Parapharyngeal and retropharyngeal infections in children: Kawasaki disease needs vigilance.

OBJECTIVE: Kawasaki Disease (KD) may mimic Parapharyngeal (PPI) and Retropharyngeal Infections (RPI), leading to misdiagnosis as Deep Neck Infections (DNIs). The treatment plans for the two diseases are different, and delayed treatment can lead to serious complications. Therefore, prompt diagnosis and management are necessary. This study was performed to evaluate the clinical features of KD mimicking DNIs and explore the treatment options. METHODS: Children with cellulitis or abscess in parapharyngeal or retropharyngeal space in neck CT were included in this study. The medical records of enrolled children were retrospectively reviewed. RESULTS: In total, 56 children were diagnosed with PPI or/and RPI. Twenty-two (39.3%) participants were eventually diagnosed with KD, and 34 (60.7%) were diagnosed with DNIs. Compared with the DNIs group, the KD group had a higher body temperature (p=0.007), and higher levels of AST (p=0.040), ALT (p=0.027), and ESR (p=0.030). Deep cervical cellulitis (p=0.005) were more common in the KD group. However, deep neck abscess often occurred in the DNIs group (p=0.002), with parapharyngeal abscess being the most common type of abscess (p=0.004). The KD mimicking DNIs cases did not respond to antibiotic treatment, but symptoms significantly improved after the use of Immunoglobulin (IVIG) and aspirin. CONCLUSION: Children with KD may exhibit retropharyngeal or parapharyngeal inflammation in the early stages. KD should be considered a differential diagnosis for children with DNIs, high fever, and no response to antibiotic therapy. Surgery in KD mimicking deep neck abscess requires caution. LEVEL OF EVIDENCE: I.

Sentinel ear bleed as a presenting sign for carotid artery blowout due to aspergillus abscess in parapharyngeal space in an immunocompetent infant.

Parapharyngeal abscesses leading to complications, although rare after the advent of antibiotics, can lead to serious complications. One such complication is carotid erosion that can lead to a potentially fatal carotid artery blowout. We report a case of a previously healthy infant who presented with fever, ear bleed and progressively increasing swelling in the right side of his neck that led to airway compromise. The child required immediate securing of the airway at presentation. Imaging revealed lobulated abscess with multiple bleeding points eroding the carotid vessels, along with internal jugular venous thrombus. Surgical exploration was done and abscess debulked. Histopathology revealed aspergillus, which was treated with antifungals. He was discharged on oral warfarin after 40 days of hospital stay and remains well on follow-up. Sentinel ear bleed warrants close observation for possibility of carotid artery blowout in children with parapharyngeal abscesses.

[Internal carotid artery pseudoaneurysm caused by parapharyngeal abscess: A case report].

Pseudoaneurysms of the neck are seldom, and those caused by neck infections especially parapharyngeal abscess are even rarer. However, it is life-threatening and may bring sudden death due to the obstruction of airway and the pseudoaneurysms rupture. We analyzed the clinical features, diagnosis and treatment of the disease through a case summary and literature review in order to guide clinical diagnosis and treatment of pseudoaneurysms. The patient, whom we presented was an 87-year-old male and admitted in emergency of our hospital with the chief complaint of neck swelling for 7 days and shortness of breath for 2 days. Cervical ultrasound examination showed that there was an liquid dark area next to the left common carotid artery which was approximately 8.0 cm × 5.0 cm, consideration of formation of left carotid artery pseudoaneurysm, and the liquid dark area which was visible on the right considered of pseudoaneurysm or infection. Angiography of neck showed a clustered high-density shadow around the bifurcation of the left carotid artery, with an overall range of approximately 65 mm × 52 mm × 72 mm, the pseudoaneurysms for sure, while on the right side of the lesion, mixed low density shadows with air could be seen, the parapharyngeal abscess for sure.Then he was diagnosed as the pseudoaneurysm of left internal carotid artery which was caused by parapharyngeal abscess. After tracheal intubation and anti-infection treatment, the patient died due to hemorrhagic shock of the ruptured of the pseudoaneurysm. Morever we performed literature search on PubMed, Wanfang database and CNKI with keywords of "neck pseudoaneurysm, neck infection, parapharyngeal abscess" and enrolled 10 cases. Then we summarized the clinical characteristics and treatment. We analyzed and summarized the 10 case reports, in which the number of male was 7. Among them, there were 4 pediatric, and 6 adults were enrolled overall. Most of the symptoms were neck swelling, and the diseased blood vessel was mainly the right internal carotid artery which accounted for half overall. All the patients underwent surgical intervention, and recovered well. So we draw the conclusion that the clinical incidence of cervical pseudoaneurysms is low and can be caused by a variety of factors, especially caused by infectious factors. When a patient has a progressive pulsating mass in the neck, the preliminary diagnosis should be made by ultrasound as soon as possible, and the aortic enhancement CT should be used to further confirm.For a patient with cervical pseudo-aneurysms caused by parapharyngeal infections, he should take operation timely combined with antibiotic treatment in time.

Estudio retrospectivo de la incidencia de los abscesos periamigdalinos y parafaríngeos en el periodo 2000-2021 / Retrospective study of the incidence of peritonsillar and parapharyngeal abscesses in the period 2000-2021

Introducción y objetivo: Las infecciones faringo-amigdalares y sus complicaciones son muy frecuentes y con características epidemiológicas variables, de unos países a otros. El objetivo de este trabajo ha consistido en determinar la incidencia, edad, género y estacionalidad, de los pacientes ingresados con amigdalitis (A), absceso periamigdalino (AP) y parafaríngeo (APF), en un hospital de tercer nivel, en Valladolid (España). Método: Estudio retrospectivo de 1339 pacientes ingresados en HCUV entre los años 2000 y 2021 por infecciones faringocervicales (A, AP y APF). Resultados: La media de edad de los pacientes ingresados con A es de 27,8 años, con AP de 35,5 y con APF de 47 años, siendo esta diferencia estadísticamente significativa (p<0,001). La amigdalitis predomina en mujeres (ratio: 1,26), y en hombres el AP (ratio: 1,44) y el APF (ratio: 2,4). No hemos encontrado relación significativa de estos procesos ni con los meses del año ni con las estaciones climáticas. Discusión: Las diferencias de género, edad media y estacionalidad entre la A y el AP generan controversia para poder entender el origen del AP y la posible influencia de los factores de riesgo. Hay pocos estudios epidemiológicos publicados sobre el APF, cuya incidencia parece que está aumentando, por causas desconocidas. Conclusiones: La A destaca en la infancia, el AP en adultos jóvenes y el APF en más mayores. Salvo la A y el AP en adolescentes, que predominan en mujeres, el resto de los abscesos faringocervicales son más frecuentes en hombres. En la población estudiada el clima no parece un factor etiopatogénico importante. (AU)

Introduction and objective: Pharyngotonsillar infections and their complications are very frequent, and their epidemiological characteristics vary from one country to another. The aim of this study was to determine the incidence, age, gender and seasonality of patients admitted with tonsillitis (T), peritonsillar abscess (PT) and parapharyngeal abscess (PPA) in a tertiary hospital in Valladolid (Spain). Method: Retrospective study of 1339 patients admitted to HCUV between 2000 and 2021 for pharyngo-cervical infections (A, PA and PPA). Results: The mean age of patients admitted with A was 27.8 years, 35.5 years with PA and 47 years with PPA, this difference being statistically significant (p<0.001). Tonsillitis predominates in women (ratio: 1.26), and in men PA (ratio: 1.44) and PPA (ratio: 2.4). We found no significant relationship between the frecuency of these processes and the months of the year or climatic seasons. Discussion: The differences in gender, mean age and seasonality between A and PA generate controversy in order to understand the origin of PA and the possible influence of risk factors. There are few epidemiological studies published on PPA, whose incidence seems to be increasing, for unknown causes. Conclusions: A tends out in childhood, PA in young adults and PPA in older patients. Except for A and PPA in adolescents, which predominate in women, the rest of the pharyngo-cervical abscesses are more frequent in men. In the population studied, climate does not seem to be an important etiopathogenic factor. (AU)

A Rare Case of Extracranial Schwannoma of the Hypoglossal Nerve Located in the Parapharyngeal Space Mimicking a Deep Neck Abscess.

Schwannomas are neurogenic benign tumors originating from the myelin sheath of peripheral nerves, and hypoglossal Schwannomas account for 5% of nonvestibular ones. Extracranial localizations are substantially rare, especially those affecting exclusively the parapharyngeal space; for this reason, the retrostyloid neoformations could initially masquerade as a carotid tumor or deep organized neck abscess. The purpose of this report is to highlight the importance of a multidisciplinary approach in the correct management of differential diagnosis.

Internal carotid artery pseudoaneurysm caused by parapharyngeal abscess: A case report / 北京大学学报(医学版)

Pseudoaneurysms of the neck are seldom, and those caused by neck infections especially parapharyngeal abscess are even rarer. However, it is life-threatening and may bring sudden death due to the obstruction of airway and the pseudoaneurysms rupture. We analyzed the clinical features, diagnosis and treatment of the disease through a case summary and literature review in order to guide clinical diagnosis and treatment of pseudoaneurysms. The patient, whom we presented was an 87-year-old male and admitted in emergency of our hospital with the chief complaint of neck swelling for 7 days and shortness of breath for 2 days. Cervical ultrasound examination showed that there was an liquid dark area next to the left common carotid artery which was approximately 8.0 cm × 5.0 cm, consideration of formation of left carotid artery pseudoaneurysm, and the liquid dark area which was visible on the right considered of pseudoaneurysm or infection. Angiography of neck showed a clustered high-density shadow around the bifurcation of the left carotid artery, with an overall range of approximately 65 mm × 52 mm × 72 mm, the pseudoaneurysms for sure, while on the right side of the lesion, mixed low density shadows with air could be seen, the parapharyngeal abscess for sure.Then he was diagnosed as the pseudoaneurysm of left internal carotid artery which was caused by parapharyngeal abscess. After tracheal intubation and anti-infection treatment, the patient died due to hemorrhagic shock of the ruptured of the pseudoaneurysm. Morever we performed literature search on PubMed, Wanfang database and CNKI with keywords of "neck pseudoaneurysm, neck infection, parapharyngeal abscess" and enrolled 10 cases. Then we summarized the clinical characteristics and treatment. We analyzed and summarized the 10 case reports, in which the number of male was 7. Among them, there were 4 pediatric, and 6 adults were enrolled overall. Most of the symptoms were neck swelling, and the diseased blood vessel was mainly the right internal carotid artery which accounted for half overall. All the patients underwent surgical intervention, and recovered well. So we draw the conclusion that the clinical incidence of cervical pseudoaneurysms is low and can be caused by a variety of factors, especially caused by infectious factors. When a patient has a progressive pulsating mass in the neck, the preliminary diagnosis should be made by ultrasound as soon as possible, and the aortic enhancement CT should be used to further confirm.For a patient with cervical pseudo-aneurysms caused by parapharyngeal infections, he should take operation timely combined with antibiotic treatment in time.

Pseudoaneurisma de la arteria facial como complicación de un absceso parafaríngeo. Presentación de un caso y revisión de la literatura / Pseudoaneurysm of the facial artery as a complication of parapharyngeal abscess. Presentation of a case and review of the literature

Un pseudoaneurisma constituye una dilatación sacular vascular que implica un defecto a nivel de la íntima y la capa media, manteniendo continuidad de la adventicia. Las dilataciones aneurismáticas de la arteria carótida extracraneal son raras, encontrándose entre sus causas traumatismos, infecciones y complicaciones iatrogénicas. Su tratamiento, recomendado en todos los casos, incluye la cirugía tradicional, la colocación de stent y la embolización. El riesgo de rotura implica una mortalidad de hasta el 30 %. Presentamos el caso de una mujer de 86 años derivada a Urgencias por cuadro de cinco días de odinofagia asociado a tumefacción dolorosa submandibular evidenciándose en el TC una colección parafaríngea compatible con absceso, en cuyo interior se objetivó una estructura vascular aumentada de calibre sugestiva de pseudoaneurisma. Se realizó una arteriografía que confirmó la presencia de una dilatación sacular compatible con pseudoaneurisma a nivel submandibular izquierdo, dependiente de la rama palatina ascendente de la arteria facial. Esta lesión se embolizó mediante coils para posteriormente realizarse drenaje y desbridamiento quirúrgico del absceso submaxilar. La evolución posterior fue satisfactoria. La presencia de una lesión poco frecuente pero con alta mortalidad en un cuadro clínico habitual en la práctica clínica pone de manifiesto la relevancia del estudio mediante TC a cargo de profesionales experimentados. La colaboración en estos casos entre radiólogos y cirujanos de cabeza y cuello resulta imprescindible. (AU)

A pseudoaneurysm is a vascular saccular dilatation that involves a defect at the level of the intima and the medial layer, maintaining continuity of the adventitia. Aneurysmal dilatations of the extracranial carotid artery are rare, with trauma, infection and iatrogenic complications among their causes. Their treatment, recommended in all cases, includes traditional surgery, stenting and embolization. The risk of rupture implies a mortality of up to 30 %. We present the case of an 86-year-old woman referred to the Emergency Department with five days of odynophagia associated with painful submandibular swelling, showing in CT a parapharyngeal collection compatible with abscess, inside which an enlarged vascular structure suggestive of pseudoaneurysm was observed. Arteriography confirmed the presence of a saccular dilatation compatible with pseudoaneurysm at the left submandibular region, dependent on the ascending palatine branch of the facial artery. This lesion was embolized by coils and later drainage and surgical debridement of the submaxillary abscess was performed. Subsequent evolution was satisfactory. The presence of an infrequent lesion but with high mortality in a common clinical condition highlights the relevance of CT study by experienced professionals. Collaboration in these cases between radiologists and head and neck surgeons is essential. (AU)

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.

[Clinical analysis of lateral cervical approach in the treatment of cervical lymphatic tuberculosis complicated with parapharyngeal space abscess].

Objective:To investigate the clinical effect of lateral cervical approach in the treatment of cervical lymphatic tuberculosis complicated with parapharyngeal space abscess. Methods:A total of 10 patients with cervical lymph node tuberculosis complicated with tuberculous abscess in parapharyngeal space were treated. Surgery was performed using a transcervical approach. The operation time and blood loss were recorded. The level of ESR, C-reactive protein（CRP）, VAS score and the rating of Kubota drinking test before and 2 weeks after operation were compared. The incision healing, symptoms of tuberculosis poisoning, and the CT findings of the cervical lesions were compared before operation, 2 weeks after operation and at the last follow-up. Results:The operation time ranged from 65 to 130 min with an average of （99.00±21.45） min. The intraoperative blood loss ranged from 100 to 250 mL with an average of （155.00±43.78） mL. The average pre-and post-operative level of ESR was （67.60±21.94） mm/1h and （30.30±13.76） mm/1h, respectively（U=5.500, P<0.01）; The average pre-and post-operative level of CRP was （69.70±31.13） mg/L and （42.40±19.70） mg/L, respectively（U=22.500, P<0.05）; The average pre-and post-operative VAS score was （5.60±1.26） points and （2.50±1.27） points, respectively（U=4.500, P<0.01）. As for Kubota drinking test, the rating was between 1-2 two weeks postoperatively. After relieving the compression, there was no obvious choking and coughing in drinking water. During the follow-up period （range: 6-24 months）, the surgical wound healed completely, and the symptoms of systemic tuberculosis poisoning disappeared. No obvious residual cavity or effusion was found in the parapharyngeal space by CT examination, nor was any protruding tissue in oropharynx. The edema of soft tissue surrounding the operational area disappeared, and the enlarged lymph nodes were significantly reduced. No sign of liquefaction, necrosis, suppuration or recurrence was observed. Conclusion:Surgery using transcervical approach effective in treating cervical lymph node tuberculosis with parapharyngeal space abscess.

Clinical characteristics for conservative therapy of pediatric parapharyngeal abscesses / Características clínicas para tratamento conservador em abscessos parafaríngeos pediátricos

Abstract Introduction The role of surgical drainage versus conservative therapy in treating patients with parapharyngeal abscesses is still a theme of debate. Objectives This study aimed to investigate the characteristics associated with good outcomes in pediatric patients with parapharyngeal abscesses treated with conservative therapy. Methods This retrospective chart review was performed on children aged 0.3-14 years with the diagnosis of parapharyngeal abscesses confirmed by computed tomography from January 2013 to March 2018. Patients with a severe upper airway obstruction required early intervention, while those in a stable condition initially received conservative therapy with antibiotics. If the patients appeared unlikely to recover, additional surgical drainage was provided. Multivariate logistic regression models were constructed to investigate the clinical characteristics associated with a good response to conservative therapy. A receiver operating characteristic curve was used to identify the age and abscess size cutoff for predicting a successful response. Results A total of 48 children were included in the study. Patient age, antecedent illness, and abscess size were significantly associated with a response to therapy (Odds Ratio = 1.326, 2.314 and 1.235, respectively). The age cutoff associated with the conservative therapy was 4.2 years (76.9% sensitivity, 68.2% specificity), and the abscess size cutoff associated with the conservative therapy was 23 mm (84.6% sensitivity, 77.3% specificity). Conclusion The findings suggested that younger age, smaller abscess size, and less frequent antecedent illnesses, such as upper respiratory tract infection and lymphadenitis, could predict a successful response to conservative therapy in pediatric patients with parapharyngeal abscesses.

Resumo Introdução O papel da drenagem cirúrgica versus tratamento conservador na abordagem de pacientes com abscessos parafaríngeos ainda é uma questão controversa. Objetivo Investigar as características associadas a um bom desfecho em pacientes pediátricos com abscessos parafaríngeos tratados com terapia conservadora. Método Revisão retrospectiva de prontuários feita em crianças de 14 anos com diagnóstico de abscesso parafaríngeo confirmado por tomografia computadorizada de janeiro de 2013 a março de 2018. Pacientes com obstrução grave das vias aéreas superiores necessitaram de intervenção precoce, enquanto aqueles em estado inicialmente estável receberam tratamento conservador com antibióticos. Se a recuperação dos pacientes parecesse improvável, drenagem cirúrgica adicional era feita. Modelos de regressão logística multivariada foram construídos para investigar as características clínicas associadas a uma boa resposta a terapia conservadora. Uma curva ROC, ou seja, característica de operação do receptor, foi usada para identificar a idade e o tamanho do abscesso com o intuito de prever uma resposta bem-sucedida. Resultados Foram incluídas no estudo 48 crianças. Idade do paciente, doenças respiratórias prévias e comorbidades e tamanho do abscesso foram significantemente associados à resposta terapêutica. (odds ratio = 1.326, 2.314 e 1.235, respectivamente). O ponto de corte da idade associado à terapia conservadora foi de 4,2 anos (sensibilidade de 76,9%, especificidade de 68,2%) e o ponto de corte do tamanho do abscesso associado à terapia conservadora foi de 23 mm (sensibilidade de 84,6%, especificidade de 77,3%). Conclusão Os achados sugerem que idade mais jovem, menor tamanho de abscesso e menor frequência de doença comuns, como infecção do trato respiratório superior e linfadenite, podem prever uma resposta bem-sucedida à terapia conservadora em pacientes pediátricos com abscessos parafaríngeos.

Different types of dysphagia alleviated by the chin-down position.

OBJECTIVE: Retrospective videofluoroscopic swallowing study (VFSS) evaluations of pharyngeal swallowing were used to evaluate the types of dysphagia alleviated by the chin-down maneuver. MATERIALS AND METHODS: The study population consisted of 64 patients who underwent VFSS evaluations during neutral and chin-down maneuvers presenting specifically penetration or aspiration. The assessment of the VFSS movie clips of each maneuver was performed using parameters of the Modified Barium Swallow Impairment Profile (MBSImP) and the presence and degree of airway invasion(PDAI) by three blinded raters in the following five subcategorized groups, 1. patietns presenting penetration or aspiration during swallow 2. after swallow, patients of 3. head and neck, 4. digestive and 5. neuromuscular disorders, respectively. The scores registered for the two maneuvers were statistically compared. Additionally, we examined statistically which factors had the impact on the improvement of the PDAI using fisher's exact test. RESULTS: Compared with the neutral position, PDAI, pharyngeal constriction, anterior hyoid movement, pharyngeal constriction, laryngeal elevation, laryngeal closure, upper esophageal sphincter opening, initiation of the pharyngeal swallow, and pharyngeal clearance in pyriform sinus were significantly (p < 0.01-0.05) improved with the chin-down maneuver. In a subcategory comparison with group 1, 3 and 4, the PDAI improved significantly (p < 0.01) with the chin-down maneuver, in which laryngeal elevation and laryngeal closure had statistically the impact (p < 0.01-0.05) on improvement of PDAI. CONCLUSION: The chin-down maneuver was most effective in improving swallow function when the impairment included penetration and aspiration during swallow caused by inadequate laryngeal elevation and laryngeal closure.

Abscés cervical profund associat a col·locació de mascareta laríngia / Absceso cervical profundo asociado a la colocación de mascarilla laríngea / Deep neck abscess associated to the placement of a laryngeal mask

INTRODUCCIÓ: Els abscessos parafaringi I retrofaringi són infeccions profundes del coll que solen associar-se a l'antecedent d'infecció de vies respiratòries altes. Ocasionalment poden ser causats per traumatismes com els que comporten algunes manipulacions mèdiques, per exemple, la col·locació de mascareta laríngia, molt utilitzada en cirurgia pediàtrica. CAS CLÍNIC: Es presenta el cas d'una nena de 6 anys amb torticoli de 8 dies d'evolució I febre de 24 hores, sense cap altra simptomatologia. La pacient havia estat intervinguda quirúrgicament sota anestèsia general amb col·locació de mascareta laríngia 36 hores abans de l'inici del quadre, sense incidències. En l'exploració, destaca una contractura cervical bilateral amb flexió del cap a la dreta, I a l'analítica es troba leucocitosi amb predomini de neutròfils I augment de la proteïna C reactiva. Es fa una ressonància magnètica cervical en què s'observa un abscés d'extensió parafaríngia I retrofaríngia, I s'indica una punció percutània ecoguiada de l'àrea abscessificada, que resulta positiva per a S. pyogenes. S'ingressa la pacient amb antibioteràpia endovenosa I s'aconsegueix la millora clínica I radiològica de l'abscés. COMENTARIS: Els abscessos cervicals profunds s'han de considerar davant de simptomatologia obstructiva I inflamatòria de la via aèria I el tracte digestiu superior, I símptomes locals o dolor al moviment cervical. El diagnòstic es basa en les troballes radiològiques, analítiques I microbiològiques, I cal instaurar antibioteràpia endovenosa empírica amb cobertura per a estafilococs, estreptococs I anaerobis. Tot I que aquests abscessos en la majoria de casos són secundaris a l'extensió d'infeccions del tracte respiratori superior, hi ha altres causes que cal considerar

INTRODUCCIÓN: Los abscesos retrofaríngeo y parafaríngeo son infecciones profundas del cuello que suelen asociarse al antecedente de infección de vías respiratorias altas. Ocasionalmente pueden ser causados por traumatismos como los que resultan de algunos procedimientos médicos, por ejemplo, la colocación de la mascarilla laríngea, muy utilizada en cirugía pediátrica. CASO CLÍNICO: Se presenta el caso de una niña de 6 años con tortícolis de 8 días de evolución y fiebre de 24 horas, sin otra sintomatología. La paciente había sido intervenida quirúrgicamente bajo anestesia general con colocación de mascarilla laríngea 36 horas antes del inicio del cuadro, sin incidencias. A la exploración, destaca una contractura cervical bilateral con flexión de la cabeza hacia la derecha, y en la analítica se encuentra leucocitosis con predominio neutrofílico y ligero aumento de proteína C reactiva. Se realiza una resonancia magnética cervical donde se observa un absceso de extensión parafaríngea y retrofaríngea, y se practica una punción percutánea ecoguiada de la zona abscesificada, que resulta positiva para S. pyogenes. La paciente ingresa con antibioterapia endovenosa y se consigue mejoría clínica y radiológica del absceso. COMENTARIO: Los abscesos cervicales profundos deben considerarse ante sintomatología obstructiva e inflamatoria de la vía aérea y del tracto digestivo superior, y síntomas locales o dolor al movimiento del cuello. El diagnóstico se basa en los hallazgos radiológicos, analíticos y microbiológicos y se debe instaurar antibioterapia endovenosa empírica con cobertura para estafilococos, estreptococos y anaerobios. Aunque en la mayoría de casos estos abscesos son secundarios a la extensión de infecciones del tracto respiratorio superior, existen otras causas que deben considerarse

INTRODUCTION: Retropharyngeal and parapharyngeal abscesses are deep neck infections that are usually associated with superior airway infections in children. However, they could also be caused by injuries secondary to medical procedures such as the placement of laryngeal masks, which are frequently used in pediatric surgery. CASE REPORT: A 6-year-old female presented to the emergency room with an 8-day history of torticollis and 24 hours of fever with no other associated symptomatology. She had undergone surgery under general anesthesia using a laryngeal mask 36 hours prior, without immediate complications. In the physical examination, the patient had bilateral cervical contracture with right bending. The blood examination showed leukocytosis with predominance of neutrophils and increase of C-reactive protein. Magnetic resonance imaging showed an abscess with parapharyngeal and retropharyngeal extension, and a percutaneous ultrasound-guided puncture of the abscessed area was performed, which resulted positive for S. pyogenes. The patient received intravenous antibiotic therapy and achieved clinical and radiological resolution of the abscess. COMMENTS: Deep neck abscesses should be considered in children with obstructive and inflammatory symptomatology of the airway and upper digestive tract and also local symptoms as neck pain. Diagnosis is based on radiological, analytical and microbiological findings and empirical intravenous antibiotics, with coverage for staphylococcus, streptococcus and anaerobics. Although in most cases these abscesses are secondary to the spread of upper respiratory tract infections, other causes should be considered

Microbiology of parapharyngeal abscesses in adults: in search of the significant pathogens.

We aimed to describe the microbiology of parapharyngeal abscess (PPA) and point out the likely pathogens using the following principles to suggest pathogenic significance: (1) frequent recovery, (2) abundant growth, (3) growth in relative abundance to other microorganisms, (4) percentage of the isolates recovered in both absolute and relative abundance, (5) more frequent recovery in PPA pus compared with tonsillar surface and tissue. Comprehensive bacterial cultures were performed on specimens obtained from adult patients (n = 60) with surgically verified PPA, who were prospectively enrolled at five Danish ear-nose-throat departments. The prevalent isolates (in PPA pus) were unspecified anaerobes (73%), non-hemolytic streptococci (67%), Streptococcus anginosus group (SAG) (40%), Corynebacterium spp. (25%), Neisseria spp. (23%), Fusobacterium spp. (22%), Fusobacterium necrophorum (17%), Prevotella spp. (12%), and Streptococcus pyogenes (10%). The bacteria most frequently isolated in heavy (maximum) growth were unspecified anaerobes (60%), SAG (40%), F. necrophorum (23%), and Prevotella spp. (17%). The predominant microorganisms (those found in highest relative abundance) were unspecified anaerobes (53%), SAG (28%), non-hemolytic streptococci (25%), F. necrophorum (15%), S. pyogenes (10%), and Prevotella spp. (10%). Four potential pathogens were found in both heavy growth and highest relative abundance in at least 50% of cases: F. necrophorum, Prevotella spp., SAG, and S. pyogenes. SAG, Prevotella spp., F. necrophorum, S. pyogenes, and Bacteroides spp. were recovered with the same or higher frequency from PPA pus compared with tonsillar tissue and surface. Our findings suggest that SAG, F. necrophorum, Prevotella, and S. pyogenes are significant pathogens in PPA development.

A giant pseudoaneurysm mimicking a parapharyngeal abscess / Pseudoaneurisma gigante simulando un absceso parafaríngeo

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Lymphoma with superimposed tuberculosis and fungal infection mimicking parapharyngeal abscess complicated with recurrent neurocardiogenic syncope: a case report.

INTRODUCTION: Lymphoma of parapharyngeal space (PPS) is a rare condition. The clinical presentations may vary and often masquerades as infection or an inflammatory condition. A misdiagnosis will lead to a delay in treatment of the disease. Due to the complex anatomy of PPS, any attributed pressure from masses can lead to a life-threatening event such as cardiac syncope. CASE REPORT: We report a rare case of PPS B-cell non-Hodgkin lymphoma with superimposed Tuberculosis (TB) and fungal infection that presents with several episodes of syncope and hemodynamic depression. DISCUSSION: The clinical entities in PPS lesions syncope and its associated syndromes, pathophysiology, and differential diagnosis together with possible managements are further discussed.

Rigidez de nuca, ¿siempre neurológico? Pensemos algo más / Stiff neck, is it always neurological? Let's think about something else

Las complicaciones supurativas de la faringoamigdalitis aguda no tratada o inadecuadamente tratada son infrecuentes. Destacan, por su potencial gravedad, el absceso retrofaríngeo y parafaríngeo. Por su presentación clínica como limitación de movilidad cervical o rigidez de nuca en contexto infeccioso, pueden plantear la sospecha inicial de meningitis aguda. Por ello, es necesario que los profesionales sanitarios conozcan las características clínicas y la evolución de estas complicaciones, para así actuar de manera correcta, precoz y eficaz, debido a su potencial gravedad. A continuación, se presentan dos casos de complicaciones supurativas del área otorrinolaringológica que debutaron con clínica cervical: rigidez de nuca o limitación de la movilidad, y que suponen un reto diagnóstico

Suppurative complications of untreated or improperly treated acute pharyngotonsillitis are uncommon. Because of its potential severity, retropharyngeal and parapharyngeal abscess are important. Due to their clinical presentation as a limitation of cervical mobility and/or neck stiffness in an infectious context, they can raise the initial suspicion of acute meningitis. For that, it is necessary for health professionals to know the clinical characteristics and the evolution of these complications, in order to act correctly, early and effectively, due to their potential severity. Below we present two cases of suppurative complications of the otorhinolaryngology area that debuted with a cervical clinic, either with neck stiffness or limited mobility, posing a diagnostic challenge

The usefulness of abscess tonsillectomy followed by intraoral drainage for parapharyngeal abscess concomitant with peritonsillar abscess in the elderly.

Parapharyngeal abscess (PPA) may cause life-threatening complications and peritonsillar abscess (PTA) and tonsillitis frequently precede PPA. The optimal management of PPA caused by PTA has been the subject of debate with respect to the surgical approach. We present three cases of PPA concomitant with PTA in elderly patients. In two cases, the abscesses in parapharyngeal space were drained by abscess tonsillectomy followed by intraoral incision of the tonsillar bed. On the other hand, the third case did not undergo abscess tonsillectomy because of his refusal of surgery and needed extraoral drainage after the aggravation of PPA. Based on the experience of those three cases, it was suggested that abscess tonsillectomy followed by intraoral incision of the tonsillar bed might be a useful surgical approach for the drainage of PPA concomitant with PTA, especially in elderly patients.

Deep neck infection of dental origin. A case report / Infección cervical profunda de origen dental. Descripción de un caso

INTRODUCCIÓN Y OBJETIVO: Al menos el 36% de las infecciones cervicales profundas pueden tener un origen dental. Descripción del caso: Mujer de 44 años que consultó por disfonía de una semana de evolución. La rinofibrolaringoscopia reveló edema aritenoideo izquierdo y parálisis de la hemilaringe izquierda y cuello normal. Se realizó una tomografía axial computarizada, encontrando absceso parafaríngeo izquierdo. Se realizó tratamiento antibiótico sistémico y quirúrgico con cervicotomía y drenaje del absceso en cuyo cultivo se aisló Prevotella buccae. Comentarios: El resultado del cultivo ayudó a establecer el origen dental de la infección. En la historia dental, se encontró una historia de pericoronitis asociada con 3.8. CONCLUSIONES: el diagnóstico del origen dental de una infección cervical profunda se establece mediante la historia dental, el examen oral, la radiología oral y el cultivo microbiológico

INTRODUCTION AND OBJECTIVE: At least 36% of deep cervical infections may have a dental origin. CASE DESCRIPTION: A 44-year-old woman who consulted for dysphonia of a week of evolution. Rhinofibrolaryngoscopy revealed left arytenoid edema and paralysis of the left hemilarynx and normal neck. A computerized axial tomography was performed, finding left parapharyngeal abscess. Systemic and surgical antibiotic treatment was performed with cervicotomy and drainage of the abscess in whose culture Prevotella buccae was isolated. COMMENTS: The result of the culture helped establish the dental origin of the infection. In the dental history, a history of pericoronitis associated with 3.8 was found. CONCLUSIONS: The diagnosis of the dental origin of a deep cervical infection is established by dental history, oral examination, oral radiology and microbiological culture

Is vessel narrowing secondary to pediatric deep neck space infections of clinical significance?

INTRODUCTION: Pediatric deep neck space infections (DNSI) may cause internal jugular vein and/or carotid artery narrowing. Radiologists and otolaryngologists are often queried by emergency room providers and pediatricians with regards to the clinical significance when this radiographic finding is noted. There are often questions raised about need for further imaging, anticoagulation and overall management strategy. There is limited data to support our answers to these questions. This study investigated the clinical significance of vessel narrowing of the internal jugular vein and carotid artery in the setting of DNSI in children. METHODS: 208 patients over a 10 year period were reviewed in retrospective fashion. CT scans reports were evaluated for vessel narrowing, and clinical outcomes were analyzed. RESULTS: This study found that nearly half (44.7%, 93 of 208) of pediatric DNSIs reviewed showed evidence of either carotid and/or internal jugular vein narrowing. There was no significant difference in vascular complications in those with vessel narrowing and those without (p = 0.09). There were no observed neurologic complications in either group. CONCLUSIONS: Vessel narrowing is a very common finding in pediatric DNSI. Vascular complications are very rare, and importantly no patients had neurologic complications in either group (vessel narrowing or not). We found no evidence to support more aggressive surgical management, getting further imaging, starting anticoagulation, nor changing overall management strategy for patients based solely to the finding of vessel narrowing in DNSI.

Isolated parapharyngeal cold abscess in a 9-year-old boy.

Tuberculous adenitis presenting as an isolated cold abscess in the parapharyngeal space is very uncommon and has not been reported in the paediatric age group; presentation as a retropharyngeal abscess, however, is well known. Nine-year-old boy with a progressively increasing swelling on the right side of the neck for 2 months was referred with a clinical diagnosis of neuroblastoma. Surgical exploration of the parapharyngeal space by needle aspiration yielded a cheesy material and Mycobacterium tuberculosis was detected by DNA TB PCR. Tuberculosis should always be considered in the differential diagnosis of a cervical swelling in a child.