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Azar A, Alkheder A, Alsodi Z, Ayob H. Effective surgical drainage of a massive retropharyngeal abscess via an incision in the posterior wall of the oropharynx under local anesthesia. Int J Surg Case Rep 2024; 123:110234. [PMID: 39232350 DOI: 10.1016/j.ijscr.2024.110234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 08/24/2024] [Accepted: 08/31/2024] [Indexed: 09/06/2024] Open
Abstract
INTRODUCTION A retropharyngeal abscess is a deep neck infection, uncommon in adults but more prevalent in children. This report details a rare case of a huge retropharyngeal abscess in an adult female, effectively managed by an incision in the posterior oropharyngeal wall under local anesthesia. CASE PRESENTATION A 76-year-old woman with hypertension, diabetes, ischemic heart disease, and total thyroidectomy presented with sudden neck swelling, dyspnea, stridor, and dysphagia. Examination and imaging revealed a large retropharyngeal abscess. The abscess was drained through an incision in the posterior wall of the oropharynx using a local anesthetic, yielding immediate symptom relief. Cultures identified Streptococcus and Staphylococcus aureus, leading to adjusted antibiotics. The patient showed significant improvement, with resolution of respiratory distress and reduced inflammation. DISCUSSION The retropharyngeal space, containing lymph nodes and connective tissue, extends from the skull base to the superior mediastinum, communicating with the carotid sheath and parapharyngeal space. Effective management of a critically ill, immunocompromised patient with a resistant retropharyngeal abscess was achieved using an intraoral approach and intravenous antibiotics. This method avoids general anesthesia and minimizes postoperative complications. CT scans are essential for assessing disease extent and planning surgery. Our case highlights the successful treatment of a large abscess with minimal risks. CONCLUSION Drainage of retropharyngeal abscesses via the intraoral approach under local anesthesia can be considered a valuable method for high-risk patients who are not candidates for general anesthesia. Additionally, we presented a rare case of an exceptionally large retropharyngeal abscess.
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Affiliation(s)
- Adel Azar
- Department of Otorhinolaryngology, Al Mouwasat University Hospital, Faculty of Medicine, Damascus University, Damascus, Syria
| | - Ahmad Alkheder
- Department of Otorhinolaryngology, Al Mouwasat University Hospital, Faculty of Medicine, Damascus University, Damascus, Syria; Faculty of Medicine, Syrian Private University, Damascus, Syria.
| | - Zeina Alsodi
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Humam Ayob
- Department of Otorhinolaryngology, Al Mouwasat University Hospital, Faculty of Medicine, Damascus University, Damascus, Syria
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Thomas A, Adam S, Goussard P, Venkatakrishna SSB, Andronikou S, Grobbelaar J. Retropharyngeal Abscess Complicated by Mediastinitis in Infants. Respiration 2024:1-9. [PMID: 39084200 DOI: 10.1159/000540525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 07/20/2024] [Indexed: 08/02/2024] Open
Abstract
INTRODUCTION Most paediatric upper respiratory infections are virally mediated and result in self-limiting reactive lymphadenopathy. In children younger than 5 years, retropharyngeal lymph nodes may give rise to deep neck space infections in this potential space. Retropharyngeal infections are rare after 5 years because lymph nodes undergo atrophy. METHODS We present a series of 6 cases of paediatric retropharyngeal abscesses (RPA) complicated by mediastinitis, managed at a tertiary hospital over a 4-year period. RESULTS All our cases presented with fever, difficulty feeding, and neck swelling. The age range was 11 weeks-11 months, and all tested negative for human immunodeficiency virus. The diagnosis and complications were confirmed on computed tomography (CT) scan. The CT scans consistently revealed RPA with varying degrees of deep neck space and mediastinal extension. All children were promptly taken to theatre for source control. Two were extubated successfully immediately after surgery, and the other 4 were extubated in the paediatric intensive care unit, with the longest duration of intubation being 3 days. Methicillin-sensitive Staphylococcus aureus (MSSA) was cultured in all 6 cases. CONCLUSION Management of these cases may be challenging, and young children with RPA require close care and airway monitoring. CT or magnetic resonance imaging is essential to delineate the extent of infection. Surgical drainage should be performed when there is a large abscess, a complication occurs, or an inadequate response in 24-48 h to medical management.
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Affiliation(s)
- Ann Thomas
- Department of Otorhinolaryngology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Shaun Adam
- Department of Otorhinolaryngology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa,
| | - Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | | | - Savvas Andronikou
- Department of Paediatric Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Johan Grobbelaar
- Department of Otorhinolaryngology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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Nakanishi R, Iio K, Nakamura T, Yoshitomi A, Enokizono M, Hataya H. Drainage of Retropharyngeal Abscess Through the External Auditory Canal. Pediatr Infect Dis J 2024; 43:e252-e253. [PMID: 38451914 DOI: 10.1097/inf.0000000000004313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Affiliation(s)
- Ryo Nakanishi
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kazuki Iio
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Toshiki Nakamura
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Ai Yoshitomi
- Department of Otolaryngology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Mikako Enokizono
- Department of Radiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Hataya
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Nicotera DJ, Islam AA, Liu Y, Dunsky K, Lieu JEC. Disparities in the Presentation and Management of Pediatric Retropharyngeal Abscess. Laryngoscope 2024; 134:1907-1912. [PMID: 37698387 DOI: 10.1002/lary.31048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Differences in management and outcomes of otolaryngologic diseases may reflect inequities driven by social determinants of health. This study aimed to investigate disparities in presentation and outcomes of retropharyngeal abscess (RPA) among 231 pediatric patients. METHODS Medical records were searched for pediatric patients with RPA from 2010 to 2021. Charts were reviewed for demographics, clinical features, and treatment decisions. Area deprivation index (ADI) scores for patient zip codes were determined. Chi-square analysis independent samples t-test, and regression analyses were used to investigate associations between variables. RESULTS Among patients presenting for RPA, Black patients were less likely to undergo surgical management than non-Black patients (53.2% vs. 71.6%, p = 0.009). Black patients had a lower rate of treatment with antibiotics prior to hospital admission (19.4% vs. 54.4%, p < 0.001). Among patients who received surgery, Black patients had higher cross-sectional abscess area on CT (6.4 ± 8.4 cm2 > vs. 3.8 ± 3.3 cm2 , p = 0.014), longer length of stay (5.4 ± 3.3 days vs. 3.2 ± 1.5, p < 0.001), and longer time between admission and surgery (2.3 ± 2.1 vs. 0.83 ± 1.1, p < 0.001). Increased ADI was correlated with increased rate of trismus. CONCLUSIONS Lower rates of pre-admission antibiotics and larger abscess area on CT imaging among Black patients may suggest disparities in access to primary care, resulting in presentation to tertiary care at later stages of disease and higher rates of medical management trial prior to surgical intervention. LEVEL OF EVIDENCE 3 (retrospective cohort study) Laryngoscope, 134:1907-1912, 2024.
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Affiliation(s)
- Dante J Nicotera
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Aseeyah A Islam
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Yupeng Liu
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Kate Dunsky
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Judith E C Lieu
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
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Liu Y, Nicotera DJ, Islam AA, Dunsky K, Lieu JEC. Prognostic Factors for Retropharyngeal Abscess in Children Receiving Surgery or Antibiotic Therapy. Laryngoscope 2024; 134:1955-1960. [PMID: 37740903 DOI: 10.1002/lary.31064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/14/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
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.
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Affiliation(s)
- Yupeng Liu
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Dante J Nicotera
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Aseeyah A Islam
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Kate Dunsky
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Judith E C Lieu
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
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Ranganath S. Lemierre's Like Syndrome: Retropharyngeal Abscess With Internal Jugular and Cerebral Venous Thromboses and Septic Embolization Leading to Pulmonary Embolism and Cerebral Abscesses Complicated by Papilledema and Residual Sixth Cranial Nerve Palsy. Cureus 2024; 16:e56250. [PMID: 38623115 PMCID: PMC11016986 DOI: 10.7759/cureus.56250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 04/17/2024] Open
Abstract
A male child with a history of sinusitis presented to the emergency medicine department with a high fever, neck swelling, headache, vomiting, and double vision. He was diagnosed with retropharyngeal abscess (RPA) with bilateral internal jugular vein (IJV) and cerebral venous thromboses. The child was treated promptly and transferred to a specialty center, where the abscess was drained. However, he developed papilledema and septic embolism, leading to pulmonary embolism and cerebral abscesses. The child was an inpatient for six weeks and had outpatient treatment for three months. He developed exotropia due to bilateral sixth cranial nerve palsy. This existed even at the 24-month follow-up. This case report highlights the rare complications and morbidity from the retropharyngeal abscess. It also emphasizes the early diagnosis and management options in a busy emergency medicine department.
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Bory C, Bory O, Guelfucci B, Nicollas R, Moreddu E. Deep cervical abscesses in children: efficacy of the cefotaxime-rifampicin combination. Eur J Pediatr 2023; 182:2315-2324. [PMID: 36881146 DOI: 10.1007/s00431-023-04917-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023]
Abstract
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.
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Affiliation(s)
- Céline Bory
- Department of Pediatric Otorhinolaryngology-Head and Neck Surgery, La Timone Children's Hospital, Aix-Marseille University, 264 rue Saint Pierre, 13385 Cedex 05, Marseille, France
- Department of Otorhinolaryngology-Head and Neck Surgery, Sainte Musse Hospital, Toulon, France
| | - Olivier Bory
- Department of Ambulatory Medicine, Louis Mourier Hospital, Université de Paris, Paris, France
| | - Bruno Guelfucci
- Department of Otorhinolaryngology-Head and Neck Surgery, Sainte Musse Hospital, Toulon, France
| | - Richard Nicollas
- Department of Pediatric Otorhinolaryngology-Head and Neck Surgery, La Timone Children's Hospital, Aix-Marseille University, 264 rue Saint Pierre, 13385 Cedex 05, Marseille, France.
| | - Eric Moreddu
- Department of Pediatric Otorhinolaryngology-Head and Neck Surgery, La Timone Children's Hospital, Aix-Marseille University, 264 rue Saint Pierre, 13385 Cedex 05, Marseille, France.
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Tecle NE, Hackenberg S, Scheich M, Scherzad A, Hagen R, Gehrke T. Surgical management of lateral neck abscesses in children: a retrospective analysis of 100 cases. Eur J Pediatr 2023; 182:431-438. [PMID: 36378330 PMCID: PMC9829626 DOI: 10.1007/s00431-022-04676-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/09/2022] [Accepted: 10/22/2022] [Indexed: 11/16/2022]
Abstract
UNLABELLED Cervical abscesses are relatively common infections in pediatric patients. There is an ongoing debate about the necessity and time point of surgical drainage. The identification of a focus of infection might play an important role in facilitating a therapeutic decision. In a retrospective study, 100 pediatric patients aged 1-18 years who underwent incision and drainage of a lateral cervical abscess at our institution were analyzed. Patients were divided into two groups based on whether a focus of infection could be identified or not. Data collection included patient characteristics, microbiological results, antibiotic regimen, and clinical course. A focus of infection was found in 29% (29/100) of the patients, most frequently in the tonsils. A causative microorganism was found in 75% (75/100) of all patients, with Staphylococcus aureus and Streptococcus pyogenes being the most common pathogens. All patients received an empiric antibiotic therapy in addition to surgery. Antibiotic medication was changed in 31% in both groups (9/29 with a focus of infection and 22/71 without a focus of infection) during therapy. Children without an identified focus of infection generally were younger and had more comorbidities reducing immune response while also showing differences in the pathogens involved. There were no complications associated to surgery or antibiotic therapy in any of the patients involved. CONCLUSION Children with an identified focus of infection show several differences compared to those with isolated lateral abscesses, especially regarding the microorganisms involved. But the focus of infection seems not to have an impact on patient's outcome. WHAT IS KNOWN • Neck abscesses are a relatively common disease in the pediatric population and may cause serious complications. • Therapy in general consists of intravenous antibiotics with or without surgery. WHAT IS NEW • The focus identification has no impact on patient's outcome. • Children with an identified focus of infection show several differences compared to those with isolated lateral abscesses, especially regarding their medical history, age, and the microorganisms involved.
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Affiliation(s)
- Nyat-Eyob Tecle
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany.
| | - Stephan Hackenberg
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany ,Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Matthias Scheich
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Agmal Scherzad
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Rudolf Hagen
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Thomas Gehrke
- Department of Otorhinolaryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery, University Hospital of Würzburg, Würzburg, Germany
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Alougly S, Alhsony A, Elarwah A, Elbragathy S. Acute Retropharyngeal Abscess in Libyan Children: Case Series and Literature Review. IBNOSINA JOURNAL OF MEDICINE AND BIOMEDICAL SCIENCES 2022. [DOI: 10.1055/s-0042-1760303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Abstract
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.
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Affiliation(s)
- Shirin Alougly
- Pediatrics Intensive Care Unit, Benghazi Children's Hospital, Benghazi, Libya
- Pediatric Department, Faculty of Medicine, Benghazi University, Benghazi, Libya
| | - Alia Alhsony
- Pediatrics Intensive Care Unit, Benghazi Children's Hospital, Benghazi, Libya
- Pediatric Department, Faculty of Medicine, Benghazi University, Benghazi, Libya
| | - Aisha Elarwah
- Pediatrics Intensive Care Unit, Benghazi Children's Hospital, Benghazi, Libya
- Pediatric Department, Faculty of Medicine, Benghazi University, Benghazi, Libya
| | - Suliman Elbragathy
- Pediatrics Intensive Care Unit, Benghazi Children's Hospital, Benghazi, Libya
- Pediatric Department, Faculty of Medicine, Benghazi University, Benghazi, Libya
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Hagelberg J, Pape B, Heikkinen J, Nurminen J, Mattila K, Hirvonen J. Diagnostic accuracy of contrast-enhanced CT for neck abscesses: A systematic review and meta-analysis of positive predictive value. PLoS One 2022; 17:e0276544. [PMID: 36288374 PMCID: PMC9604924 DOI: 10.1371/journal.pone.0276544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/08/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Jon Hagelberg
- Department of Radiology, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere University, Tampere, Finland
| | - Bernd Pape
- Turku Clinical Research Center, Turku University Hospital, Turku, Finland
- School of Technology and Innovations, University of Vaasa, Vaasa, Finland
| | - Jaakko Heikkinen
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Janne Nurminen
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Kimmo Mattila
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere University, Tampere, Finland
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
- * E-mail:
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Sturgill L, Fadil A, Hinthorn D, Schrepfer T. Salmonella Retropharyngeal Abscess Linked to Backyard Poultry Exposure in a 12-Month-Old Girl. Cureus 2022; 14:e28375. [PMID: 36171844 PMCID: PMC9508688 DOI: 10.7759/cureus.28375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 11/10/2022] Open
Abstract
We report a rare complication of nontyphoidal Salmonella infection in a 12-month-old girl with a retropharyngeal abscess. The patient presented with a four-day history of nasal congestion, cough, decreased oral intake, and increased irritability. She was admitted for a suspected deep neck infection. Computed tomography confirmed a retropharyngeal abscess with airway narrowing. Incision and drainage was performed, and intraoperative cultures grew nontyphoidal Salmonella. Epidemiologic investigation revealed exposure to a backyard flock of chickens. The patient had little direct contact with chickens but did go with family to collect eggs, riding on a vehicle that likely became contaminated. This case highlights the risks to infants and young children in contact with live poultry or contaminated environments.
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Villanueva-Fernández E, Casanueva-Muruáis R, Vivanco-Allende A, Llorente JL, Coca-Pelaz A. Role of steroids in conservative treatment of parapharyngeal and retropharyngeal abscess in children. Eur Arch Otorhinolaryngol 2022; 279:5331-5338. [PMID: 35767057 PMCID: PMC9519669 DOI: 10.1007/s00405-022-07423-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/25/2022] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Eva Villanueva-Fernández
- Department of Otorhinolaryngology, Hospital Universitario Central de Asturias, Avenida de Roma s/n, 3301, Oviedo, Spain.
| | - R Casanueva-Muruáis
- Department of Otorhinolaryngology, Hospital Universitario Central de Asturias, Avenida de Roma s/n, 3301, Oviedo, Spain
| | - A Vivanco-Allende
- Department of Pediatrics, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - J L Llorente
- Department of Otorhinolaryngology, Hospital Universitario Central de Asturias, Avenida de Roma s/n, 3301, Oviedo, Spain.,University of Oviedo, Instituto de Investigación Sanitaria del Principado de Asturias, IUOPA, CIBERONC, Oviedo, Spain
| | - A Coca-Pelaz
- Department of Otorhinolaryngology, Hospital Universitario Central de Asturias, Avenida de Roma s/n, 3301, Oviedo, Spain.,University of Oviedo, Instituto de Investigación Sanitaria del Principado de Asturias, IUOPA, CIBERONC, Oviedo, Spain
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Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses. CHILDREN 2022; 9:children9050618. [PMID: 35626793 PMCID: PMC9139861 DOI: 10.3390/children9050618] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022]
Abstract
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.
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14
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Heikkinen J, Nurminen J, Velhonoja J, Irjala H, Soukka T, Happonen T, Nyman M, Mattila K, Hirvonen J. MRI Findings in Acute Tonsillar Infections. AJNR Am J Neuroradiol 2022; 43:286-291. [PMID: 34916205 PMCID: PMC8985668 DOI: 10.3174/ajnr.a7368] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Previous literature is vague on the prevalence and exact nature of abscesses in tonsillar infections, ranging from intratonsillar and peritonsillar collections to deep extension involving the parapharyngeal and retropharyngeal spaces. MR imaging has excellent diagnostic accuracy in detecting neck infections and can potentially clarify this issue. We sought to characterize the spectrum of MR imaging findings regarding tonsillar infections. MATERIALS AND METHODS We conducted a retrospective cohort study of emergency neck MR imaging scans of patients with tonsillar infections. Imaging data were assessed in terms of signs of infection and the location of abscesses and were compared with clinical findings, final diagnoses, and surgical findings as reference standards. RESULTS The study included 132 patients with tonsillar infection. Of these, 110 patients (83%) had ≥1 abscess (99 unilateral, 11 bilateral; average volume, 3.2 mL). Most abscesses were peritonsillar, and we found no evidence of intratonsillar abscess. Imaging showed evidence of parapharyngeal and retropharyngeal extension in 36% and 10% of patients, respectively. MR imaging had a high positive predictive value for both abscesses (0.98) and deep extension (0.86). Patients with large abscesses and widespread edema patterns had a more severe course of illness. CONCLUSIONS Emergency neck MR imaging can accurately describe the extent and nature of abscess formation in tonsillar infections.
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Affiliation(s)
- J. Heikkinen
- From the Departments of Radiology (J. Heikkinen, J.N., T.H., M.N., K.M., J. Hirvonen)
| | - J. Nurminen
- From the Departments of Radiology (J. Heikkinen, J.N., T.H., M.N., K.M., J. Hirvonen)
| | - J. Velhonoja
- Otorhinolaryngology-Head and Neck Surgery (J.V., H.I.)
| | - H. Irjala
- Otorhinolaryngology-Head and Neck Surgery (J.V., H.I.)
| | - T. Soukka
- Oral and Maxillofacial Surgery (T.S.), University of Turku, Turku, Finland
| | - T. Happonen
- From the Departments of Radiology (J. Heikkinen, J.N., T.H., M.N., K.M., J. Hirvonen)
| | - M. Nyman
- From the Departments of Radiology (J. Heikkinen, J.N., T.H., M.N., K.M., J. Hirvonen)
| | - K. Mattila
- From the Departments of Radiology (J. Heikkinen, J.N., T.H., M.N., K.M., J. Hirvonen)
| | - J. Hirvonen
- From the Departments of Radiology (J. Heikkinen, J.N., T.H., M.N., K.M., J. Hirvonen)
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15
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Alkhodair AA, Alkusayer MM, Albadah AA. Retropharyngeal abscess: A rare complication of nasogastric tube insertion. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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16
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Heilbronn C, Heyming TW, Knudsen-Robbins C, Schomberg J, Simon D, Bacon K, Huoh K. Features associated with surgically significant abscesses on computed tomography evaluation of the neck in pediatric patients. Int J Pediatr Otorhinolaryngol 2021; 150:110893. [PMID: 34438187 DOI: 10.1016/j.ijporl.2021.110893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/27/2021] [Accepted: 08/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neck-related chief complaints are common in the pediatric Emergency Department (ED), and although the incidence of pathology such as retropharyngeal abscesses is rare, the ability to rule out abscesses requiring surgical/procedural intervention is essential. However, there are no clear clinical guidelines regarding work-up and diagnosis in this population, possibly contributing to an excess use of potentially harmful and costly computed tomography (CT) imaging. OBJECTIVE In this study we sought to identify historical, physical exam, and laboratory findings associated with surgically significant neck abscesses to better delineate CT neck imaging criteria. METHODS We conducted a retrospective chart review of all patients ≤18 years presenting to a pediatric ED between 2013 and 2017 who underwent CT neck imaging. Surgically significant abscesses (SSAs) were defined as abscesses ≥2 cm, retropharyngeal abscesses (RPA), parapharyngeal abscesses (PPA), or peritonsillar abscesses (PTA). Historical factors, physical exam findings, laboratory results, demographics, and CT results were analyzed using univariate statistical analysis and regression models. RESULTS A total of 718 patients received neck CTs and 153 SSAs were identified. In children younger than 6 years, factors associated with statistically significant increased odds of an SSA were reported throat pain (OR 1.18; 95% CI 1.05, 1.33), fussiness (OR 1.18; 1.01, 1.39), lethargy (OR 1.43; 1.07, 1.91), tonsillar enlargement (OR 1.17; 1.02, 1.34), C-reactive protein (CRP) > 10 (OR 1.22; 1.07, 1.40), and an ED visit within the preceding week (OR 1.18; 1.04, 1.33). In children older than 6 years, the factors associated with statistically significant increased odds of an SSA included current antibiotic use (OR 1.12; 1.02, 1.22) and a CRP >10 (OR 1.14; 1.03, 1.26). CONCLUSION Some historical, physical exam, and laboratory findings are associated with SSAs, and while not definitive in isolation, may be beneficial additions to routine SSA assessment, as a supplement to clinical judgement regarding CT and observation decisions. This may potentially allow for the identification of patients requiring CT versus those who may not, and thus the opportunity to safely reduce the use of CT imaging in select patients.
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Affiliation(s)
- Cameron Heilbronn
- Children's Hospital of Orange County, Department of Otolaryngology, Orange, CA, USA
| | - Theodore W Heyming
- Children's Hospital of Orange County, Department of Emergency Medicine, Orange, CA, USA; Department of Emergency Medicine, University of California, Irvine, USA.
| | | | - John Schomberg
- Children's Hospital of Orange County, Research Institute, Orange, CA, USA
| | - Dina Simon
- Children's Hospital of Orange County, Research Institute, Orange, CA, USA
| | - Kellie Bacon
- Children's Hospital of Orange County, Research Institute, Orange, CA, USA
| | - Kevin Huoh
- Children's Hospital of Orange County, Department of Otolaryngology, Orange, CA, USA
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17
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Heikkinen J, Nurminen J, Velhonoja J, Irjala H, Happonen T, Soukka T, Mattila K, Hirvonen J. Clinical and prognostic significance of emergency MRI findings in neck infections. Eur Radiol 2021; 32:1078-1086. [PMID: 34331114 PMCID: PMC8794929 DOI: 10.1007/s00330-021-08200-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/17/2021] [Accepted: 07/02/2021] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Jaakko Heikkinen
- Department of Radiology, Turku University Hospital, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Janne Nurminen
- Department of Radiology, Turku University Hospital, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Jarno Velhonoja
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, FI-20520, Turku, Finland
| | - Heikki Irjala
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, FI-20520, Turku, Finland
| | - Tatu Happonen
- Department of Radiology, Turku University Hospital, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Tero Soukka
- Department of Oral and Maxillofacial Surgery, University of Turku, Turku, Finland
| | - Kimmo Mattila
- Department of Radiology, Turku University Hospital, Kiinamyllynkatu 4-8, 20521, Turku, Finland.,Department of Radiology, University of Turku, Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, Turku University Hospital, Kiinamyllynkatu 4-8, 20521, Turku, Finland. .,Department of Radiology, University of Turku, Turku, Finland.
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18
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Ohnishi T, Sato S, Asanuma S, Ikeda S, Suganuma E. Retropharyngeal abscess due to Staphylococcus aureus complicated by bilateral neck and intraabdominal abscesses in an immunocompetent infant. IDCases 2021; 25:e01209. [PMID: 34307046 PMCID: PMC8258633 DOI: 10.1016/j.idcr.2021.e01209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 06/27/2021] [Accepted: 06/27/2021] [Indexed: 11/25/2022] Open
Abstract
This is a rare case of multiple neck abscesses in an immunocompetent infant. Symptoms were only fever and neck swelling. Patient was successfully treated with antibiotics supported by surgical drainage.
Retropharyngeal abscess is a serious condition, with potentially high morbidity and mortality if not detected early. The patient, a previously healthy 10-month-old girl, was admitted due to retropharyngeal and bilateral cervical lymph node abscesses. The neck abscesses recurred, despite surgical drainage and treatment with intravenous ampicillin-sulbactam. Methicillin-susceptible Staphylococcus aureus was identified from the abscess culture. A mesenteric abscess was also found during treatment. Intravenous ampicillin-sulbactam was switched to intravenous cephazolin and metronidazole, and the patient was successfully treated without further surgical intervention. No recurrence was observed throughout the 1-year follow-up period. Immune function testing, especially neutrophil function, did not reveal any abnormality. Neck abscesses can spread to the deep or shallow neck spaces directly or through the lymph node chains, even in immunocompetent hosts. Clinicians should consider deep neck infection in patients with cervical lymph node abscess, even if they present without the typical signs and symptoms of retropharyngeal abscess.
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Affiliation(s)
- Takuma Ohnishi
- Division of Infectious Diseases and Immunology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama-shi, Saitama, 330-8777, Japan
| | - Satoshi Sato
- Division of Infectious Diseases and Immunology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama-shi, Saitama, 330-8777, Japan
| | - Satoshi Asanuma
- Division of Otorhinolaryngology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama-shi, Saitama, 330-8777, Japan
| | - Sho Ikeda
- Department of Pediatrics, Soka Municipal Hospital, Saitama, 2-21-1 Soka, Soka-shi, Saitama, 340-8560, Japan
| | - Eisuke Suganuma
- Division of Infectious Diseases and Immunology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama-shi, Saitama, 330-8777, Japan
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19
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Oommen JZ, Valiuddin H, Ring H, Shotkin P. A rare life-threatening complication of acute mastoiditis: Case report and literature review. Clin Case Rep 2021; 9:e04421. [PMID: 34267907 PMCID: PMC8271251 DOI: 10.1002/ccr3.4421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/25/2021] [Accepted: 05/18/2021] [Indexed: 11/10/2022] Open
Abstract
Severe complications may not always present with "classic" signs and symptoms. In the setting of recent mastoiditis, complications including cerebral venous sinus thrombosis, skull base osteomyelitis, and retropharyngeal abscess should be considered, particularly with persistent or worsening symptoms. A broad differential can lead to prompt diagnosis and treatment, thereby reducing the likelihood of morbidity and mortality.
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Affiliation(s)
- Jerry Z. Oommen
- Michigan State University College of Osteopathic MedicineEast LansingMIUSA
| | - Hisham Valiuddin
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPAUSA
| | - Hope Ring
- Department of Emergency MedicineSt. Mary Mercy HospitalLivoniaMIUSA
| | - Paul Shotkin
- Department of Emergency MedicineSt. Mary Mercy HospitalLivoniaMIUSA
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20
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Akhavan M. Ear, Nose, Throat: Beyond Pharyngitis: Retropharyngeal Abscess, Peritonsillar Abscess, Epiglottitis, Bacterial Tracheitis, and Postoperative Tonsillectomy. Emerg Med Clin North Am 2021; 39:661-675. [PMID: 34215408 DOI: 10.1016/j.emc.2021.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ear, nose, and throat (ENT) emergencies presenting with a chief complaint of pharyngitis can be due to infection, trauma, or postprocedure complications. The entities described in this article include retropharyngeal abscess, peritonsillar abscess, epiglottitis, bacterial tracheitis, and post-tonsillectomy bleeding. This article provides the emergency physician with the tools needed to decipher between the mundane and the critical, variations in presentation, and their emergent management. All of them require early recognition for any airway compromise or obstruction in order to avoid serious complications.
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Affiliation(s)
- Mahsa Akhavan
- Goryeb Children's Hospital, Morristown Medical Center/Atlantic Health System, 100 Madison Ave, Morristown, NJ 07960, USA.
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21
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Xu X, Hu X. Two cases of tuberculous retropharyngeal abscess in adults. J Int Med Res 2021; 49:3000605211011972. [PMID: 33942632 PMCID: PMC8113966 DOI: 10.1177/03000605211011972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Retropharyngeal abscess (RPA) is an acute or chronic deep neck tissue infection. Tuberculous RPA is chronic and extremely rare in adults. A 20-year-old female patient visited the local hospital due to cough and sputum. The sputum smear was positive for acid-fast staining, and lung computed tomography (CT) indicated pulmonary tuberculosis (TB). The patient received the standard regimen of isoniazid+rifampicin+pyrazinamide+ethambutol (HRZE) for 6 months. After HRZE, pulmonary symptoms improved, but some pharyngeal discomfort remained. In another case, a 25-year-old male patient was admitted to our hospital because of a mass on the left side of his neck. Lymph node TB was considered after a puncture biopsy. Lung CT showed no obvious abnormality. After HRZE for 5 months, the mass had progressively enlarged. Both patients underwent B-ultrasonography-guided puncture, and Xpert® MTB/RIF of the abscess was positive and rifampin-sensitive. Tuberculous RPA was diagnosed and treated with isoniazid+rifampicin (HR) for 12 months. After combination anti-TB therapy and surgical drainage, both patients fully recovered. Tuberculous RPA is rare in adults; because of pharyngeal symptoms or progressive enlargement of a neck mass with anti-TB treatment, clinicians need to suspect tuberculous RPA in adults, which is treated with anti-TB therapy and surgery.
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Affiliation(s)
- Xiaofeng Xu
- Department of Hematology, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Zhejiang Integrated Traditional and Western Medicine Hospital (Hangzhou Red Cross Hospital), Hangzhou, Zhejiang, P.R. China
| | - Xue Hu
- Department of Tuberculosis, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Zhejiang Integrated Traditional and Western Medicine Hospital (Hangzhou Red Cross Hospital), Hangzhou, Zhejiang, P.R. China. Currently working in Hangzhou Occupational Disease Prevention Hospital
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22
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Velhonoja J, Lääveri M, Soukka T, Hirvonen J, Kinnunen I, Irjala H. Early surgical intervention enhances recovery of severe pediatric deep neck infection patients. Int J Pediatr Otorhinolaryngol 2021; 144:110694. [PMID: 33799100 DOI: 10.1016/j.ijporl.2021.110694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Jarno Velhonoja
- Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - Meira Lääveri
- Department of Oral and Maxillofacial Surgery, Turku University Hospital and University of Turku, Lemminkäisenkatu 2, 20520, Turku, Finland.
| | - Tero Soukka
- Department of Oral and Maxillofacial Surgery, Turku University Hospital and University of Turku, Lemminkäisenkatu 2, 20520, Turku, Finland.
| | - Jussi Hirvonen
- Department of Radiology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - Ilpo Kinnunen
- Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - Heikki Irjala
- Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
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23
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Sanz Sánchez CI, Morales Angulo C. Retropharyngeal Abscess. Clinical Review of Twenty-five Years. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2021. [DOI: 10.1016/j.otoeng.2020.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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24
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Stevens C, Ladd P, Ghadersohi S, Gitomer SA. Minimally invasive transoral image-guided drainage of a retropharyngeal abscess with mediastinal extension. Int J Pediatr Otorhinolaryngol 2020; 138:110288. [PMID: 32836140 DOI: 10.1016/j.ijporl.2020.110288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 11/16/2022]
Abstract
Retropharyngeal abscess (RPA) in children is a serious deep neck space infection that rarely is complicated by extension into the mediastinum. RPA with mediastinal abscess requires prompt surgical management, generally via external or transoral approach. We present the case of a 3-year-old boy with RPA with mediastinal extension who was managed with a unique multidisciplinary surgical approach with otolaryngology and interventional radiology. A transoral approach was utilized to pass a transnasal drain with image guidance into the mediastinal fluid collection. This report reviews the presentation and surgical management of RPA with mediastinal extension and describes a unique minimally invasive approach to drainage.
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Affiliation(s)
| | - Patricia Ladd
- Division of Pediatric Radiology, Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Saied Ghadersohi
- Department of Otolaryngology - Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, Aurora, CO, USA
| | - Sarah A Gitomer
- Department of Otolaryngology - Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, Aurora, CO, USA.
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25
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Malia L, Sivitz A, Chicaiza H. A novel approach: Point-of-care ultrasound for the diagnosis of retropharyngeal abscess. Am J Emerg Med 2020; 46:271-275. [PMID: 33046324 DOI: 10.1016/j.ajem.2020.07.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Laurie Malia
- Department of Emergency Medicine, Columbia University Medical Center/Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY, United States of America.
| | - Adam Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Children's Hospital of New Jersey, Newark, NJ, United States of America
| | - Henry Chicaiza
- Department of Pediatric Emergency Medicine, Connecticut Children's Medical Center, Hartford, CT, United States of America
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26
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Sanz Sánchez CI, Morales Angulo C. Retropharyngeal Abscess. Clinical Review of Twenty-five Years. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2020; 72:71-79. [PMID: 32487430 DOI: 10.1016/j.otorri.2020.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/06/2019] [Accepted: 01/03/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Retropharyngeal abscess is a serious condition. Its rare occurrence, thus sharing symptoms with other processes, make it a diagnostic challenge for the clinician. Therefore, it is critical to make an early diagnosis to prevent delaying treatment and avoid complications. OBJECTIVES To gain knowledge of the epidemiology, pathogenesis, clinical manifestations, the most commonly implicated microorganisms, the type of treatment used, morbidity and mortality of retropharyngeal abscesses at a tertiary institution over the last 25 years. METHODS A retrospective study was conducted by reviewing medical records of all patients diagnosed with retropharyngeal abscess in a single centre between 1 January 1990 and 31 February 2016. Thirty-three patients were included in our study. Data such as personal history, present illness, diagnoses and treatment procedures were collected from the medical records. RESULTS The incidence during the years of study was 0.2 cases/100 000 inhabitants/year. Personal medical histories most often associated were alcoholism, smoking, diabetes and obesity. The most common aetiology found was impaction of a foreign body (especially fishbone). The most common presenting symptoms were odynophagia and neck pain accompanied by fever. Preventive tracheotomy was performed in the initial management of the patient in 9 cases (27%). The most frequent complication was descending necrotizing mediastinitis. Surgical drainage of the abscess was required in 27 patients (82%), especially with external approaches (17 cases). Two patients had sequelae: paralysis of unilateral vocal cord and Horner's syndrome. No mortality was observed in the patients of the study. CONCLUSION Retropharyngeal abscesses must be considered medical-surgical emergencies as they are likely to produce serious complications. We must pay attention to the warning symptoms such as odynophagia and cervical pain, associated or otherwise with dyspnoea, stridor, trismus, and neck stiffness. Advances in diagnostic and therapeutic procedures together with advances in critical care have been a key factor in improving the prognosis and mortality of these patients.
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Affiliation(s)
| | - Carmelo Morales Angulo
- Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, IDIVAL, Universidad de Cantabria, Santander, España
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Prestwood CA, Mitchell RB, Liu C. A Neck Mass and Stridor in a 54-Day-Old Infant. EAR, NOSE & THROAT JOURNAL 2020; 100:902S-904S. [PMID: 32466733 DOI: 10.1177/0145561320928205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Ron B Mitchell
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern and Children's Medical Center, Dallas, TX, USA
| | - Cristopher Liu
- Division of Pediatric Otolaryngology, Department of Otolaryngology Head and Neck Surgery, UT Southwestern and Children's Medical Center, Dallas, TX, USA
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Menéndez Del Castro M, Coca-Pelaz A, Menéndez S, Vivanco-Allende A, Pedregal-Mallo D, García-Cabo P, Fernández-Vañes L, Llorente JL. Retropharyngeal abscess and mediastinitis as an uncommon complication of varicella infection. Int J Pediatr Otorhinolaryngol 2020; 132:109904. [PMID: 32018164 DOI: 10.1016/j.ijporl.2020.109904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
| | - Andrés Coca-Pelaz
- Department of Otolaryngology. Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturia, IUOPA, Oviedo, Spain
| | - Sergio Menéndez
- Pediatric Intensive Care Unit, Department of Pediatrics. Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ana Vivanco-Allende
- Pediatric Intensive Care Unit, Department of Pediatrics. Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Daniel Pedregal-Mallo
- Department of Otolaryngology. Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Patricia García-Cabo
- Department of Otolaryngology. Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Laura Fernández-Vañes
- Department of Otolaryngology. Hospital Universitario Central de Asturias, Oviedo, Spain
| | - José Luis Llorente
- Department of Otolaryngology. Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturia, IUOPA, Oviedo, Spain
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Ali NES, Alyono JC, Koltai PJ. Neonatal retropharyngeal abscess with complications: Apnea and cervical osteomyelitis. Int J Pediatr Otorhinolaryngol 2019; 126:109613. [PMID: 31382216 DOI: 10.1016/j.ijporl.2019.109613] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the clinical presentation and management strategies for neonatal retropharyngeal abscess (RPA). METHODS Retrospective chart review was performed, and literature reviewed. RESULTS We report two cases of neonatal RPA, with one complicated by cervical osteomyelitis, and the other presenting with apparent life-threatening events (ALTEs). A 6-week-old female underwent transoral drainage of an RPA, which grew methicillin sensitive Staphylococcus aureus. She had a prolonged recovery course and was found to have developed osteomyelitis of the dens and atlas. She was treated with 14 weeks of IV antibiotics and rigid collar fixation for spinal cord instability. A 2-month-old female was admitted after multiple ALTEs with episodes of apnea and pallor. Direct laryngoscopy revealed a bulging RPA, which was drained transorally. This grew multiple organisms including methicillin resistant Staphylococcus aureus, Streptococcal oralis and Prevotella species. CONCLUSIONS Uncommon in neonates, RPA can present in this age group without fever, and are is likely to have airway complications than in older children. In cases with prolonged recovery, additional diagnostic intervention is recommended to rule out rare complications such as osteomyelitis. Emphasis in such complex cases is placed on a multidisciplinary approach to patient care, coordinating neonatologists, infectious disease specialists, neurosurgeons, and otolaryngologists.
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Affiliation(s)
- Noor-E-Seher Ali
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer C Alyono
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter J Koltai
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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30
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Lim S, Lee NY, Han SB, Jeong DC, Kang JH. Deep Neck Inflammation: Probable Kawasaki Disease in Korean Children. Clin Exp Otorhinolaryngol 2019; 13:77-82. [PMID: 31599139 PMCID: PMC7010501 DOI: 10.21053/ceo.2019.00948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/23/2019] [Indexed: 11/27/2022] Open
Abstract
Objectives Deep neck infections (DNIs) can cause life-threatening complications, and prompt diagnosis and management are necessary. Kawasaki disease (KD) may be accompanied by deep neck inflammation; making it difficult to distinguish from DNIs. This study was performed to evaluate clinical features and outcomes of children with parapharyngeal and retropharyngeal inflammation. Methods Medical records of the children diagnosed with parapharyngeal and retropharyngeal cellulitis or abscess using cervical computed tomography (CT) between 2013 and 2017 were retrospectively reviewed. Results A total of 47 children were diagnosed with parapharyngeal and retropharyngeal inflammation. Eleven (23.4%) of them were eventually diagnosed with KD, and 36 (76.6%) were diagnosed with DNIs. There were no significantly different clinical and laboratory characteristics on admission between children diagnosed with KD and DNIs; however, significantly more children with KD were febrile for ≥3 days after admission compared to those with DNIs (P=0.009). Deep neck abscesses on CT were observed in 16 children with DNIs (44.4%) and in no child with KD (P=0.009). Among the 36 children with DNIs, 30 (83.3%) were cured with antibiotic therapy only. Conclusion A quarter of children presenting with deep neck inflammation were diagnosed with KD. KD should be considered in children showing deep neck inflammation unresponsive to empirical antibiotic therapy after 3 days, especially in those presenting with deep neck cellulitis rather than deep neck abscess.
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Affiliation(s)
- Sooyeon Lim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Na Young Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Beom Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Han Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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31
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Ruiz de la Cuesta F, Cortes Castell E, Garcia Ruiz ME, Severa Ferrandiz G. Deep neck space abscesses in children: 15 years of experience in a children's ENT referral unit. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2018.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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32
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Ruiz de la Cuesta F, Cortes Castell E, Garcia Ruiz ME, Severa Ferrandiz G. Abscesos cervicales profundos infantiles: experiencia de una unidad de ORL infantil de referencia durante 15 años. An Pediatr (Barc) 2019; 91:30-36. [DOI: 10.1016/j.anpedi.2018.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 09/22/2018] [Accepted: 09/27/2018] [Indexed: 11/16/2022] Open
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Sudhanthar S, Garg A, Gold J, Napolova O. Parapharyngeal abscess: A difficult diagnosis in younger children. Clin Case Rep 2019; 7:1218-1221. [PMID: 31183097 PMCID: PMC6552945 DOI: 10.1002/ccr3.2209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/23/2019] [Accepted: 04/28/2019] [Indexed: 11/08/2022] Open
Abstract
Parapharyngeal abscess is a difficult diagnosis to make in the pediatric population. Children <3 years of age present with fever, often the only sign at the initial presentation, thus causing a delay in diagnosis until the patient presents with more focal findings, such as a painful neck mass. Repeated follow-up visits with the patient until the diagnosis is confirmed are critically important to prevent complications.
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Affiliation(s)
- Sathyanarayan Sudhanthar
- Department of Pediatrics and Human Development, College of Human MedicineMichigan State UniversityEast LansingMichigan
| | - Anjali Garg
- Department of Pediatrics and Human Development, College of Human MedicineMichigan State UniversityEast LansingMichigan
- Present address:
UH Rainbow Babies and Children's Hospital11100 Euclid Avenue, RB&C Suite 838ClevelandMI44106‐1716
| | - Jonathan Gold
- Department of Pediatrics and Human Development, College of Human MedicineMichigan State UniversityEast LansingMichigan
| | - Olga Napolova
- Department of Pediatrics and Human Development, College of Human MedicineMichigan State UniversityEast LansingMichigan
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Difficult Intubation and Ventilation in an Infant With Retropharyngeal Abscess With Mediastinal Extension. Pediatr Emerg Care 2019; 35:e104-e106. [PMID: 28719483 DOI: 10.1097/pec.0000000000001242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A previously healthy 7-month-old male infant presented for evaluation of fever, deceased oral intake, and intermittent noisy breathing. Physical examination revealed neck tenderness. Soft tissue neck radiographs and computed tomography (CT) scan supported a diagnosis of retropharyngeal swelling with extension to the superior mediastinum. Surgical exploration was planned, and endotracheal intubation was performed in the operating room. Significant cardiorespiratory derangements developed immediately after the tracheal tube was inserted, including hypotension, hypoxia, and bradycardia with signs of cardiac ischemia. The patient was resuscitated with intravenous fluids, vasopressors, and bronchodilators; his condition improved after resuscitation and surgical evacuation of purulent material. A combination of mediastinal mass effect, aspiration, and bronchospasm likely contributed to the patient's deterioration. The subsequent clinical course was uneventful. The patient was extubated in a delayed fashion and discharged on the fourth postoperative day. This case highlights the importance of preparing for a difficult airway in cases of retropharyngeal abscesses that necessitate tracheal intubation. A multidisciplinary approach is best suited to manage the airway, preferably in the operating room.
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Wilkie MD, De S, Krishnan M. Defining the role of surgical drainage in paediatric deep neck space infections. Clin Otolaryngol 2019; 44:366-371. [PMID: 30784193 DOI: 10.1111/coa.13315] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/05/2019] [Accepted: 02/15/2019] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Mark D Wilkie
- Department of Otorhinolaryngology - Head and Neck Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Sujata De
- Department of Otorhinolaryngology - Head and Neck Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Madhankumar Krishnan
- Department of Otorhinolaryngology - Head and Neck Surgery, Alder Hey Children's Hospital, Liverpool, UK
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Gill C, Scott O, Beck CE. A Toddler With Prolonged Fever and Intermittent Cough. Glob Pediatr Health 2019; 6:2333794X18822999. [PMID: 30719495 PMCID: PMC6348535 DOI: 10.1177/2333794x18822999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/18/2018] [Accepted: 11/20/2018] [Indexed: 11/17/2022] Open
Abstract
Fever of unknown origin is an important diagnostic challenge in pediatrics that requires a thoughtful approach. The differential diagnosis is broad and includes infectious, autoimmune, oncologic, neurologic, genetic, and iatrogenic causes. Infection remains the most common etiology, and uncommon presentations of infections are still more likely than classic presentations of rare conditions. We report a case of a retropharyngeal abscess in a toddler whose presentation is marked by a prolonged fever (>3 weeks). This case highlights the importance of close follow-up with serially repeated history and physical examinations to guide the evaluation of a patient with fever of unknown origin.
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Affiliation(s)
- Carson Gill
- Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Ori Scott
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carolyn E Beck
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, Ontario, Canada.,Univeristy of Toronto, Toronto, Ontario, Canada
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LÓPEZ-SIMÓN E, CORRIOLS-NOVAL P, CASTILLO-LEDESMA NATHALIA, MORALES-ANGULO C. Absceso cervical profundo con riesgo de obstrucción de vía aérea en un lactante. Descripción de un caso. REVISTA ORL 2019. [DOI: 10.14201/orl.19703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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38
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Balfour-Lynn IM, Wright M. Acute Infections That Produce Upper Airway Obstruction. KENDIG'S DISORDERS OF THE RESPIRATORY TRACT IN CHILDREN 2019. [PMCID: PMC7152287 DOI: 10.1016/b978-0-323-44887-1.00023-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This chapter discusses the common and potentially serious infective causes of acute upper airway obstruction in children. The laryngeal anatomy of young children makes them particularly susceptible to upper airway obstruction, and during acute infections this is exacerbated by inflammation and edema of the airway mucosa. The most common cause of infective upper airway obstruction in children is viral laryngotracheobronchitis, or croup, which is usually a mild and self-limiting illness, but management with corticosteroids may still be necessary. Bacterial causes of upper airway obstruction have fortunately become rare since the introduction of the Haemophilus influenzae B (HiB) immunization, but a few cases of epiglottitis do still occur due to nonimmunization, vaccine failure, and infection with non-HiB organisms. These cases constitute a medical emergency due to the risk of rapid progression to complete airway obstruction. Other rare conditions are discussed including bacterial tracheitis, diphtheria, retropharyngeal, and peritonsillar abscesses. Key learning points in this chapter include the main discriminating factors of the various causes of infective upper airway obstruction, the importance of a calm and minimally distressing approach to the child presenting with stridor, and the need for early anesthetic team involvement in cases with a suspected bacterial etiology or signs of impending airway obstruction.
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Infants Are More Likely Than Older Children to Have Surgery for Cervical Infections. Int J Otolaryngol 2018; 2018:7824380. [PMID: 29997652 PMCID: PMC5994566 DOI: 10.1155/2018/7824380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 02/25/2018] [Accepted: 04/01/2018] [Indexed: 11/18/2022] Open
Abstract
Objectives To identify differences in cervical infection management in infants versus older children. Methods Charts of patients 0–18 years, diagnosed with a cervical infection at our institution between 2004 and 2015, were included. Age, gender, presenting symptoms, comorbidities, CT scan findings and management including admission, procedures, antibiotics, cultures, length of stay, readmission rates, and complications were included. Results 239 patients were included: mean age was 4.6 years, with 55.6% boys and 44.4% girls. Mean length of stay was 3.2 days, with no significant difference between age categories. 12.55% were readmitted within 30 days with no significant difference when stratified for age (p = 0.268). The most common presenting symptoms were fever (74.3%), swelling (71.4%), and neck pain (48.2%). Infants had fewer symptoms documented than older children. 51% has lateral neck infections, and these were more common in younger children (p < 0.001). The most common antibiotic used was amoxicillin-clavulanic acid in 53.96% of inpatients and 48.05% of outpatients. Infants were most likely to have MRSA isolates (29.2% versus 11.7% of older children, p = 0.011). 70.0% went to the operating room for incision and drainage procedures. Younger children were more likely to undergo surgery, with an odds ratio of 2.38 for children under 1 year. (p = 0.029). 90.9% of infants underwent surgery with radiolucencies of at least 1 cm diameter in contrast to 50% of children over 8 years old. Conclusions This study emphasizes the importance of considering early operative treatment of cervical abscesses in infants despite fewer symptoms and smaller radiolucencies on CT.
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Infections of the Upper and Middle Airways. PRINCIPLES AND PRACTICE OF PEDIATRIC INFECTIOUS DISEASES 2018. [PMCID: PMC7152082 DOI: 10.1016/b978-0-323-40181-4.00028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
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41
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Balasubramanian A, Shah JR, Gazali N, Rajan P. Life-threatening parapharyngeal and retropharyngeal abscess in an infant. BMJ Case Rep 2017; 2017:bcr-2017-221269. [PMID: 28993356 DOI: 10.1136/bcr-2017-221269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Severe extensive deep neck abscess in an infant is uncommon. We share the case of a previously well 4-month old infant who was referred for a 4-day history of fever, lethargy and left lateral neck swelling. Contrast-enhanced CT scan revealed a large 5.3×8 cm collection involving the left parapharyngeal and retropharyngeal space, causing significant airway narrowing. 40 mL of frank pus was drained via intraoral incision and drainage with the aid of endoscope, and undesirable complications from an external approach were averted. The infant was extubated 48 hours postsurgery and was discharged home well after completion of 1 week of intravenous antibiotics. The child was discharged well from our follow-up at 1 month review. We discuss the pathophysiology of deep neck space abscesses, its incidence in the paediatric population and the various management options.
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Affiliation(s)
- Anusha Balasubramanian
- Department of Otorhinolaryngology, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia.,Department of Otorhinolaryngology, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
| | - J Redzwan Shah
- Department of Otorhinolaryngology, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Norzi Gazali
- Department of Otorhinolaryngology, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
| | - Philip Rajan
- Department of Otorhinolaryngology, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
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Abstract
Fever is a common presenting chief complaint in the pediatric emergency department. We report the case of a well-appearing 11-month-old female with 2 weeks of daily fevers who was found to have an extensive retropharyngeal abscess with mediastinal and extrapleural extension. We review the literature on retropharyngeal abscesses and mediastinitis in children and note that this patient is unusual as she presented with such extensive disease with minimal symptoms. This case demonstrates the importance of a thorough history and broad differential diagnosis when evaluating children presenting prolonged fevers.
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44
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Khudan A, Jugmohansingh G, Islam S, Medford S, Naraynsingh V. The effectiveness of conservative management for retropharyngeal abscesses greater than 2 cm. Ann Med Surg (Lond) 2016; 11:62-65. [PMID: 27761237 PMCID: PMC5065001 DOI: 10.1016/j.amsu.2016.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/02/2016] [Accepted: 10/02/2016] [Indexed: 11/06/2022] Open
Abstract
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. Drainage of these abscesses is associated with multiple complications. Patient presenting with hoarseness requires surgical intervention. Conservative management can be successfully performed in patients who have abscesses that are greater than 2 cm. Patients treated with antibiotic alone need to be closely followed up for lack of improvement or deterioration.
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Affiliation(s)
- A Khudan
- Otorhinolaryngology-Head and Neck Surgery, San Fernando General Hospital, Trinidad and Tobago
| | - G Jugmohansingh
- Otorhinolaryngology-Head and Neck Surgery, San Fernando General Hospital, Trinidad and Tobago
| | - S Islam
- Department of General Surgery, San Fernando General Hospital, Trinidad and Tobago
| | - S Medford
- Otorhinolaryngology-Head and Neck Surgery, San Fernando General Hospital, Trinidad and Tobago
| | - V Naraynsingh
- Department of Clinical Surgical Sciences, University of West Indies, St. Augustine, Trinidad and Tobago
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Diep J, Kam D, Kuenzler KA, Arthur JF. Emergent Airway Management of an Uncooperative Child with a Large Retropharyngeal and Posterior Mediastinal Abscess. ACTA ACUST UNITED AC 2016; 6:61-4. [PMID: 26599735 DOI: 10.1213/xaa.0000000000000267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Retropharyngeal abscesses are deep neck space infections that can lead to life-threatening airway emergencies and other catastrophic complications. Retropharyngeal abscesses demand prompt diagnosis and early establishment of a definitive airway when there is airway compromise. This can be difficult in an uncooperative patient. We present the case of a 12-year-old girl with mediastinitis and tracheal compression and anterior displacement from a large retropharyngeal and posterior mediastinal abscess secondary to traumatic esophageal perforation, who received successful awake nasal fiberoptic intubation. Anesthesiologists must be prepared for airway emergencies in uncooperative patients, especially children, but there is controversy concerning the use of sedation.
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Affiliation(s)
- Jack Diep
- From the *Department of Anesthesiology and Perioperative Medicine, Rutgers New Jersey Medical School, Newark, New Jersey; †New Jersey Medical School, Newark, New Jersey; ‡Division of Pediatric Surgery, Hackensack University Medical Center, Hackensack, New Jersey; and §Division of Pediatric Anesthesiology, Hackensack University Medical Center, Hackensack, New Jersey
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Woods CR, Cash ED, Smith AM, Smith MJ, Myers JA, Espinosa CM, Chandran SK. Retropharyngeal and Parapharyngeal Abscesses Among Children and Adolescents in the United States: Epidemiology and Management Trends, 2003-2012. J Pediatric Infect Dis Soc 2016; 5:259-68. [PMID: 26407249 DOI: 10.1093/jpids/piv010] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 02/10/2015] [Indexed: 11/14/2022]
Abstract
INTRODUCTION The epidemiology and hospital course of children with retropharyngeal abscess (RPA) or parapharyngeal abscess (PPA) have not been fully described at the national level in the United States. METHODS Pediatric discharges for PPA and RPA were evaluated by using the Kids' Inpatient Database from 2003, 2006, 2009, and 2012. Cases were identified by using International Classification of Disease, Ninth Revision, Clinical Modification codes 478.22 and 478.24 for PPA and RPA, respectively. Nationally representative incidence data were calculated by using weighted case estimates and US census data. Demographic and cost analyses were conducted by using unweighted analyses. RESULTS There were 2685 hospital discharges for PPA and 6233 hospital discharges for RPA during the 4 study years combined. The incidence of RPA increased from 2.98 per 100 000 population among children <20 years old in 2003 to 4.10 per 100 000 in 2012. The incidence of PPA peaked at 1.49 per 100 000 in 2006. Incidences were highest among children <5 years old and boys in all age groups for PPA and RPA. Winter-to-spring seasonality also was evident for both. PPA was managed surgically in 58.1% of the cases, and RPA was managed surgically in 46.7%. Surgery was performed most often on the day of admission or the following day, was more frequent at teaching hospitals, and was associated with higher hospital charges. The mean hospital length of stay was longer for children who had surgery versus those who did not (4.4 vs 3.1 days [for PPA] and 4.8 vs 3.2 days [for RPA], respectively; both P < .001). The median charges for RPA and PPA were similar. The proportions of children with RPA or PPA covered by Medicaid increased during the study period. CONCLUSION PPA and RPA represent relatively common male-predominant childhood infections with similar epidemiologies. The incidence of hospital discharges with a diagnosis of RPA increased during the study period. Substantial proportions of children with PPA or RPA are now managed without surgery. Surgical drainage was associated with higher hospital charges and longer lengths of stay.
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Affiliation(s)
| | - Elizabeth D Cash
- Department of Otolaryngology-HNS and Communicative Disorders, University of Louisville School of Medicine, Kentucky
| | - Aaron M Smith
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis
| | | | - John A Myers
- Department of Pediatrics, Division of Infectious Diseases
| | | | - Swapna K Chandran
- Department of Otolaryngology-HNS and Communicative Disorders, University of Louisville School of Medicine, Kentucky
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Absceso retrofaríngeo con invasión mediastínica: antibioterapia exclusiva. An Pediatr (Barc) 2016; 85:112-113. [DOI: 10.1016/j.anpedi.2015.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 10/29/2015] [Accepted: 11/04/2015] [Indexed: 11/20/2022] Open
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Abstract
Skull base osteomyelitis is a rare condition in childhood and can be described according to whether it is associated with spread of infection from the middle ear (otogenic) or not (nonotogenic). Early recognition of this serious disease and prompt treatment are key to preventing extension to adjacent vascular and nervous system structures. Diagnosis can be challenging due to the variable presentation of the disease and potentially subtle radiological appearances. We present 2 cases of nonotogenic skull base osteomyelitis in childhood both affecting the clivus and review the 6 cases previously described. Both children presented with fever, headache and neck stiffness and responded well to medical management alone; detailed imaging was key to making a diagnosis.
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Intraoral drainage under surgical microscopy with tonsillectomy for parapharyngeal abscesses. The Journal of Laryngology & Otology 2015; 129:595-7. [DOI: 10.1017/s0022215115000791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:An intraoral approach combined with tonsillectomy has been used to access the parapharyngeal space. However, the utility of this technique for parapharyngeal abscesses in paediatric patients has not been investigated. This paper describes an intraoral drainage technique combined with tonsillectomy for treating children with a parapharyngeal abscess that obviates the need for skin incision.Methods:Clinical case records are presented, along with a description of the surgical procedure accompanied by a video clip.Results:Both cases encountered involved paediatric parapharyngeal space abscesses that extended to the skull base. The patients underwent an intraoral approach combined with tonsillectomy performed under surgical microscopy; this resulted in a good post-operative course without complications.Conclusion:To our knowledge, no previous reports have addressed the use of surgical microscopy to help access the parapharyngeal space. The procedure described herein, performed under surgical microscopy, was specifically helpful in enabling access to these challenging spaces; it also meant that surgical procedures could be recorded clearly and findings shared with other medical staff.
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Abstract
A retrospective review of 33 patients comparing community-associated methicillin-resistant Staphylococcus aureus retropharyngeal abscess (RPA) with community-associated methicillin-susceptible S. aureus RPA from 2002-2013 at Texas Children's Hospital revealed most cases of S. aureus RPA have been due to community-associated methicillin-resistant S. aureus, which appears to be associated with a more complicated clinical course than RPA caused by community-associated methicillin-susceptible S. aureus.
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