Pediatric Deep Neck Space Infections

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Pediatric Deep Neck Space Infections

Pediatric Otolaryngology
Author Credentials 

William O. Collins, MD
Associate Professor
Department of Otolaryngology
University of Florida College of Medicine
Gainesville, FL

Module Summary

Pediatric patients frequently suffer from upper respiratory tract infections. Fortunately, most are self limited and only a rare few progress to complications such as a deep neck space infection. Prompt recognition and diagnosis of these infections, will allow earlier intervention and hopefully prevention of complications. Treatment will usually consist of antibiotic therapy combined with surgical drainage of any associated abscesses.

Module Learning Objectives 
  1. Review the anatomic & physiologic characteristics of the pediatric neck that leads to the development of deep neck space infections.
  2. Identify common clinical presentations and diagnostic testing options on pediatric patients with suspected deep neck space infections. 
  3. Describe medical and surgical options to treat deep neck space infections in children.

Embryology

Learning Objectives 

To describe the embryologic development of the structures and deep tissue spaces within the pediatric neck.

References 
  1. Hotaling AJ. Deep neck infections. In: Cotton RT, Myer CM, editors. Practical pediatric otolaryngology. Philadelphia: Lippincott-Raven; 1999:711-25.

Anatomy

Learning Objectives 

To identify the various deep neck spaces and their relevance to the development of deep neck space infections:

  1. Peritonsillar space
  2. Submandibular space
  3. Parapharyngeal space
    1. Pre-styloid
    2. Post-styloid
  4. Retropharyngeal space
  5. Danger space

 

References 
  1. Hotaling AJ. Deep neck infections. In: Cotton RT, Myer CM, editors. Practical pediatric otolaryngology. Philadelphia: Lippincott-Raven; 1999:711-25.
  2. Yellon RF, Bluestone CD. Head and neck space infections in children. In: Bluestone CD, Stool SE, Alper CM, Arjmand EM, Casselbrant ML, Dohar JE, Yellon RF, editors. Pediatric otolaryngology. 4th ed. Philadelphia: W.B. Saunders Co.; 2003:1681-701.

Pathogenesis

Learning Objectives 

To identify processes which can lead to the development of a deep neck space infection:

  • Upper respiratory infections
  • Cervical procedures
  • Dental conditions

Pediatric Neck Masses. 

References 
  1. Tan PT, Chang LY, Huang YC, Chiu CH, Wang CR, Lin TY. Deep neck infections in children. J Microbiol Immunol Infect. 2001;34:287-92.
  2. Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, González-Valdepeña H, Bluestone CD. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg. 1995 Mar;112(3):375-82. [EBM Level 4]

Patient Evaluation

Learning Objectives 

To identify common elements of the clinical presentation in pediatric patients with deep neck space infections.

References 
  1. Lee SS, Schwartz RH, Bahadori RS. Retropharyngeal abscess: epiglottitis of the new millennium. J Pediatr. 2001;138:435-7.
  2. Papalia E, Rena O, Oliaro A, Cavallo A, Giobbe R, Casadio C, et al. Descending necrotizing mediastinitis: surgical management. Eur J Cardiothorac Surg. 2001;20:739-42.
  3. Schraff S, McGinn JD, Derkay CS. Peritonsillar abscess in children: a 10-year review of diagnosis and management. Int J Pediatr Otorhinolaryngol. 2001;57:213-8.

Imaging

Learning Objectives 

To describe the role of common imaging modalities used in the diagnosis and management of pediatric deep neck space infections:

  • Ultrasound
  • CT scanning
  • MRI imaging

 

References 
  1. Elden LM, Grundfast KM, Vezina G. Accuracy and usefulness of radiographic assessment of cervical neck infections in children. J Otolaryngol. 2001;30:82-9.
  2. Lazor JB, Cunningham MJ, Eavey RD, Weber AL. Comparison of computed tomography and surgical findings in deep neck infections. Otolaryngol Head Neck Surg. 1994;111:746-50. [EBM Level 4]
  3. Muñoz A, Castillo M, Melchor MA, Gutiérrez R. Acute neck infections: prospective comparison between CT and MRI in 47 patients. J Comput Assist Tomogr. 2001;25:733-41.
  4. Collins B, Stoner JA, Digoy GP. Benefits of ultrasound vs. computed tomography in the diagnosis of pediatric lateral neck abscesses. Int J Pediatr Otorhinolaryngol. 2014;78(3):423-426.

Pathology

Learning Objectives 

To identify common infective agents which cause pediatric deep neck space infections:

  • Strep species
  • Staph aureus species
  • Anaerobic bacteria and mixed infections

 

References 
  1. Tan PT, Chang LY, Huang YC, Chiu CH, Wang CR, Lin TY. Deep neck infections in children. J Microbiol Immunol Infect. 2001;34:287-92.
  2. Thomason T, Brenski A, McClay J, Ehmer D. The rising incidence of methicillin-resistant Staphylococcus aureus in pediatric neck abscesses. Otolaryngol Head Neck Surg. 2007;137:459-64.
  3. Duggal P, Naseri I, Sobol SE. The Increased Risk of Community Acquired Methicillin-Resistant Staphylococcus aureus Neck Abscesses in Young Children. Laryngoscope. 2011;121:51-55.

Treatment

Learning Objectives 

To describe a systematic approach to management of a pediatric patient with a deep neck space infection:

  • Medical options
  • Airway management
  • Surgical options

 

References 
  1. Choi SS, Vezina G, Grundfast KM. Relative incidence and alternative approaches for surgical drainage of different types of deep neck abscesses in children. Arch Otolaryngol Head Neck Surg. 1997;123:1271-5.
  2. Yellon RF, Bluestone CD. Head and neck space infections in children. In: Bluestone CD, Stool SE, Alper CM, Arjmand EM, Casselbrant ML, Dohar JE, Yellon RF, editors. Pediatric otolaryngology. 4th ed. Philadelphia: W.B. Saunders Co.; 2003:1681-701.
  3. Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg. 2008 Mar;138(3):300-6.

Medical Therapies

Learning Objectives 

To describe the most commonly indicated antimicrobial therapies recommended based on the known prevalence of different etiologic agents. 

References 
  1. Fairbanks DF. Antimicrobial therapy in otolaryngology - head and neck surgery. 13th ed: American Academy of Otolaryngology - Head and Neck Surgery Foundation, Alexandria, VA; 2007.
  2. PMID: 14623752 McClay JE, Murray AD, Booth T. Intravenous antibiotic therapy for deep neck abscesses defined by computed tomography. Arch Otolaryngol Head Neck Surg. 2003;129:1207-12.

Surgical Therapies

Learning Objectives 
  1. To describe the indications for initiating surgical treatment of deep neck space infections.
  2. To describe surgical approaches to drain deep neck space infections in different anatomic spaces:
    1. Peritonsillar abscess
    2. Submandibular abscess
    3. Parapharyngeal abscess
      1. Pre-styloid compartment
      2. Post-styloid compartment
    4. Retropharyngeal abscess
    5. Danger space extension

 

References 
  1. Choi SS, Vezina G, Grundfast KM. Relative incidence and alternative approaches for surgical drainage of different types of deep neck abscesses in children. Arch Otolaryngol Head Neck Surg. 1997;123:1271-5.
  2. Lazor JB, Cunningham MJ, Eavey RD, Weber AL. Comparison of computed tomography and surgical findings in deep neck infections. Otolaryngol Head Neck Surg. 1994;111:746-50. [EBM Level 4]
  3. Yellon RF. Head and Neck Space Infections. In Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders, Philadelphia, PA. 2003;1681-1701.

Case Studies

  1. A 10 year old male presents to the ED with a 4 day history of lateral neck swelling, pain, erythema of the neck, and fevers. On physical exam he is noted to have an asymmetric bulging of his posterior oropharyngeal wall. What respective imaging modalities would be appropriate choices to evaluate this child?  What findings on a CT scan would be important to determine the feasibility of external vs. transoral approaches to draining a retropharyngeal abscess?
  2. A 6 month old female presents with a 5 day history of lateral neck swelling, which has progressed to form a fluctuant area with surrounding erythema. Ultrasound imaging is suggestive of a lateral neck abscess.  Which organism is likely to be the causative agent? What would be the preferred antimicrobial choice if a trial of medical therapy is desired first?

Complications

Learning Objectives 

To recognize and treat potential complications of pediatric deep neck space infections:

  • Airway compromise
  • Descending mediastinitis

 

References 
  1. Hotaling AJ. Deep neck infections. In: Cotton RT, Myer CM, editors. Practical pediatric otolaryngology. Philadelphia: Lippincott-Raven; 1999:711-25.
  2. Lee SS, Schwartz RH, Bahadori RS. Retropharyngeal abscess: epiglottitis of the new millennium. J Pediatr. 2001;138:435-7.
  3. Schraff S, McGinn JD, Derkay CS. Peritonsillar abscess in children: a 10-year review of diagnosis and management. Int J Pediatr Otorhinolaryngol. 2001;57:213-8.
  4. Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, González-Valdepeña H, Bluestone CD. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg. 1995;112:375-82. [EBM Level 4]
  5. Yellon RF. Head and Neck Space Infections. In Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders, Philadelphia, PA; 2003:1681-1701.

Review

Review Questions 
  1. What are the deep neck spaces present in children, and what are their anatomic boundaries?
  2. What are the most common pathophysiologic processes which cause deep neck space infections in children?
  3. What are the most likely causative agents in pediatric neck abscesses?
  4. What are the most appropriate first and second-line antimicrobial agents in a child with a deep neck space infection?
  5. What patient characteristics would lead one to attempt a trial of medical therapy before any surgical intervention?
  6. What are the surgical approaches for draining deep neck space infections in pediatric patients?

 

Resources 

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  1. Patient Management Perspectives (Pmp):