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J Infect Chemother 21 (2015) 110e113

Contents lists available at ScienceDirect

Journal of Infection and Chemotherapy


journal homepage: http://www.elsevier.com/locate/jic

Original article

Diagnosis and management of deep neck infections in children: the


experience of an Italian paediatric centre
Irene Raffaldi a, *, Daniele Le Serre a, Silvia Garazzino a, Carlo Scolfaro a, Chiara Bertaina a, c,
Federica Mignone a, Federica Peradotto b, Paolo Tavormina b, Pier-Angelo Tovo a
a
Department of Paediatrics, Infectious Diseases Unit, University of Turin, Regina Margherita Children's Hospital, Piazza Polonia 94, 10126 Turin, Italy
b
Department of Paediatric Otolaryngology, Regina Margherita Children's Hospital, Piazza Polonia 94, 10126 Turin, Italy
c
Unit of Immunology and Infectious Diseases, University-Hospital Pediatric Department, Bambino Gesù Children Hospital, IRCCS, Rome, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Deep neck infection (DNI) is a severe occurrence in children. We've examined the presenting signs and
Received 7 April 2014 symptoms, the value of single diagnostic procedures, the rate of complications and the impact of the
Received in revised form therapeutic options on the final outcome, in children with a DNI.
20 September 2014
We retrospectively evaluated patients, aged 0e18 years, who were admitted for a DNI, from January
Accepted 14 October 2014
Available online 20 November 2014
2006 through December 2012, at Regina Margherita Children's Hospital, Turin, Italy. We subdivided them
on the basis of type of treatment: pharmacological treatment alone or antimicrobial treatment plus
surgery. An univariate analysis has been performed to examine the differences between the two groups.
Keywords:
Deep neck infections
Sixty patients (32 males, 28 females) with diagnosis of DNI were enrolled; 33 children only received
Children medical treatment (group 1), whereas 27 patients underwent also surgical interventions (group 2). The
Antibiotic treatment mean abscess size was significantly higher in group 2 than in group 1 (p ¼ 0.01). The predominant or-
Surgery ganisms were Streptococcus sp. (11 cases, 52.4%, mostly Streptococcus pyogenes). The most frequent
Complications antibiotic regimen was a b lactam alone (either III generation cephalosporin or amoxicillin/clavulanate).
The duration of intravenous antibiotic varied between the two groups, without statistical significance
(p ¼ 0.052); whereas the oral antibiotic administration was significantly shorter in group 1 than in group
2 (p ¼ 0.0003). Three patients (5%) developed complications.
This research confirms that the medical approach, with high doses of intravenous antibiotics for a
minimum of 5 days, could be a tolerable and safe option for the treatment of patients with stable
condition and/or small DNIs.
© 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases.
Published by Elsevier Ltd. All rights reserved.

1. Introduction symptoms often overlap with those of other common clinical


pictures (i.e. pharyngitis, tonsillitis and torticollis), particularly in
Deep neck infections (DNIs) are a group of life-threatening children, in whom physical examination may be more difficult
diseases localized in the potential spaces and fascial planes of than in adults. In addition, use of analgesic and anti-inflammatory
the neck. Deep neck abscesses can be categorized into retro- drugs may mask presentations.
pharyngeal, peritonsillar, masseteric, pteropalatine maxillary, DNIs require prompt diagnosis and management to avoid life-
parapharyngeal, submandibular, parotid and floor of mouth ab- threatening complications, such as airway obstruction, cervical
scesses [1]. Despite the improved diagnostic techniques and the necrotizing fasciitis, empyema, mediastinitis, aspiration pneu-
widespread availability of antimicrobial therapy, DNIs are still monia or thrombosis/aneurysm of the carotid artery. However,
associated with significant morbility and mortality rates and there are no specific guidelines to outline the best management and
represent a diagnostic challenge to emergency physicians, paedi- treatment of DNIs.
atricians and otolaryngologists, because clinical signs and We revised the diagnostic investigations and the outcomes of a
series of children admitted to a tertiary care children's hospital for
DNIs to evaluate the presenting symptoms and signs, the value of
* Corresponding author. Tel.: þ39 011 313 5032; fax: þ39 011 313 5015.
single diagnostic procedures, the rate of complications and the
E-mail address: ire_raffaldi@yahoo.it (I. Raffaldi). impact of the therapeutic options on the final outcome.

http://dx.doi.org/10.1016/j.jiac.2014.10.011
1341-321X/© 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
I. Raffaldi et al. / J Infect Chemother 21 (2015) 110e113 111

2. Materials and methods Signs and symptoms at admission are listed in Table 1: fever and
pain were present in almost all cases; other common clinical
We retrospectively evaluated all consecutive patients, aged manifestations included neck swelling, pharyngodynia, torticollis,
0e18 years, who were admitted, from January 2006 through dysphagia and odynophagia. These last ones, together with dysp-
December 2012, at a tertiary paediatric Centre, Regina Margherita noea, were significantly more common in patients who underwent
Children's Hospital, Turin, Italy, for a DNI. surgical procedures as compared to those who received only anti-
DNIs were defined as infections involving the deep neck spaces biotic therapy (p ¼ 0.002 and 0.04 respectively), whereas the others
[2]. DNIs were divided into peritonsillar (PTA), retropharyngeal had a similar distribution through the two study groups.
(RPA), parapharyngeal (PPA) and mixed, according to the usual Thirty patients were given oral antibiotics (mainly amoxicillin/
literature criteria [3]. In particular, RPA is an infection initially clavulanate or cephalosporins) before admission. Twenty-five
confined to the pharynx and cervical vertebrae that may extend (41.4%) subjects had also been treated with paracetamol, and 23
particularly into the superior mediastinum. PPA is localized medi- (38%) with non-steroid antinflammatory drugs.
ally to the space surrounded by pharynx, posteriorly to the carotid Radiological evaluation was performed in 54 patients (90%) to
sheath and laterally to the muscles of styloid process. The PTA is an establish the precise location and the extension of the infection,
infection surrounding the tonsil. Abscesses involving more than whereas 6 patients (admitted between 2006 and 2007) only had a
one compartment are defined as mixed type [3]. clinical diagnosis. In 20 patients (34.5%), ultrasonography was the
The diagnosis of DNI was made according to clinical and/or first step of investigations. CT was performed in 50 patients (83.3%),
radiological findings, such as ultrasound imaging or contrast- and in all cases confirmed clinical suspicion for DNIs.
enhanced Computed Tomography scan (CT). The abscess diameter was calculated in 46 cases (23 in each
Patients with masseteric, pteropalatine maxillary, submandib- group). The mean size was 3.4 ± 1.6 cm. It was different for every
ular, parotid and floor of mouth abscesses were excluded. type of DNI: 3.23 cm for PTA, for RPA was 3.78 cm, 2.58 cm for PPA
All medical records were reviewed for demographic character- and finally 3.85 cm for mixed ones.
istics, presenting signs and symptoms, previous use of antibiotics or The mean diameter was significantly higher in group 2 than in
anti-inflammatory drugs, laboratory results, clinical evolution, group 1 (4.0 ± 1.8 vs. 2.8 ± 1.2; p ¼ 0.01, see Table 1). Twenty-one
medical treatment and type of surgical drainage (oral or external blood cultures and twenty-seven pus cultures were performed.
approach). Three blood cultures (14.3%) yielded a positive result, whereas 18
According to the literature, the major complications analysed pus cultures (66.7%) grew pathogens. The predominant organisms
were: respiratory obstruction, mediastinitis, jugular vein throm- were Streptococcus sp. (11 cases, 52.4%, mostly Streptococcus pyo-
bosis and sepsis [4]. genes), followed by Staphylococcus aureus (3 cases, 14.3%) and Vei-
Final outcomes were categorised as: complete recovery, lonella (2 cases, 9.5%). Mycobacterium scrofulaceum, Gemella
persistence of infection or relapse, the latter being defined as the morbillorum, Pseudomonas aeruginosa, Bacteroides uniformis, and
reappearance of the infection after clinical remission [3]. Prevotella melaninogenica were detected in single patients. In 5
Patients were stratified on the basis of type of treatment:
pharmacological treatment alone (group 1) or antimicrobial treat-
ment plus surgery (group 2). Table 1
Statistical analysis was performed using SPSS 15 for Windows. Comparison of demographic and clinical data between patients treated with medical
and medical plus surgical therapy for deep neck infections.
The differences between groups were analysed using the c2 test or
the Fisher exact test for categorical data and the t test or Man- Characteristics Group 1a Group 2b p value
neWhitney test for continuous data, as appropriate. All tests were Age, years (Median, IQR) 5.1 (IQR 3.2e8.9) 7.4 (IQR 3.7e11.3) 0.19
two sided and significance was set at p value 0.05. Gender, N (%)
Male 18 (54.5) 14 (51.9) 0.84
Female 15 (45.5) 13 (48.1)
3. Results
Clinical presentation, N (%)
Fever 32 (97) 23 (85.2) 0.1
A total of 60 patients (32 males, 28 females) with diagnosis of Pain 28 (84.8) 23 (85.2) 0.97
DNI were enrolled; their median age was 6.1 years (IQR 3.5e10.5 Neck swelling 27 (818) 19 (70.4) 0.3
years). Three children had an underlying heart disease; one chronic Pharyngodynia 23 (70) 18 (66.7) 0.8
Torticollis 21 (63.7) 13 (48.2) 0.23
renal failure. Dysphagia/odynophagia 10 (30.3) 19 (70.4) 0.002
Twenty-two children had PTA (36.7%), 19 RPA (31.7%), 13 PPA Trismus 7 (21.2) 7 (26) 0.66
(21.6%), and 6 (10%) had mixed abscesses. Otodynia 8 (24.2) 3 (11) 0.19
There was a marked increase in the number of patients with Cutaneous hyperemia 3 (9) 4 (14.8) 0.49
Drooling 1 (3) 4 (14.8) 0.1
DNIs over the study period with a four-fold enhancement in the last
Cough 1 (3) 3 (11) 0.21
year compared to the first two years of observation. The abscess site Dyspnoea 0 (0) 3 (11) 0.04
varied depending on the patient's age: in the pre scholar age (<4 Site of infection, N (%)
years) RPAs were more frequent (n ¼ 12); from 4 to 10 years, PTA e PTA 12 (36.4) 10 (37) 0.96
PPA have a similar incidence (n ¼ 9 and n ¼ 8 respectively), whereas RPA 10 (30.3) 9 (33.4) 0.8
PPA 8 (24.2) 5 (18.5) 0.59
in pre-adolescent age (age >10 years) PTAs were predominant Mixed 3 (9.1) 3 (11.1) 0.8
(n ¼ 11). Abscess mean dimension (cm) 2.8 ± 1.2 4.0 ± 1.8 0.01
Thirty-three children only received medical treatment (group 1, Mean hospital stay (days) 11.5 ± 6.7 15.9 ± 10.5 0.054
55%), whereas 27 patients underwent also surgical intervention Mean duration i.v. antibiotic 10.9 ± 5.9 14.9 ± 9.6 0.052
therapy (days)
(group 2, 45%). In twenty five (92.6%) patients the surgical inter-
Mean duration oral antibiotic 8.5 ± 4.1 12.7 ± 4.3 0.0003
vention had been performed immediately after the radiological therapy (days)
confirmation of DNI. This information was not available in two
IQR: interquartile range, N: number, PTA: peritonsillar abscess, RPA: retro-
children. pharyngeal abscess, PPA: parapharyngeal abscess, i.v.: intravenous.
The mean age was not statistically different between the two a
Group 1: Medical treatment alone.
groups (6.1 ± 3.4 years vs. 7.5 ± 4.8 years; p ¼ 0.19, see Table 1). b
Group 2:Medical plus surgical treatment.
112 I. Raffaldi et al. / J Infect Chemother 21 (2015) 110e113

cases the cultures yielded multiple microorganisms. Antimicrobial There is general agreement that CT is the gold standard for DNI
susceptibility testing did not show any particular pattern of anti- diagnosis [16]; in our Centre, in case of high suspicion of DNI, CT is
biotics resistance. No significant associations were detected be- performed in the Emergency Department, because of its immediacy
tween the isolated pathogens and patients age or disease in the acquisition time [16]. It must be underlined that CT is useful
localization. not only in the diagnostic algorithm, but also in monitoring the
All patients received intravenous (i.v.) antibiotics and switched disease progression and in detecting vascular complications [7].
to oral therapy later on. The most frequent regimens were: a b Ultrasonography was used in one third of our patients, mostly
lactam alone (either III generation cephalosporin or amoxicillin/ children with cervical lymphadenopathy. It is advantageous in
clavulanate) in 18 cases (30%), carbapenems plus glycopeptides in distinguishing between cellulitis and abscess and may be used to
15 cases (25%), and b lactam plus metronidazole in 15 (25%). guide needle aspiration; however, it cannot provide accurate in-
The duration of antibiotic therapy varied between the two formation about the location of a DNI and to guide surgical inter-
groups. Intravenous therapy was administered for a mean of vention [17].
10.9 ± 5.9 days in group 1 and 14.9 ± 9.6 days in group 2 (p ¼ 0.052). The majority of our patient was successfully treated with anti-
Similarly, the oral antibiotic administration was significantly microbial therapy alone. Based on the results obtained, we consider
shorter in group 1 than in group 2 (p ¼ 0.0003, see Table 1). reasonable to reserve medical treatment alone to less severe cases
Surgical procedures included intra-oral approach in 17 patients and small DNIs without complications. The mean dimension of
(63%) or external incision and drainage in 10 patients (37%). DNIs in patients who received only antimicrobial treatment was
In the entire population, the mean hospital stay was 13.5 ± 8.8 2.8 cm, whereas abscesses measuring >4 cm were always drained.
days (median 11 days, IQR 6e17.3). This was shorter in group 1 Recently, several studies reported a favourable outcome with
than in group 2, though the difference was not statistically sig- medical therapy alone: a positive response, for instance, was noted
nificant (11.5 ± 6.7 days [median 11 days, IQR 6e14] vs. 15.9 ± 10.5 in children with small DNIs (<25 mm) treated with high doses of
days [median 14 days, IQR 6.5e21.5] respectively (p ¼ 0.054, see antibiotics; Grisaru-Soen et al. recorded complete recovery in about
Table 1). half of their population, and Hoffmann et al. successfully treated 36
Three patients (5%) developed complications: one with PTA had of 44 children with RPA with antibiotics solely [6,18,19]. Empirical
mediastinitis, another with RPA had both mediastinitis and sepsis broad-spectrum intravenous therapy was promptly started in all
and, finally, one with PPA developed a sepsis. All of them belonged our patients; antibiotics were subsequently changed according to
to group 2. the culture results, when appropriate.
The follow-up was both clinical and radiological: most patients Since DNIs are often polymicrobial, antibiotic spectrum should
performed an MRI about 10 days after the discharge. One child cover both Gram-positive and Gram-negative, and both aerobic and
showed a persistent disease, whereas no relapse was found. All anaerobic pathogens. III generation cephalosporins, alone or in
patients ultimately recovered without sequelae at a mean follow- association with metronidazole, was most frequent first-line i.v.
up of 2.7 months. treatments [1,6]. A glycopeptide, especially teicoplanin, was
administered in case of high suspicion of a MRSA infection. Car-
4. Discussion bapenems were used for severely ill patients infected by extended-
spectrum b lactamase producing organisms.
DNI is an uncommon but severe occurrence in children [5] In the The duration of i.v. antimicrobial treatment was longer in group
present study, PTAs were the most frequent DNIs and they were 2 than in group 1; this difference may be explained by the fact that
more common among adolescents, whereas RPAs were more often group 2 children had a more severe disease, requiring also surgical
diagnosed in children under the age of 4 years. These findings are intervention. The indications for surgery were based on a combi-
consistent with those reported in other studies [3,6,7], suggesting nation of clinical, radiological and laboratory findings, including
that younger children are more likely to develop infections in ret- severity of clinical picture, location and size of DNI, inadequate
ropharyngeal space because of the presence, in this space, of lymph response to antimicrobial therapy within 48 h, with worsening of
nodes of the paramedian chain [6]. Conversely, adolescents are patient's general condition or increasing white blood cells count
more prone to S. pyogenes throat infections which often may lead to and C-reactive protein. The type of surgical intervention strictly
peritonsillar abscesses [3]. depended on type and location of the abscess. DNIs located in the
The lymph nodes regression with increasing age reduces the risk peritonsillar or in the retropharyngeal spaces, with no extension to
of DNIs; indeed, in our study the incidence of DNIs was extremely the cervical area, were aspirated trans-orally. The cervical incision
low beyond 14 years of age. was performed as a second-line treatment in case of deep position,
As reported by other surveys [1,8,9], also at our Centre there was presence of a complication or cutaneous fistulisation.
a marked increase in the incidence of DNIs over the study period. Differently from other studies, probably due to the small sample
This is probably due not only to the improvement of diagnostic size, we did not find a statistical difference in the age between the
imaging techniques, but also to a changing spectrum of pathogen two examined groups [20].
virulence [10]. In children with surgical drainage or excision and in three cases
The most common clinical disturbances, which emerged from of positive blood cultures, it was possible to identify the responsible
our survey, were fever, pain and neck swelling, regardless of DNI pathogen. It worth mentioning that about half of children had been
location. These findings are in agreement with those reported by treated with oral antibiotic before admission: this may account for
others [3,11]. Three children (5%) had dyspnoea at admission; all the small number of isolates in our study.
were younger than 4 years; therefore they need an early and ac- Consistent with other paediatric studies, aerobic organisms
curate diagnosis to avoid serious complications. None of our pa- were predominant, particularly Streptococcus sp., mostly isolated
tients had stridor. Differently from first reports on DNIs, which had in RPA abscesses; anaerobic pathogens, scantily found in this series,
evidenced a higher prevalence of stridor and dyspnoea [12e14], were generally responsible for PTA. Conversely to what reported by
recent studies, in paediatric populations, highlighted a decrease in the study of Bakir et al., we observed a low incidence of poly-
airway obstructions [6,15]: this probably reflects the improvement, microbial DNIs [21].
over the years, of clinical practice in diagnosis and management of We also recorded one case of a RPA due to M. scrofulaceum, that
DNIs, even in paediatric setting. has been previously described [22]. Non-tuberculous mycobacteria
I. Raffaldi et al. / J Infect Chemother 21 (2015) 110e113 113

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