Lack of association of CT findings and surgical drainage in pediatric neck abscesses

Prognostic Factors for Retropharyngeal Abscess in Children Receiving Surgery or Antibiotic Therapy

OBJECTIVE

Effective management of retropharyngeal abscess (RPA) may predicate upon identification of key patient characteristics. We analyzed characteristics and outcomes of pediatric patients with RPA to identify prognostic factors associated with successful surgical intervention.

METHODS

A financial database was searched for pediatric otolaryngology patients with RPA from 2010 to 2021. Medical charts were reviewed for demographics, presenting history, physical examination, laboratory testing, imaging, surgical findings, and hospital course. Bivariate analyses were performed to identify potentially significant predictors of positive drainage. These variables were included in multivariate analysis of surgical outcomes.

RESULTS

Of 245 total patients, 159 patients (65%) received surgery and 86 patients (35%) received antibiotics only. Patients with restricted cervical motion, neck swelling, and computed tomography (CT) cross-sectional area (CSA) >2 cm2 were more likely to receive surgery. Rim enhancement on CT imaging was associated with positive surgical drainage (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.16-5.74). However, no variables from clinical symptoms or physical exam were associated with positive drainage. Variables that approached significance were included in multivariate analysis, which revealed only rim enhancement predicted positive drainage (OR 2.57, 95% CI 1.13-5.83). The mean length of stay (LOS) was 2.6 versus 3.5 days (p < 0.001) for medical vs surgical treatment groups, respectively.

CONCLUSION

Our study revealed a high success rate of medical management. Although patient characteristics and clinical features were not significant predictors of surgical outcomes, CT findings such as rim enhancement were strongly associated with positive surgical drainage.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1955-1960, 2024.

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.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Magnetic resonance imaging findings in pediatric neck infections-a comparison with adult patients

BACKGROUND

Differences in the functioning of the immune system and the anatomical proportions of the neck between children and adults lead to different manifestations of deep neck infections. Magnetic resonance imaging (MRI) may serve as an alternative to computed tomography (CT) as the primary imaging modality.

OBJECTIVE

To study characteristic MRI findings and the diagnostic accuracy of MRI in pediatric deep neck infections.

MATERIALS AND METHODS

We retrospectively studied a cohort of pediatric patients who underwent a neck 3-tesla MRI study over a five-year period. Inclusion criteria were: 1) emergency MRI findings indicating an infection, 2) infection as the final clinical diagnosis, 3) diagnostic image quality verified by the radiologist reading the study and 4) age under 18 years. Patient record data, including surgery reports, were compared with the MRI findings.

RESULTS

Data of 45 children were included and analysed. Compared to adults, children had a higher incidence of retropharyngeal infection and lymphadenitis, and a lower incidence of peritonsillar/parapharyngeal infection. MRI showed evidence of an abscess in 34 children. Of these 34 patients, 24 underwent surgery, which confirmed an abscess in 21 but no abscess in three patients. In addition, three patients underwent surgery without MRI evidence of abscess, and an abscess was found in one of these cases. The measures of diagnostic accuracy among the children were sensitivity 0.96, specificity 0.77, positive predictive value 0.89, negative predictive value 0.91 and accuracy 0.89. Compared with adults, children had lower C-reactive protein, but a similar proportion of them had an abscess, and abscess size and rate of surgery were similar.

CONCLUSION

Despite the differences in the infection foci, emergency MRI in children had equal diagnostic accuracy to that in adults.

Clinical and prognostic significance of emergency MRI findings in neck infections

OBJECTIVES

Due to its superior soft-tissue contrast and ability to delineate abscesses, MRI has high diagnostic accuracy in neck infections. Whether MRI findings can predict the clinical course in these patients is unknown. The purpose of this study was to determine the clinical and prognostic significance of various MRI findings in emergency patients with acute neck infections.

MATERIALS AND METHODS

We retrospectively reviewed the 3-T MRI findings of 371 patients with acute neck infections from a 5-year period in a single tertiary emergency radiology department. We correlated various MRI findings, including retropharyngeal (RPE) and mediastinal edema (ME) and abscess diameter, to clinical findings and outcomes, such as the need for intensive care unit (ICU) treatment and length of hospital stay (LOS).

RESULTS

A total of 201 out of 371 patients (54%) with neck infections showed evidence of RPE, and 81 out of 314 patients (26%) had ME. Both RPE (OR = 9.5, p < 0.001) and ME (OR = 5.3, p < 0.001) were more prevalent among the patients who required ICU treatment than among those who did not. In a multivariate analysis, C-reactive protein (CRP) levels, RPE, and maximal abscess diameter were independent predictors of the need for ICU treatment, and CRP, ME, and maximal abscess diameter were independent predictors of LOS.

CONCLUSION

In patients with an acute neck infection that requires emergency imaging, RPE, ME, and abscess diameter, as shown by MRI, are significant predictors of a more severe illness.

KEY POINTS

• Two hundred one out of 371 patients (54%) with neck infection showed evidence of retropharyngeal edema (RPE), and 81 out of 314 patients (26%) had mediastinal edema (ME). • Maximal abscess diameter, RPE, and C-reactive protein (CRP) were independent predictors of the need for intensive care unit (ICU) treatment, and maximal abscess diameter, ME, and CRP were independent predictors of length of hospital stay. • Prognostic significance of MRI findings was evident also while controlling for CRP values.

Pediatric lateral neck infections - Computed tomography vs ultrasound on initial evaluation

OBJECTIVE

Review the evaluation of children with a deep lateral neck infection and define the impact of initial imaging modality on outcomes and costs.

METHOD

Case series, pediatric patients <18 years of age admitted to a tertiary care hospital with lateral neck infection between 01/01/14-05/31/16 as identified by ICD-9 and ICD-10 codes: 289.3 (lymphadenitis, unspecified), 682.1 (cellulitis and abscess of neck), 683 (acute lymphadenitis), I88.9 (nonspecific lymphadenitis, unspecified), L02.11 (cutaneous abscess of neck), L03.221 (cellulitis of neck), and L03.222 (acute lymphangitis of neck). Patients were divided into two groups based on initial imaging modality: primary ultrasound or primary computed tomography. Differences in length of stay, type and total number of imaging studies obtained, number of procedures, hospital readmission, and hospital cost were compared between cohorts.

RESULTS

There were 40 (31%) primary ultrasound and 88 (69%) primary computed tomography patients (128 total). Median length of stay was 46 (IQR: 25,90) hours (1.9 days) for primary ultrasound and 63 (IQR: 39,88) hours (2.6 days) for primary computed tomography patients (p = 0.33). Drainage was performed in 48% of both groups. Additional imaging occurred in 17 (43%) primary ultrasound and 18 (20%) primary computed tomography patients (p = 0.02). Readmission occurred in 8 patients (6.3%). Retropharyngeal infection was encountered in 13 patients (10%); this was only discovered in patients who had a computed tomography performed. Median cost per primary ultrasound patients was $5363 (IQR: 3011, 7920) and $5992 (IQR: 3450, 8060) for primary computed tomography patients.

CONCLUSIONS

The primary imaging modality (ultrasound or computed tomography) used to work-up children with a lateral neck infection did not impact length of stay or hospital cost. However, a significant subset had a coexisting retropharyngeal infection that was only identified on computed tomography. Future studies are needed to identify appropriate criteria for imaging in the work-up of lateral neck infections.

Fluid collections in amputations are not indicative or predictive of infection

BACKGROUND

In the acute postoperative period, fluid collections are common in lower extremity amputations. Whether these fluid collections increase the risk of infection is unknown.

QUESTIONS/PURPOSES

The purposes of this study were to determine (1) the percentage of patients who develop postoperative fluid collections in posttraumatic amputations and the natural course of the collection; (2) whether patients who develop these collections are at increased risk for infection; and to ask (3) are there objective clinical or radiologic signs that are associated with likelihood of infection when a fluid collection is present?

METHODS

We performed a review of all 300 patients injured in combat operations who sustained at least one major lower extremity amputation (at or proximal to the tibiotalar joint) and were treated definitively at our institution between March 2005 and April 2009. We segregated the groups based on whether cross-sectional imaging was performed less than 3 months (early group) after closure, greater than 3 months (late group) after closure, or not at all (control group, baseline frequency of infection). Our primary study cohort where those patients with a fluid collection in the first three months. The clinical course was reviewed and the primary outcome was a return to the operating room for irrigation and débridement with positive cultures. For those patients with cross-sectional imaging, we also collected objective clinical parameters within 24 hours of the scan (white blood cell count, maximum temperature, presence of bacteremia, tachycardia, oxygen desaturation), extremity examination (presence of erythema, warmth, and/or drainage), and characteristics of the fluid collections seen (size of the fluid collection, enhancement, complexity (simple versus loculated), surrounding edema, skin changes, tract formation, presence of air, and changes within the bone itself). The presence of a fluid collection on imaging was analyzed to determine whether it was associated with infection. We further analyzed clinical parameters, objective physical examination findings at the extremity, and characteristics of the fluid collection to determine if there were other parameters associated with infection.

RESULTS

Over half (55%) of the limbs demonstrated fluid collection in the early postoperative period and the prevalence decreased in the late group (11%; p = 0.001). There was no association between the presence of a fluid collection and infection. However, there was an association between objective clinical signs at the extremity (erythema and/or drainage) and infection (p < 0.001) in our primary study cohort.

CONCLUSIONS

Fluid collections are common in combat-related amputations in the immediate postoperative period and become smaller and less frequent over time. In the absence of extremity erythema and wound drainage, imaging of a residual limb to evaluate for the presence of a fluid collection appears to be of little clinical use.

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.

Preoperative computed tomography of suspected thyroglossal duct cysts in children under 10-years-of-age

OBJECTIVE

The purpose of this study was to evaluate the preoperative computed tomography (CT) features of thyroglossal duct cysts (TDCs), with the main purpose of evaluating criteria helpful in differentiating TDCs from other lesions in children under 10-years-of-age.

METHODS

A retrospective chart review was performed at Chonnam National University Hospital for the period of March 2005 to June 2011. Pediatric patients under 10-years-of-age with suspected TDCs were divided into two groups depending on their histopathologic diagnosis.

RESULTS

Of the 29 pediatric patients with suspected TDCs, 16 patients (55%) had histopathologically confirmed TDCs. Thirteen patients (45%) had dermoid cysts (n=6), ranula (n=3), and inflammatory lesions (n=4). There were no statistically significant differences between the preoperative CT findings and the final histopathologic diagnosis of TDC. There were no major complications resulting from surgical interventions.

CONCLUSION

CT is not helpful in differentiating TDC from other lesions in children under 10-years-of-age. Therefore, we suggest that preoperative CT of suspected TDCs in children should be performed more selectively.

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.

Imaging of pediatric neck masses

Palpable neck masses are a common indication for pediatric imaging. Such lesions may be caused by infectious, inflammatory, tumoral, traumatic, lymphovascular, immunologic, or congenital etiologies. Radiological assessment of neck masses in young children should be tailored based on patient presentation and physical examination, as well as clinical suspicion. The goal of imaging should be to help arrive at a diagnosis or limited differential in an efficient manner while minimizing radiation exposure.

Retropharyngeal infections in children. Treatment strategies and outcomes

OBJECTIVE

To optimize the treatment of retropharyngeal infections in children.

METHODS

Retrospective chart review of 101 consecutive pediatric cases of retropharyngeal infections referred to our center from January 2006 to July 2009.

RESULTS

Two-thirds of patients were males. Their mean age was 52 months (range: 6-163). Upper airway obstruction was observed in three patients. In another child, the infection evolved towards a diffuse cervical cellulitis. Medical treatment was initially planned in 44% of patients. Failures requiring surgical drainage occurred in 18% of them. In 56% of cases, surgical treatment was immediately instigated. It failed in 16% of patients, requiring a second surgical drainage. There was no difference in the duration of fever and of hospital stay between patients initially treated medically or surgically. Both medical and surgical treatment failures were associated with longer durations of fever (p=0.002, and p<0.0001, respectively) and of hospital stay (p=0.0006, and p=0.0005, respectively). Some characteristics of CT-scan anomalies were correlated with treatment failure. A hypodense core surrounded by rim enhancement, with a largest long axis ≥ 20 mm, was more frequent in case of medical failure (p=0.02). Surgical failure was associated with the same feature, but with a largest long axis ≥ 30 mm (p=0.05).

CONCLUSIONS

The present study suggests that severe complications are rare in pediatric retropharyngeal adenitis, and that CT-scan is a useful tool to choose between medical and surgical treatment.

A pain in the neck--imaging in neck sepsis

Deep neck infection has a high morbidity and mortality and the extent of infection is often difficult to estimate clinically. The complex anatomy and the communication between neck spaces means that infection can spread along fascial planes leading to life-threatening complications such as airway compromise, vascular erosion/thrombosis, neural dysfunction, and ultimately descending necrotizing mediastinitis. Imaging has an important role to play in identifying the extent of infection and the presence of complications.

The patient with sore throat

Sore throat is a common medical complaint seen by the emergency practitioner, internist, pediatrician, and otolaryngologist. The differential for sore throat is vast. However, with a directed history this can often be narrowed down to 2 to 3 possible diagnoses. By paying particular attention to the associated symptoms and duration of symptoms, common self-limited etiologies like viral pharyngitis and nonstreptococcal tonsillitis can be distinguished from those that require more investigation, such as supraglottitis and tonsillar cancer. A sore throat is most commonly caused by an infectious, inflammatory, or neoplastic etiologic factor.