter within diffuse cervical suppurations is necrotic cervical fasciitis, a polymicrobial infection with the most common oropharyngeal or odontogenic starting point, with rapidly progressive, destructive evolution in the deep fascial planes of the neck. Materials and method We will present a retrospective clinical study carried out on 26 cases diagnosed and treated between September 2013 and September 2018 in the ENT Clinic Department of the Bucharest University Emergency Hospital. Results Our retrospective analysis of a cohort of 26 patients in a tertiary referral center showed that deep cervical suppurations are slightly more common in men than in women. The most affected age groups were 50-59 years, followed by 20-29 years, representing a percentage of 53.84% of all cases. Also, 53.84% of the studied patients with deep cervical suppurations had a precarious and modest status. The most common clinical signs at presentation were malaise, cervical swelling, neck pain, dysphagia, fever, dysphonia, dyspnea, and cervical erythema. More than 60% of suppurations were odontogenic and 23% were caused by a traumatic element. Diabetes mellitus represents a comorbidity in 30.8% of patients, while 42.3% of patients had no personal pathological history, and thus this pathology has a lethal potential also in a patient in full health. In the study group, 46 (15%) had cervicomediastinitis, and 61.53% developed necrotizing fasciitis. One-third (34.61%) of our patients had undergone previous drainage surgery. Bacteriological examinations of the wound were with group C, D, G betahemolytic streptococcus, while 61.53% of the cultures were negative. Most patients required at least two cervicotomies. The average duration of hospitalization was 28.26 days, and the mortality rate was 23.07%; therefore, practically, one out of four cases resulted in death. In the studied group, no direct relationship can be established between the length of hospitalization and the favorable and unfavorable evolution of the patient. We propose a 10-step management protocol for the management of a cervical suppuration. Conclusion The multidisciplinary approach to these suppurations by the head and neck surgeon, the thoracic surgeon, the oromaxillofacial surgeon, anesthetist, imagist, specialist in infectious diseases, pathologist, psychologist, and so on, is the key to success in a patient who presents not only a suppuration in the throat but also a disease with systemic resonance and significant lethal potential.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Paediatric Deep Neck Infection—The Risk of Needing Intensive Care

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

Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses

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