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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 4  |  Page : 169-174

Deep neck space infection of the pediatric patients: Our experiences at a tertiary care teaching hospital of Eastern India


Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission17-Jul-2020
Date of Decision06-Aug-2020
Date of Acceptance11-Aug-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMJM.AMJM_52_20

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  Abstract 


Background: Deep neck space infections are uncommon life-threatening clinical entity. It can cause significant morbidity in the pediatric age group. Objective: This study analyzes the clinical presentations, diagnosis, and management of the deep neck space infection of the pediatric patients. Materials and Methods: A retrospective study was conducted at a tertiary care teaching hospital during May 2015–June 2020. The medical records pediatric patients diagnosed with deep neck space infections with age <16 years were reviewed. Data of demographics, clinical symptoms, hospital course, and management were retrieved. Results: There was the predominance of male children with deep neck space infections (65.38%) and mean age of 8.3 years. The most common symptom was neck swelling (61.53%). The most common deep neck space infection was peritonsillitis (21.15%), followed by parapharyngeal abscess (17.30%). The important life-threatening complications in this study were stridor found in 3 children (5.76%). Conclusion: Deep neck space infections are an uncommon clinical entity in the pediatric age group. Odontogenic infections are the most common etiology for the deep neck space infection. The common clinical presentations are restricted neck movement, fever, neck swelling, and pain in the neck. Imaging like computed tomography scan is helpful to assess the site and extent of the deep neck space infection. Incision and drainage and appropriate antibiotics are important options for treatment.

Keywords: Deep neck space infections, parapharyngeal abscess, pediatric patient, retropharyngeal abscess


How to cite this article:
Swain SK, Baliarsingh P, Panda S. Deep neck space infection of the pediatric patients: Our experiences at a tertiary care teaching hospital of Eastern India. Amrita J Med 2020;16:169-74

How to cite this URL:
Swain SK, Baliarsingh P, Panda S. Deep neck space infection of the pediatric patients: Our experiences at a tertiary care teaching hospital of Eastern India. Amrita J Med [serial online] 2020 [cited 2021 Apr 15];16:169-74. Available from: https://www.ajmonline.org.in/text.asp?2020/16/4/169/304579




  Introduction Top


Deep neck space infections are life-threatening clinical entity in the pediatric age. It may cause serious complications because of the rapid spread of neck infections. It often presents a true clinical challenge to the otorhinolaryngologists and pediatricians. Although the incidence of deep neck space infection is gradually reduced, it stills has a relevant health problem. It may lead to lethal complications such as obstruction of the airway, mediastinitis, or septic shock.[1] A reduced incidence has been observed because of the improvement in the antibiotics and improved oral hygiene and development in the health-care system.[2] However, recent studies documented an increased incidence of deep neck infections in children.[3] These infections are broadly separated into parapharyngeal, retropharyngeal, peritonsillar, submandibular, and parotid infections. The infections of the peritonsillar space are called as peritonsillitis or peritonsillar abscess. The complexity of the neck spaces makes diagnosis, and exact localization of the infections is difficult. Many times, the clinical confirmation of the deep neck space infection is difficult as it may not be relevant by just palpation or inspection. This deep neck space infection often affects the peritonsillar space, retropharyngeal, and parapharyngeal spaces. These deep neck space infections of the children contribute to the major part of the health-care expenditure and morbidity among children.[4] Untreated, deep neck space infection can spread rapidly and land in airway obstruction, mediastinitis, jugular vein thrombosis, cranial nerve dysfunction, osteomyelitis, meningitis, and even death.[4] The early diagnosis with the help of proper clinical assessment and imaging, followed by appropriate and prompt treatment are crucial for pediatric deep neck space infections. Securing the airway in pediatric patients during surgical intervention for controlling these infections are usually challenging for the anesthesiologists and otolaryngologists. Here, the aim of this study is to do analyze the deep neck space infection of pediatric patients, including its clinical presentations, diagnosis, and management.


  Materials and Methods Top


This is a retrospective study conducted at a tertiary care teaching hospital during the period from May 2015 to June 2020. The medical records of the pediatric patients with deep neck space infections aged up to 16 years were analyzed retrospectively. This study was approved by institutional ethics committee with reference number IMS/SOAU/14/21.03.2015. The consents from the parents of the participant children were taken for this study. Deep neck space infection is the infection of the potential spaces and fascial planes of the neck. The deep neck space infections or neck abscess included in this study were parapharyngeal abscess, retropharyngeal abscess or cellulitis, submandibular space cellulitis or abscess, parotid abscess, peritonsillar abscess, and peritonsillitis. Personal clinical data of the patients such as age, sex, site of the deep neck space infections, investigations, treatment, and complications were analyzed. All the patients were investigated by contrast-enhanced computed tomography (CT) scan of the neck. The locations of the deep neck space infections were identified as the anterior triangle, posterior triangle, parapharyngeal space, retropharyngeal space, parotid space, submandibular space, and peritonsillar space. The locations of the infections or abscess were identified by imaging or surgical findings. Children with deep neck space infections, along with head-and-neck neoplasms, skin abscess, and iatrogenic infections, were excluded from this study. Medical and surgical treatment for each patient was analyzed. The culture and sensitivity of the results of the organisms isolated from the pus were documented. Patients' outcome was analyzed based on the resolution of the abscess, hospital stay period, complications, and need of further surgical procedure. This is an observational analytical study. Data are presented as mean ± standard deviation and median. The categorical variables are presented as frequencies and percentages.


  Results Top


There were 52 children presented with deep neck space infections in this study. The age ranges of the children participating were up to 16 years, with a mean age of 8.3 years. Of the 52 children, 34 were male (65.38%) and 18 were female (34.61%) with a male: female ratio 1.8:1. None of the children were suffering from a previous deep neck space infection. The frequency of hospitalization of the children with deep neck space infections was marked in different seasons during the study period. During the summertime, the deep neck space infections were more, i.e., 18 cases (34.61%), followed by 14 cases (26.92%) in spring, 12 cases (23.06%) in winter and 8 cases (15.38%) in autumn. The most common etiology for deep neck space infection was odontogenic in origin, followed by upper respiratory tract infections [Table 1]. Three children (5.76%) were suffering from the congenital thyroglossal cyst complicated by infection and formation of the abscess. The most common deep neck space infection was peritonsillitis, which constitutes 21.15%, followed by peritonsillar abscess in 15.38%, parapharyngeal abscess in 17.30%, and retropharyngeal abscess in 13.46% [Table 2]. There was no evidence of parapharyngeal or retropharyngeal space cellulitis. The most common clinical presentations among the children with deep neck space infections were neck swelling (61.53%) [Figure 1], fever (57.69%), odynophagia (36.53%), and pain in the neck (32.69%) [Table 3]. All the children with deep neck infections recovered without morbidity and mortality except two cases. One is 8 months [Figure 1] and another 14 months [Figure 2]. These two infants had retropharyngeal abscess complicated with airway compromise followed by aspiration pneumonia. They, later on, underwent tracheostomy [Figure 3] and died because of the sepsis and disseminated intravascular coagulation. Out of 52 patients, 36 underwent incision and drainage (I and D), where 26 drained externally and 10 drained intra-orally. Meantime for surgery (I/D) after the development of the symptoms was 1.8 days with a range of 4 h–7 days. In addition, 5 out of the 36 children were treated with needle aspiration of the neck before I and D. Pus cultures were received from 36 cases, whereas no growth was found in 3 children (8.33%). Patients showed pus culture of Staphylococcus aureus in 13 cases (36.11%) and 8 cases showed Streptococcus pyogenes (22.22%). One case showed methicillin-resistant S. aureus (2.77%) [Table 4]. Polymicrobial infection was found in 5 cases out of 36 cases of pus culture. Antibiotic therapy was started empirically in all patients and later on tailored to organism sensitivity. The most common antibiotic regimen was amoxicillin potassium clavulanate in 32 children (61.53%) and in the rest of the pediatric patients' second generation of clindamycin and third generation of the cephalosporins. Pediatric patients with deep neck space infections landed in complications such as airway obstruction in 3 cases (5.76%), mediastinitis in 2 cases (3.84%), and necrotizing fascitis in 1 case (2.77%). The mean length of the hospital stay was 7.82 days.
Table 1: Etiology of the deep neck space infection/neck abscess in pediatric patients

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Table 2: Types of deep neck space infection found among children

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Figure 1: Parapharyngeal abscess of the neck in an 8-month-old baby presenting with neck swelling

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Table 3: Clinical presentations of the deep neck space infections in children

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Figure 2: Ludwig's angina (submandibular space infection) in a 14-month-old child presented with neck swelling

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Figure 3: Ludwig's angina in a child who developed stridor and so underwent tracheostomy

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Table 4: Identification of the bacteria from deep neck space infection

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  Discussion Top


Deep neck space infection was common in the past and associated with morbidity and mortality. After the advent of the broad spectrum of antibiotics, better laboratory service, improved imaging quality, and early surgical interventions have dramatically reduced these infections.[5] However, the deep neck space infections in the pediatric age group are often challenging and may lead to life-threatening complications such as airway obstruction. Infections of the neck can be classified into two types such as superficial and deep infections. Superficial infections of the neck include the skin, subcutaneous tissue, and superficial fascia of the neck. Deep neck space infections include infections of the deeper tissues of the neck, which are surrounded by several layers of the deep cervical fascia along with potential spaces between them. Infections in the potential fascial planes of the neck are called deep neck infections.[6] The anatomy of the neck is very complex and includes several spaces which are interconnected to each other. There is lymphatic drainage occurring from the oral cavity, facial area, and superficial compartment to the deep neck spaces leading to cervical lymphadenopathy.[6] The cervical lymphadenopathy may cause suppuration and form abscess in the neck. Penetrating injury to the neck can also cause introduce the infection of the neck and cause neck abscess. This infection in the neck can spread through fascial planes and potential spaces in between the different layers of the deep cervical fascia. The drainage of the abscess from these potential spaces is often complex because of the proximity to the neurovascular structures and communications to other parts of the body, such as mediastinum and coccyx.[7] Before the antibiotic era, tonsillar and peritonsillar infections were common sources of deep neck infections, but in present days, the most common etiology is odontogenic.[8] One study shows tonsillitis is the most common etiology for deep neck infections in children, whereas odontogenic infection is the most common etiology for deep neck space infections in adults.[9] Odontogenic infections often spread from mandible or maxilla to the submandibular, sublingual, or masticatory spaces, which directly spread into parapharyngeal space.[10] In this study, the odontogenic infection was the most common etiology for deep neck space infection followed by upper respiratory tract infections. Peritonsillar space was the most common deep neck space affected with infection followed by parapharyngeal space. The pus cultures from the deep neck space infections are usually polymicrobial, reflecting the oral flora, which includes aerobic and anaerobic organisms and both Gram-positive and negative in cultures.[11] S. aureus was the most common bacteria identified from the deep neck space infection of this study.

The clinical presentations of the deep neck space infections depend on the mass effects of the inflamed tissues or the presence of the abscess on the surrounding parts and direct involvement of the surrounding structures of the neck. The common clinical presentations of the children are sore throat, neck swelling, otalgia, dysphagia, odynophagia, trismus, fever, and airway obstruction. Neck swelling was the most common symptom in this study. The most important life-threatening clinical manifestation is stridor because of airway compromise.[12],[13] Initially, the detection of the deep neck space infection of pediatric patients is usually difficult because of the subtle symptoms and lack of co-operation of the children toward the physical examination. The children are also unable to communicate their exact symptoms effectively related to the deep neck space infection.[14] The clinical presentations of the peritonsillar abscess or quinsy are odynophagia, fever, trismus, and deviation of the uvula and enlargement of the tonsils, which usually alert the clinician for this disease.[15] However, in case of parapharyngeal or retropharyngeal abscess, fever may be the only feature at the initial part of the disease, and hence, accurate diagnosis may be late unless caregivers or parents disclose the swelling of the neck, pain, and fever.[16] The complications of the deep neck space infections occur due to low immunity, the involvement of the two or several neck spaces or along with comorbidities.[17] Early diagnosis of deep neck infections in the pediatric age is often challenging because of the subtleness of the clinical features and difficulty in self-expression of the symptomatology in this age group. The laboratory tests are useful to confirm the raised markers of the deep neck space infection and blood culture are needed in case septic child. Radiological tests of the neck such as X-ray of the neck with lateral view, ultrasonography, and CT scan. A CT scan with contrast is useful to find out the presence of the air, which indicates abscess. It is also helpful to differentiate the retropharyngeal adenitis from the retropharyngeal abscess, which avoids unnecessary surgical intervention. Contrast-enhanced CT scans of the neck has 64%–100% sensitivity for confirming the extent and characteristic of the deep neck infections.[18] Radiological findings of the cellulitis in the neck have a better prognosis than abscess. If the infection spread rapidly, the preoperative CT picture may underestimate the risk of difficult airway. The site of the infection in the neck has more impact on the normal airway anatomy than its size alone, which are critical factors during preparation to secure the airway in deep neck infections.

The management of pediatric deep neck infections is usually challenging to the clinicians and should be carried out by multidisciplinary approach.[19] There is no such gold standard and established treatment approach for deep neck space infections of the pediatric age. The treatment options include appropriate antibiotics with proper duration and surgical intervention. In this study, we had done I and D in case of the neck abscess along with intravenous antibiotics. In the case of surgical intervention for deep neck infection, securing the airway is usually challenging. Altered airway anatomy, tissue edema, limited mouth opening, and immobility often make it difficult for securing the airway with intubation by direct laryngoscope or awake blind nasal intubation, awake fiberoptic bronchoscopy-guided intubation or an elective tracheostomy.[20] Induction of general anesthesia may aggravate for airway closure. Abscess in the peritonsillar space may be ruptured during attempting intubation, which may lead to aspiration of pus.[21] Awake videolaryngoscope guided intubation is an alternative to awake fiberoptic intubation in case of a difficult airway.[22] All the children were treated empirically with broad-spectrum intravenous antibiotics on hospitalization. The first-line antibiotic was given as per the microbiological report. In certain cases, I and D is not done in cases of the reduced dimension of the pus collection, i.e., in pericentimetric abscess, good clinical response received with the help of proper medical treatment. There are no gold standard operative methods available for neck abscess or deep neck infections. The conservative medical approach and or incisional drainage are considered in deep neck infections.[23] Here, the children with purulence in the neck underwent external I and D in the majority of the cases. The children with peritonsillar abscess and retropharyngeal abscess underwent intraoral I and D. Intraoral I and D were done under microscope for parapharyngeal abscess, which located medial to the great vessels or near to the skull base, so avoiding the external incision approach. Two pediatric patients with purulence in the neck underwent tracheostomy. Sometimes, less invasive methods for dealing with deep neck infection of the children may contribute to decreased clinical outcomes in terms of morbidity and mortality. The peritonsillar abscess may be managed by aspiration of the pus and administration of the oral antibiotics prescribed by clinicians.[24] However, the patients should be hospitalized if the symptoms persist absence of improvement of the symptoms in follow-up. Hospitalization is required in all patients of parapharyngeal and retropharyngeal abscess because of the potential life-threatening airway obstruction and treatment for abscess drainage under general anesthesia and high-dose antibiotics.[25]


  Conclusion Top


Deep neck space infections in children are often insidious presentations with fever and neck swelling. Sometimes, it may rapidly progress and cause airway compromise, which warrants careful observation in pediatric patients. Clinical presentations, proper evaluation of the radiological findings, bacteriological study, and associated comorbidities are considered as important factors before managing the deep neck space infection. Close attention must be given to the pediatric patient with deep neck space infection as it may land in life-threatening situations such as airway obstruction. Appropriate management includes a combination of early surgical interventions and systemic antibiotics. The primary preventive measures for avoiding such deep neck space infections in the pediatric age include awareness for dental and oral hygiene and enhance immunity for preventing upper respiratory tract infections.

Limitation of the study

The limitation of this study are small sample size because of the relatively low prevalence of the deep neck space infections among the children, retrospective study design and performing study at a single medical center. Further studies may cover basic research, multicentric and prospective studies with assessment of the different characteristics of the pediatric patients with deep neck infections for overcoming these limitations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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