Mycoplasma salivarium in a Retropharyngeal abscess - nidus in a niche!

Retropharyngeal abscess (RPA) is considered one of the life threatening conditions which can present either as dysphagia or dyspnoea. Timely management for the airway obstruction along with etiology identification plays a pivotal role in saving a patient's life. Here we present a case of RPA due to a rare pathogen.

Pediatric deep neck infections: Clinical description and analysis of therapeutic management.

OBJECTIVES: The aim of our study was to describe clinical presentations, bacteriological results, and therapeutic management in a pediatric population presenting with acute pharyngeal suppuration. A further aim was to identify clinical, bacteriological, and radiological predictors of success associated with exclusive medical treatment. METHOD: A retrospective study was carried out including patients under 18 years of age hospitalized between January 1, 2015 and December 31, 2017 in our center for acute pharyngeal suppuration. We identified three groups of patients: group A, treated with exclusive intravenous antibiotics; group B, surgically treated after 48 h of appropriate antibiotic therapy, due to persistent fever and/or clinical worsening and/or persistence of a collection on follow-up imaging; group C, surgically treated as first-line therapy in association with intravenous antibiotics. A total of 83 patients were included: 36 in group A, 12 in group B, and 35 in group C. These three groups were compared for several variables: age of the patients, polynuclear neutrophil counts, diameter of the collections (the largest diameter found on imaging), duration of antibiotic therapy, delay before return to apyrexia, and hospitalization duration. RESULTS: A neck mass and torticollis were present, respectively, in 48.8 and 47.6% of cases. No breathing difficulties were reported. Streptococcus pyogenes was the most frequently identified microorganism. The average diameter of the collections from patients treated surgically as first-line therapy (group C) was significantly larger than that of the patients treated with antibiotics (group A) (27.89 mm vs. 18.73 mm, respectively, p = 0.0006). All the patients who required surgery despite 48 h of appropriate antibiotic therapy (group B) had collections with diameters greater than or equal to 15 mm. There was no significant difference between the groups concerning hospitalization duration. CONCLUSION: Exclusive medical treatment is associated with a high cure rate, mainly for collections with small diameter. We recommend special attention to patients treated with first-line exclusive intravenous antibiotic therapy and with a collection diameter greater than or equal to 15 mm.

Tuberculous retropharyngeal abscess with Pott disease and tuberculous abscess of the chest wall: A case report.

RATIONALE: Tuberculous retropharyngeal abscess is rare, but it can be fatal if not treated appropriately. It usually occurs secondary to tuberculosis of the cervical spine. Moreover, tuberculous abscess involving the chest wall is relatively rare in skeletal tuberculosis. Although the optimal treatment is controversial, most clinicians suggest a combination of sufficient antituberculous medication and complete resection to prevent recurrence and increase therapeutic efficacy. Herein, we present an unusual case of retropharyngeal abscess with cervical Pott disease and tuberculous abscess of the chest wall. PATIENT CONCERNS: The patient was a 27-year-old Indonesian woman who had neck pain, dysphagia, and odynophagia, but no neurological deficit. Examination of the oral cavity showed anterior displacement of the posterior pharyngeal wall. The mass over the right anterior chest wall measured approximately 5 × 4 cm in size. DIAGNOSES: Radiography and computed tomography findings were suggestive of retropharyngeal abscess extending to the cervical spine and chest wall abscess. INTERVENTIONS: She was admitted to the hospital for treatment. Drainage of the retropharyngeal and chest wall abscesses with debridement of the chest wall was performed. OUTCOMES: No complications occurred after early surgical treatment and administration of antituberculous medication. The patient recovered well and went back to her own country after discharge. LESSONS: Tuberculous retropharyngeal abscess with Pott disease and tuberculous abscess of the chest wall are both complicated diagnoses that physicians have to consider in similar patient presentations.

Retropharyngeal Tuberculous Abscess: A Rare Cause of Upper Airway Obstruction and Obstructive Sleep Apnea in Children: A Case Report.

Retropharyngeal tuberculous abscess (RPTBA) is a rare manifestation of tuberculosis (TB) even in high TB burden areas. It rarely manifests as a cause of upper airway obstruction and obstructive sleep apnea (OSA) in children with few case reports in the literature. We report a 22 months old toddler who presented with upper airway obstruction and OSA and was diagnosed with RPTBA. The child recovered completely and growing normally after intra-oral aspiration and 6 months of anti-tuberculosis treatment.

Peritonsillar and deep neck infections: a review of 330 cases / Infecções peritonsilares e cervicais profundas: revisão de 330 casos

Abstract Introduction: Deep neck infections are defined as suppurative infectious processes of deep visceral spaces of the neck. Objective: The aim of this study is to review different factors that may influence peritonsillar and deep neck infections and may play a role as bad prognosis predictors. Methods: We present a retrospective study of 330 patients with deep neck infections and peritonsillar infections who were admitted between January 2005 and December 2015 in a tertiary referral hospital. Statistical analysis of comorbidities, diagnostic and therapeutic aspects was performed with Excel and SPSS. Results: There has been an increase in incidence of peritonsilar and deep neck infections. Systemic comorbidities such as diabetes or hepatopathy are bad prognosis factors. The most common pathogen was S. viridans (32.1% of positive cultures). 100% of the patients received antibiotics and corticosteroids, 74.24% needed surgical treatment. The most common complications were mediastinitis (1.2%) and airway obstruction (0.9%). Conclusion: Systemic comorbidities are bad prognosis predictors. Nowadays mortality has decreased thanks to multidisciplinary attention and improvements in diagnosis and treatment.

Resumo Introdução: Infecções cervicais profundas são definidas como processos infecciosos supurativos dos espaços viscerais profundos do pescoço. Objetivo: Analisar diferentes fatores que podem influenciar as infecções peritonsilares e cervicais profundas que podem desempenhar um papel como preditores de mau prognóstico. Método: Apresentamos um estudo retrospectivo de 330 pacientes portadores de infecções cervicais profundas e de infecções peritonsilares admitidos entre janeiro de 2005 e dezembro de 2015 em um hospital terciário de referência. A análise estatística de comorbidades, aspectos diagnósticos e terapêuticos foi realizada utilizando-se os programas Excel e o SPSS. Resultados: Houve um aumento na incidência de infecções peritonsilares e infecções cervicais profundas. Comorbidades sistêmicas como diabetes ou doença hepática são fatores de mau prognóstico. O patógeno mais comum foi S. viridans (32,1% das culturas positivas). 100% dos pacientes receberam antibióticos e corticosteroides, e 74,24% necessitaram de tratamento cirúrgico. As complicações mais comuns foram mediastinite (1,2%) e obstrução das vias aéreas (0,9%). Conclusão: Comorbidades sistêmicas são preditores de mau prognóstico. Atualmente, a mortalidade diminuiu graças ao cuidado multidisciplinar e melhorias no diagnóstico e tratamento.

Deep head and neck infections: outcome following empirical therapy with early generation antibiotics.

In order to study the bacteriological profile, antibiotic sensitivity and outcome following empirical therapy with early generation antibiotics in patients with deep head and neck infection, a retrospective review of 42 patients admitted for drainage and intravenous antibiotic therapy was performed. Ludwig's angina was the commonest infection, with the most common organisms isolated being Group F ß-haemolytic (15%) and non-haemolytic (12.5%) streptococcus. All streptococci and anaerobic gram-positive cocci were susceptible to penicillin. S. aureus isolates were oxacillin-sensitive and enterococcus isolates were ampicillin-sensitive. All 42 patients received empirical therapy with either intravenous penicillin or its derivatives. In only three patients was a change of antibiotic required based on culture and sensitivity results. Early generation antibiotics appear ideal as empirical therapy for deep head and neck infection.

Peritonsillar and deep neck infections: a review of 330 cases.

INTRODUCTION: Deep neck infections are defined as suppurative infectious processes of deep visceral spaces of the neck. OBJECTIVE: The aim of this study is to review different factors that may influence peritonsillar and deep neck infections and may play a role as bad prognosis predictors. METHODS: We present a retrospective study of 330 patients with deep neck infections and peritonsillar infections who were admitted between January 2005 and December 2015 in a tertiary referral hospital. Statistical analysis of comorbidities, diagnostic and therapeutic aspects was performed with Excel and SPSS. RESULTS: There has been an increase in incidence of peritonsilar and deep neck infections. Systemic comorbidities such as diabetes or hepatopathy are bad prognosis factors. The most common pathogen was S. viridans (32.1% of positive cultures). 100% of the patients received antibiotics and corticosteroids, 74.24% needed surgical treatment. The most common complications were mediastinitis (1.2%) and airway obstruction (0.9%). CONCLUSION: Systemic comorbidities are bad prognosis predictors. Nowadays mortality has decreased thanks to multidisciplinary attention and improvements in diagnosis and treatment.

[Retropharyngeal abscess with cervical discitis and vertebral osteomyelitis caused by Escherichia coli in a patient with liver cirrhosis].

We describe the case of a 67-year-old male with liver cirrhosis who presented with fever and neck pain. Magnetic resonance imaging of the spine detected cervical vertebral osteomyelitis, and enhanced CT of the neck and spine revealed retropharyngeal abscess. The patient was treated with empirical antimicrobial therapy and surgical drainage due to significant airway involvement. Escherichia coli was cultured from the blood and pus in inferior cervical vertebrae which was a rare pathogen. Haematogenous spread may have resulted in cervical vertebral osteomyelitis and retropharyngeal abscess. With high mortality rates, early diagnosis of retropharyngeal abscess is required to avoid debilitating complications such as airway obstruction.

Deep neck abscesses: study of 101 cases / Abscessos cervicais profundos: estudo de 101 casos

Abstract Introduction: Although the incidence of Deep Cervical Abscess (DCA) has decreased mainly for the availability of antibiotics, this infection still occurs with considerable frequency and can be associated with high morbidity and mortality. Objective: This study aimed to present our clinical-surgical experience with deep neck abscesses. Methods: A retrospective study analyzed 101 patients diagnosed with deep neck abscesses caused by multiple etiologies, assisted at a medical school hospital during 6 years. One hundred one patients were included and 27 (26.7%) were younger than 18 years old (the children group), 74 patients (73.3%) were older than 18 years old (the adults group). The following clinical features were analyzed and compared: age, gender, clinical symptoms, leukocyte count, the affected cervical area, lifestyle habits, antibiotic therapy, comorbidities, etiology, bacterial culture, time of hospitalization, the need of tracheostomy and complications. Results: There was predominance in the male gender (55.5%) and young people (mean age 28.1 years). All of the 51 patients with associated disease comorbidity were adults. The most frequent etiologies were bacterial tonsillitis (31.68%) and odontogenic infections (23.7%). The most common cervical areas affected were the peritonsillar (26.7%), submandibular/mouth floor (22.7%) and parapharyngeal spaces (18.8%). In children group, the site most commonly involved was the peritonsillar space (10 patients, 37%). In adults group, the site most commonly involved was multispace (31 patients, 41.8%). Streptococcus pyogenes (23.3%) was the most common microorganism present. Amoxicillin associated with clavulanate (82.1%) was the more used antibiotic. The main complications of abscesses were septic shock (16.8%), pneumonia (10.8%) and mediastinitis (1.98%). Tracheostomy was necessary in 16.8% of patients. The mortality rate was 1.98%. Conclusion: The clinical features and severity of DCA varied according to different age groups, perhaps due to the location of the infection and a higher incidence of comorbidity in adults. Thus, DCA in adults is more facile to have multispace involvement and lead to complications and seems to be more serious than that in children.

Resumo Introdução: Embora a incidência dos abscessos cervicais profundos (ACP) tenha diminuído, principalmente pela disponibilidade dos antibióticos, essa infecção ainda ocorre com frequência considerável e pode estar associada a alta morbidade e mortalidade. Objetivo: Este estudo teve como objetivo apresentar nossa experiência clínico-cirúrgica com os abcessos cervicais profundos. Método: Um estudo retrospectivo realizado em um hospital universitário analisou 101 pacientes, durante seis anos, diagnosticados com abscessos cervicais profundos causados por múltiplas etiologias. Foram incluídos 101 pacientes, sendo que 27 (26,7%) tinham menos de 18 anos (grupo das crianças) e 74 (73,3%) tinham mais de 18 anos (grupo dos adultos). As seguintes características clínicas foram analisadas e comparadas: idade, sexo, sintomas clínicos, área cervical acometida, hábitos de vida, antibioticoterapia, comorbidades, etiologia, cultura bacteriana, tempo de internação, necessidade de traqueotomia e complicações. Resultados: Houve predominância do sexo masculino (55,5%) e de jovens (idade média de 28,1 anos). Todos os 51 pacientes com comorbidade associada eram adultos. As etiologias mais frequentes foram tonsilite bacteriana (31,68%) e infecções odontogênicas (23,7%). As áreas cervicais acometidas mais comuns foram a peritonsilar (26,7%), submandibular/assoalho da boca (22,7%) e os espaços parafaríngeos (18,8%). No grupo das crianças, o local mais comumente envolvido foi o espaço peritonsilar (10 pacientes, 37%). No grupo dos adultos, houve predomínio de acometimento de múltiplos espaços cervicais (31 pacientes, 41,8%). Streptococcus pyogenes foi o microrganismo presente mais comum (23,3%). A amoxicilina associada ao clavulanato foi o antibiótico mais usado (82,1%). As principais complicações dos abscessos foram choque séptico (16,8%), pneumonia (10,8%) e mediastinite (1,98%). A traqueostomia foi necessária em 16,8% dos pacientes. A taxa de mortalidade foi de 1,98%. Conclusão: As características clínicas e a gravidade dos ACP variam de acordo com as diferentes faixas etárias, possivelmente devido à localização da infecção e à maior incidência de comorbidades em adultos. Assim, o ACP em adultos acomete mais facilmente múltiplos espaços, apresenta mais complicações e parece ser também mais grave do que em crianças.

Deep neck infections in children.

BACKGROUND/PURPOSE: Deep neck infections (DNIs) often have a rapid onset and can progress to life-threatening complications. There are only a few reports on pediatric DNIs' clinical manifestations, diagnostic clues, and etiology in Taiwan. METHODS: A retrospective chart review of patients (aged ≤ 18 years) diagnosed with DNI from January 2005 to December 2014 was performed. DNIs were classified into retropharyngeal, parapharyngeal, peritonsillar, submandibular, and multispace abscesses. RESULTS: A total of 52 patients with DNI were identified. The most common site of DNI was the parapharyngeal space (n = 22, 42.3%). The most commonly associated antecedent illness was preceding upper respiratory tract infection (30.8%). The most common clinical presentation was neck mass or swelling (82.7%) and fever (75%). Pus drainage or needle aspiration was performed to obtain pus samples from the infection site for pus culture (n = 31). The most commonly isolated pathogen was Staphylococcus aureus (n = 7). Amoxicillin-clavulanic acid (56.6%) was the most commonly used antibiotics, followed by penicillin (15.1%). There was no long-term morbidity or mortality. CONCLUSION: When a patient (regardless of age) presents with neck mass or swelling, the DNI should always be included in the differential diagnosis. The low culture rate in Taiwan and previous partial treatment of infections may have affected identification of pathogens in cultures. Performing Gram staining and acid-fast staining of pus, instead of culture alone, as early as possible before initiating the initial antimicrobial therapy are thus crucial. The recurrence of DNI should alert the physician to the possibility of an underlying bronchogenic cyst. Excision surgery is required to cure recurrent infections.

Deep neck abscesses: study of 101 cases.

INTRODUCTION: Although the incidence of Deep Cervical Abscess (DCA) has decreased mainly for the availability of antibiotics, this infection still occurs with considerable frequency and can be associated with high morbidity and mortality. OBJECTIVE: This study aimed to present our clinical-surgical experience with deep neck abscesses. METHODS: A retrospective study analyzed 101 patients diagnosed with deep neck abscesses caused by multiple etiologies, assisted at a medical school hospital during 6 years. One hundred one patients were included and 27 (26.7%) were younger than 18 years old (the children group), 74 patients (73.3%) were older than 18 years old (the adults group). The following clinical features were analyzed and compared: age, gender, clinical symptoms, leukocyte count, the affected cervical area, lifestyle habits, antibiotic therapy, comorbidities, etiology, bacterial culture, time of hospitalization, the need of tracheostomy and complications. RESULTS: There was predominance in the male gender (55.5%) and young people (mean age 28.1 years). All of the 51 patients with associated disease comorbidity were adults. The most frequent etiologies were bacterial tonsillitis (31.68%) and odontogenic infections (23.7%). The most common cervical areas affected were the peritonsillar (26.7%), submandibular/mouth floor (22.7%) and parapharyngeal spaces (18.8%). In children group, the site most commonly involved was the peritonsillar space (10 patients, 37%). In adults group, the site most commonly involved was multispace (31 patients, 41.8%). Streptococcus pyogenes (23.3%) was the most common microorganism present. Amoxicillin associated with clavulanate (82.1%) was the more used antibiotic. The main complications of abscesses were septic shock (16.8%), pneumonia (10.8%) and mediastinitis (1.98%). Tracheostomy was necessary in 16.8% of patients. The mortality rate was 1.98%. CONCLUSION: The clinical features and severity of DCA varied according to different age groups, perhaps due to the location of the infection and a higher incidence of comorbidity in adults. Thus, DCA in adults is more facile to have multispace involvement and lead to complications and seems to be more serious than that in children.

Predisposing factors and management of complications in acute tonsillitis.

CONCLUSION: RPA and NF was diagnosed with a sensitivity/specificity of 100%/94% in patients with acute tonsillitis and without suspicion for disease complication after ENT examination, but an age >35 years and serum CRP >15.5mg/dl. BACKGROUND: Acute tonsillitis represents a frequent disease in the otorhinolaryngology. Some patients exhibit disease aggravations resulting in (descending) peritonsillar abscess (PTA, dPTA), para-/retropharyngeal abscess (PPA, RPA), or necrotising fasciitis (NF). The study analyses the underlying predisposing factors. METHODS: The retrospective cohort study includes a total of 1636 patients comprising 852 outpatients with acute bacterial tonsillitis, 279 in-patients with acute bacterial tonsillitis, 452 patients with PTA, 31 patients with dPTA/PPA, 12 patients with RPA, and 10 patients with NF. Patients were analysed for disease-related data. RESULTS: While leucocytes do not distinguish the sub-groups, C-reactive protein demonstrated a significant increase resulting in the highest level for RPA and NF (p < 0.0001). PTA and RPA are usually caused by streptococcus, dPTA/PPA by anaerobic bacterias, and NF mixed infections (p < 0.0001). Patients with PTA were younger than dPTA/PPA (p = 0.002) or RPA/NF (p < 0.0001). Subsequently, the rate of internistic comorbidities was significantly increased in RPA/NF (p < 0.0001). ROC-analysis identified cut-offs for age <36 years and CRP <15.5mg/dl to distinguish acute bacterial tonsillitis from RPA.

A Case of a Methicillin-Resistant Staphylococcus Aureus Retropharyngeal Abscess With Mediastinal Extension in an 11-Month-Old Girl.

We present the case of an 11-month-old girl with Mycoplasma pneumoniae-associated pneumonia who was subsequently diagnosed with a methicillin-resistant Staphylococcus aureus retropharyngeal abscess with mediastinal extension.

Community-acquired adult Escherichia coli meningitis leading to diagnosis of unrecognized retropharyngeal abscess and cervical spondylodiscitis: a case report.

BACKGROUND: Escherichia coli is a rare cause of community-acquired meningitis in adults unless predisposing factors are present (e.g., previous penetrating cranio-cerebral injury or neurosurgery, immunosuppression, chronic alcoholism, history of cancer, diabetes mellitus, advanced age). CASE PRESENTATION: We describe the case of a 53-year-old woman, resident in Germany, suffering from community-acquired bacterial meningitis caused by CTX-M-9 type extended spectrum ß-lactamase producing Escherichia coli. Because typical predisposing factors were not apparent, pathogen identification resulted in expanded diagnostics to exclude a distant or contiguous primary focus. By magnetic resonance tomography, a previously unrecognized large retropharyngeal abscess with cervical spondylodiscitis was detected. In retrospect, the patient had complained about neck pain for a few weeks prior to meningitis onset, but the symptoms were interpreted as being related to a herniated disk. Meningitis and osteomyelitis resolved completely under surgical treatment and meropenem therapy. CONCLUSION: In case of adult Escherichia coli meningitis, underlying diseases should always be carefully excluded, especially if predisposing factors are not apparent.

Airway compromise during central venous cannulation in an undiagnosed tubercular retropharyngeal abscess: a case report.

Central venous cannulation is often associated with complications during insertion even by expert's hand and with the aid of ultrasound. We encountered a patient for central line insertion through the right internal jugular vein having a retropharyngeal abscess of tubercular origin. We accidentally punctured the abscess cavity leading to increased respiratory distress and subsequent need of intubation to the patient. This kind of complication during central line insertion has never been reported before. We intend to report such a case to alert everyone about the grave complications it can lead to and the methods to minimize them in the times ahead.

Endovascular treatment of an infected pseudoaneurysm secondary to retropharyngeal abscess in a child.

We describe a rare case of carotid pseudoaneurysm secondary to a retropharyngeal abscess, treated with coil embolization in a 2-year-old boy. The patient presented to an emergency department with symptoms suggesting meningitis but was subsequently diagnosed with streptococcal pharyngitis. He was discharged home on oral antibiotics after a short hospitalization. He returned to the emergency department two weeks later with limited neck motion and pain. Neck CT demonstrated a retropharyngeal abscess with a large left cervical internal carotid artery (ICA) pseudoaneurysm. The petrous ICA distal to the pseudoaneurysm had thrombosed prior to treatment. The ICA proximal to the pseudoaneurysm was sacrificed with coil embolization. Post-treatment imaging demonstrated complete thrombosis of the pseudoaneurysm but also demonstrated acute strokes in the left MCA/ACA watershed distribution. His parents noted that the patient was clumsier and exhibited some mild speech changes and a steppage gait prior to evaluation in the ED; therefore, these were thought to be secondary to emboli from partial thrombosis of the pseudoaneurysm prior to treatment. The patient was discharged home in good condition and his neurological function improved.