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.

Emerging findings for the assessment and treatment of pediatric deep neck abscesses

PURPOSE OF REVIEW

The purpose of this review is to summarize new literature regarding the description, diagnosis, and treatment of pediatric deep neck abscesses.

RECENT FINDINGS

Providers should include multi-inflammatory syndrome in children (MIS-C) in a differential diagnosis in children suspected of having a retropharyngeal abscess. MRI may guide the proper management of children with deep neck abscesses by more accurately detecting free fluid compared to computed tomography imaging. Factors that may predict the need for surgical management include elevations in white blood cell counts and abscess size more than 3 cm. However, future investigation is necessary to establish consistent guidelines. Medical management is effective in many children, with a new study indicating success using a combination of cefotaxime and rifampicin.

SUMMARY

Anatomical and age-related risk factors predispose children to the development of deep neck abscesses. Findings from recent studies may aid providers in making an accurate diagnosis and providing proper medical or surgical management of children with these infections.

Does systemic steroid use affect the length of hospital stay for head and neck infections?

OBJECTIVE

The purpose of this study was to conduct a systematic review to perform a meta-analysis to investigate the outcomes of head and neck infections treated with systemic steroids.

STUDY DESIGN

The protocol was registered to the International Prospective Register of Systematic Reviews on August 24, 2020. The studies were compiled using PubMed/Medline with a single reviewer from their inception until August 17, 2020. The studies were uploaded onto Convidence.org, and a repeat search was conducted and uploaded on August 17, 2021. Two independent reviewers (J.S. and S.H.) blinded to each other's assessments reviewed the title and/or abstract for inclusion. After a first pass, full-text reviews of the articles were assessed (J.S. and K.F.) for study inclusion. Data were extracted from the steroid (test) and nonsteroid (control) cohorts.

RESULTS

The initial search of key terms yielded 2,711 studies. Titles and abstracts were reviewed, and only cohort and/or cross-sectional studies with the relevant study groups and the relevant outcomes were retrieved for the filtration system. The 2 reviewers reviewed 188 full-text studies, and 3 studies met the inclusion criteria. Although all 3 studies included the mean length of stay for the treatment and a control group, only 2 studies included the confidence interval, and only 1 included P values. Overall, the studies presented insufficient data to pool outcomes and ran a statistical analysis for meta-analysis.

CONCLUSIONS

Steroid use reduced the length of stay in 2 studies and increased the length of stay in another larger study. Given the lack of data to perform a meta-analysis, more studies need to be conducted, with a prospective randomized control trial design being essential for guiding evidence-based practice regarding the use of steroids in head and neck infections.

Clinical and Microbiological Characteristics of Deep Neck Abscesses in Pediatrics: Analysis of a Case Series from a 3rd Level Pediatric Hospital

As there is currently no consensus on managing deep neck infections in pediatric populations, we report a case series from a large pediatric hospital. Clinical data of patients discharged from Istituto Gaslini-Children's Hospital from January 2014 to June 2020 with peritonsillar, parapharyngeal, or retropharyngeal abscess diagnoses were collected. A total of 59 patients were identified. Patients underwent surgical drainage in 47% of cases. Streptococcus mitis/oralis was the most isolated pathogen. Surgically treated patients did have larger abscesses compared to others, but there were no differences in the duration of hospitalization. Children who received NSAIDs at home had significant delays in diagnosis (median 4 vs. 1.5 days, p = 0.008). In our experience, clinical presentation of DNIs is often evocative, but evaluation should include imaging with CT/MRI. Surgery is effective in larger abscesses, allowing for etiological diagnosis with consequent antibiotic adjusting. From an anamnestic point of view, home medications such as NSAIDs could delay diagnosis.

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).

Deep cervical abscesses in children: efficacy of the cefotaxime-rifampicin combination

The objective is to determine whether a medical treatment, the combination of cefotaxime and rifampicin, is effective in avoiding surgery for managing deep cervical abscesses in children and to determine prognostic factors in the efficacy of this medical treatment. This is a retrospective analysis of all patients under 18 presenting with para- or retro-pharyngeal abscess over the period 2010-2020 in two hospitals' pediatric otorhinolaryngology departments. One hundred six records were included. Multivariate analyses were performed to study the relationship between the prescription of the Cefotaxime-rifampicin protocol at the onset of the management and the use of surgery and to evaluate the prognostic factors of its efficacy. The 53 patients who received the cefotaxime-rifampicin protocol as first-line treatment (vs. 53 patients receiving a different protocol) required surgery less frequently: 7.5% versus 32.1%, validated by a Kaplan-Meier survival curve and a Cox model analysis adjusted for age and abscess size (Hazard Ratio = 0.21). This good outcome of the cefotaxime-rifampicin protocol was not demonstrated when it was instituted as a second-line treatment after the failure of a different protocol. An abscess larger than 32 mm at hospitalization was significantly associated with more frequent use of surgery in multivariate analysis adjusted for age and sex (Hazard Ratio = 8.5).    Conclusions: The cefotaxime-rifampicin protocol appears to be an effective first-line treatment in managing non-complicated deep cervical abscesses in children. What is Known: • Nowadays, medical treatment is preferred for managing deep neck abscesses in children. There has yet to be a consensus on the antibiotic therapy to be proposed. • Staphylococcus aureus and streptococci are the most frequent causative organisms. What is New: • The cefotaxime-rifampicin protocol introduced at first intention is effective, with only 7.5% of patients requiring drainage surgery. • The only risk factor for failure of the medical treatment is the initial size of the abscess.

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.

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.

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.

Surgical multidisciplinary approach in the management of odontogenic or non-odontogenic neck infections

In recent years, in our university hospital, the number of odontogenic and non-odontogenic abscesses has been rapidly increasing. We included 70 patients from January 4^th 2018 to February 19^th 2020 affected by the odontogenic ones. Deep neck infection can spread to the chest and is associated with high morbidity and mortality. The purpose of this mini-review is to demonstrate that, in case of complications, a multidisciplinary approach is needed to treat these infections, so that all practitioners should work together to achieve the patient’s rapid recovery.

[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.

Best Practice Recommendations for Pediatric Otolaryngology during the COVID-19 Pandemic

Objective

To review the impact of coronavirus disease 2019 (COVID-19) on pediatric otolaryngology and provide recommendations for the management of children during the COVID-19 pandemic.

Data Sources

Clinical data were derived from peer-reviewed primary literature and published guidelines from national or international medical organizations. Preprint manuscripts and popular media articles provided background information and illustrative examples.

Methods

Included manuscripts were identified via searches using PubMed, MEDLINE, and Google Scholar, while organizational guidelines and popular media articles were identified using Google search queries. Practice guidelines were developed via consensus among all authors based on peer-reviewed manuscripts and national or international health care association guidelines. Strict objective criteria for inclusion were not used due to the rapidly changing environment surrounding the COVID-19 pandemic and a paucity of rigorous empirical evidence.

Conclusions

In the face of the COVID-19 pandemic, medical care must be judiciously allocated to treat the most severe conditions while minimizing the risk of long-term sequelae and ensuring patient, physician, and health care worker safety.

Implications for Practice

The COVID-19 pandemic will have a profound short- and long-term impact on health care worldwide. Although the full repercussions of this disease have yet to be realized, the outlined recommendations will guide otolaryngologists in the treatment of pediatric patients in the face of an unprecedented global health crisis.