Abscesses of the neck in infants and young children. A review of 112 cases

The changing microbiology of neck abscesses in children: implications for antibiotic therapy

Objectives

To provide an update on the microbiology, sensitivity rates and antibiotic prescribing patterns for superficial neck lymph node abscesses at Scotland's largest paediatric tertiary centre. Findings were compared to historical data from our institution.

Methods

A retrospective case series was conducted of paediatric patients undergoing incision and drainage of a superficial neck lymph node abscess at the Royal Hospital for Children in Glasgow, from 2018 to 2021.

Results

Thirty-nine abscesses were identified. Methicillin-susceptible Staphylococcus aureus was the commonest micro-organism (28 per cent), followed by Streptococcus pyogenes (13 per cent). Eighty-two per cent of patients were administered a drug regimen containing co-amoxiclav. Only three children required a change in their antibiotics.

Conclusion

There was a significant change in causative micro-organisms, including a decrease in S aureus and an increase in the Streptococcus anginosus group. Empirical use of co-amoxiclav is recommended. In abscesses showing no clinical improvement, second-line options such as clindamycin, cefotaxime and vancomycin should be considered.

Predictors of a drainable suppurative adenitis among children presenting with cervical adenopathy

OBJECTIVES

We sought to identify predictors for a drainable suppurative adenitis [DSA] among patients presenting with acute cervical lymphadenitis.

METHODS

A retrospective cross sectional study of all patients admitted to an urban pediatric tertiary care emergency department over a 15 year period. Otherwise healthy patients who underwent imaging for an evaluation of cervical lymphadenitis were included. Cases were identified using a text-search module followed by manual review. We excluded immunocompromised patients and those with lymphadenopathy felt to be not directly infected (i.e. reactive) or that was not acute (symptom duration >28 days). Data collected included: age, gender, duration of symptoms, highest recorded temperature, physical exam findings, laboratory and imaging results, and surgical findings. A DSA was defined as >1.5 cm in diameter on imaging. We performed binary logistic regression to determine independent clinical predictors of a DSA.

RESULTS

Three hundred sixty-one patients met inclusion criteria. Three hundred six patients (85%) had a CT scan, 55 (15%) had an ultrasound and 33 (9%) had both. DSA was identified in 71 (20%) patients. Clinical features independently associated with a DSA included absence of clinical pharyngitis, WBC >15,000/mm³, age ≤3 years, anterior cervical chain location, largest palpable diameter on exam >3 cm and prior antibiotic treatment of >24 h. The presence of fever, skin erythema, or fluctuance on examination, was not found to be predictive of DSA.

CONCLUSIONS

We identified independent predictors of DSA among children presenting with cervical adenitis. Risk can be stratified into risk groups based on these clinical features.

Clinical and bacteriological differences of deep neck infection in pediatric and adult patients: Review of 123 cases

OBJECTIVES

Deep neck infections (DNIs) can lead to life-threatening disease. However, the detailed pathophysiology remains unclear due to its rarity and only a few reports have directly compared DNIs in children and adults. This study aimed to reveal the clinical differences between DNIs in children and adults.

METHODS

We retrospectively reviewed 123 patients who suffered from DNIs at Tohoku University Hospital from August 2005 to July 2015. We extracted data on patient sex, age, antecedent illness, extension of infections, operative procedures, and bacteriology results. The patients were categorized into pediatric (≤18 years) and adult (>18 years) groups. Fisher's exact test was performed to determine significant differences between the two groups.

RESULTS

Fifteen children (6 males and 9 females) and 108 adults (71 males and 37 females) were identified. The most common antecedent illness in pediatric patients was lymphadenitis, which was the least common in adult patients (73% vs 7%, p < 0.0001). The incidence of DNIs extending below the hyoid bone was significantly lower in pediatric patients than in adult patients (20% vs 53%, p < 0.05). Regarding bacterial culture analysis, Staphylococcus species was the most common pathogen in children (60%), whereas only 9% of adults were positive for Staphylococcus (p < 0.001). Streptococcus species were significantly less common in children than in adults (27% vs 56%, p = 0.05). Anaerobes were also significantly less common in children than in adults (13% vs 45%, p < 0.01). Concerning surgical intervention, 53% of pediatric patients underwent external incision compared with 70% of adults. Specifically, tracheostomy was significantly less frequently performed in children than in adults (7% vs 54%, p < 0.01).

CONCLUSION

DNIs in children feature different characteristics from those in adults regarding severity, antecedent illness, bacteriology, and clinical management.

Acute paediatric neck abscesses

Acute neck swellings in a paediatric setting are often treated with antibiotics, proceeding to incision and drainage if an abscess is suspected. A variety of investigations are available and the causative organism can vary. A five-year retrospective study analysing trends in microbiology, antibiotic sensitivity, clinical evaluation and management of children presenting with an acute cervical abscess of four weeks duration or less was performed. The case notes of 175 children admitted between January 1996 and December 2000 to the acute surgical admission unit at the Royal Hospital of Sick Children, Glasgow were studied. During this period there were 90 males and 85 females with a mean age of three years (range: one month to 13 years). One hundred and twenty three (70%) children underwent surgery with pus being confirmed in 114 (93%) of cases. Ultrasound was performed in 70 (40%) patients with 48 proceeding to surgery. Positive culture of pus from abscess cavities revealed Staphylococcus aureus in 46% (85% sensitive to both flucloxacillin and erythromycin) and Streptococcus pyogenes in 15% (80% sensitive to penicillin and 75% to erythromycin). The role of investigations and the available treatment options are discussed.

Is ultrasound useful for evaluating paediatric inflammatory neck masses?

OBJECTIVE

To determine the accuracy of ultrasound in detecting the presence of pus in a neck mass in children.

DESIGN

Retrospective case sheet review.

SETTING

A district general hospital.

PARTICIPANTS

Children admitted from January 2000 to January 2004 with an acute cervical mass who were investigated by ultrasonography.

MAIN OUTCOME MEASURES

The presence of a clinically relevant abscess that did not respond to clinical management was used to determine the accuracy of the ultrasound result.

RESULTS

The sensitivity of ultrasound in the detection of an abscess was 65% and the specificity 88%. The predictive value of a positive ultrasound result was 81% and the predictive value of a negative test 77%.

CONCLUSIONS

Ultrasound is a useful modality in the evaluation of acute cervical masses but is observer dependent and has a relatively low sensitivity in detecting whether or not pus is present. The clinical indicators for the presence of an abscess are discussed and clinicians should combine clinical findings with the ultrasound findings in order to determine treatment.

Computed tomography in the evaluation of pediatric neck infections

In children, infections involving both the superficial and deep neck spaces are common. Children so affected typically present with fever, neck mass, neck stiffness, and, occasionally, airway compromise. Radiologic modalities used in the evaluation of neck infections include plain lateral neck radiography, ultrasound, computed tomography, and magnetic resonance imaging. All these modalities have proved useful in the treatment of such infections, specifically the decision to perform incision and drainage. The charts of 66 patients-33 with superficial and 33 with deep neck infections-were analyzed with respect to symptoms, signs, computed tomography findings, and need for surgical intervention. Computed tomography was not particularly helpful in superficial neck infections with regard to the decision to perform surgical drainage; however, it did localize and demonstrate the extent of infection. In deep neck infections we found a 92% correlation between computed tomographic evidence of an abscess and surgical confirmation of one. Contrast-enhanced computed tomography remains an excellent tool in the treatment of neck infections in children.

Complicated neonatal submandibular suppurative sialadenitis

Acute suppurative infection of salivary glands in the neonatal period is a rare entity; and almost always involves the parotid glands. A rare case of neck abscess in association with right submandibular suppurative sialadenitis in a 7-day-old baby is presented. The possible etiology, diagnosis, and management of this uncommon disease are discussed.

Contemporary management of deep infections of the neck

Odontogenic infections rarely lead to involvement of the lateral and retropharyngeal spaces. When this does occur, the microbiology of the infection is similar to the typical odontogenic infection, ie, Streptococcus and oral anaerobes including Peptostreptococcus, Bacteroides, and Fusobacterium. There is an increased incidence of Fusobacterium seen in the more severe infections, as well as a higher incidence of Streptococcus milleri. Many patients who have deep cervical infections also have some compromise in their host defense mechanism, such as diabetes. The signs and symptoms of deep cervical space infections are similar to those of the severe submandibular space infection, but also includes sialorrhea, respiratory distress, odynophagia, and dysphagia. Lateral soft-tissue radiographs of the neck are useful in assisting with the diagnosis of retropharyngeal infections, and CT scans can provide definitive information regarding lateral pharyngeal space involvement. Treatment includes the use of high-dose intravenous bacteriocidal antibiotics. The recommended antibiotics are penicillin-metronidazole, ampicillin-sulbactam, or clindamycin. Certain cephalosporins may also be useful in selected patients. Early surgical intervention is also indicated. Aggressive incision and drainage of all of the involved spaces is necessary to assure early resolution of the infection. Continual airway monitoring and the establishment of surgical airways is the final portion of the treatment triad.