Descending necrotising mediastinitis: a rare entity in children.

We present a case of descending necrotising mediastinitis (DNM) originating from a retropharyngeal abscess in a healthy early childhood patient. The patient had a history of fever, odynophagia and refusal to eat, followed by rapid deterioration of the clinical state. Cervicothoracic CT was performed, which revealed a right parapharyngeal abscess, extending to the mediastinum and occupying the retropharyngeal/visceral space, with gaseous content throughout this collection, associated with bilateral pleural effusion, aspects compatible with DNM. She started broad-spectrum antibiotic therapy and transoral drainage of the parapharyngeal and retropharyngeal collections was performed under general anaesthesia. She was admitted to the intensive care unit. The patient showed clinical, analytical and imaging improvement, having been transferred to the ear, nose and throat department, with favourable evolution. Early diagnosis of DNM by cervicothoracic CT and multidisciplinary approaches, including intensive care, broad-spectrum antibiotics and surgical intervention, are crucial to minimise the morbidity and mortality.

Retropharyngeal abscess due to Fusobacterium necrophorum complicated by progressive internal carotid artery stenosis and multiple cranial nerve palsies.

BACKGROUND: A case of retropharyngeal abscess complicated by both artery and nerve injury has rarely been reported. METHODS: A 36-year-old woman suddenly presented with right eye visual loss, dilated pupil, reduced direct light reflex, ptosis and ocular motility disorder on the side of inflammation progression, and was diagnosed with retropharyngeal abscess due to Fusobacterium necrophorum. The patient was treated only with antibiotics and, no further surgery was necessary but tracheotomy. Four months later, MRA showed right ICA occlusion and left ICA stenosis. MRI revealed continuous spread of inflammation due to the abscess from the retropharyngeal to the intracranial space. RESULTS: These severe complications would be attributed to an endothelial damage to the arterial wall and an ischemic neuropathy caused by inflammation and thrombogenesis due to Fusobacterium necrophorum. CONCLUSIONS: This case should provide a better understanding of the mechanism of vascular and cranial nerve injury due to retropharyngeal infections, and highlights the need for early antibiotic therapy and repeated vascular evaluation.

Demographic disparities in children with retropharyngeal and parapharyngeal abscesses.

PURPOSE: To explore the impact that demographic and socioeconomic factors such as age, gender, race, and insurance status have on the diagnosis of retropharyngeal (RPA) and parapharyngeal abscesses (PPA) in the pediatric population. METHODS: The 2016 HCUP KID was searched for all RPA/PPA discharges using the joint ICD-10 code J39.0. Descriptive statistics, univariate, and multivariate analyses were performed to assess the relationship between demographic factors and their impact on RPA/PPA diagnosis. Results were reported with their corresponding odds ratio with a 95 % confidence interval and p-value. RESULTS: 56.4 per 100,000 weighted discharges were discharged with a diagnosis of a RPA/PPA, the average age was 5.7 years old, with a male predominance. Pediatric discharges diagnosed with a RPA/PPA were less likely to identify as Hispanic or Asian/Island Pacific. They were also less likely to be insured by Medicaid and reside in zip codes with a lower median income. CONCLUSION: The analysis of this national pediatric database demonstrated significant demographic differences in children diagnosed with RPA/PPAs. Following the multivariate analysis, children from a higher socioeconomic background and those with private insurance were more likely to be diagnosed with a RPA/PPAs. However, disparities in children's overall hospital course and complications is a potential area for future research.

Utility of a clinical risk scale to predict the requirement of advanced airway management in patients with a diagnosis of deep neck abscess.

OBJECTIVES: To analyze the clinical utility of a clinical risk scale to predict the need for advanced airway management in patients with deep neck abscess. METHODS: Observational, analytical, cross-sectional study. Patients over 18 years old, both genders, with surgical management of a deep neck abscess, between January 1st, 2015 to December 31th, 2021, who were applied the clinical risk scale (https://7-414-5-19.shinyapps.io/ClinicalRiskScore/). The sensitivity, specificity, and predictive values of the scale were calculated based on the identified clinical outcomes. A p<0.05 was considered significant. RESULTS: A sample of 213 patients was obtained, 121 (56.8%) men, of whom 50 (23.5%) required advanced airway management. Dyspnea was the variable with the most statistical weight in our study, (p=0.001) as well as the multiple spaces involvement, (p=0.001) the presence of air corpuscles, (p=0.001) compromise of the retropharyngeal space (p=0.001) and age greater than 55 years (p=0.001). Taking these data into account, were found for the clinical risk scale a sensitivity of 97% and a specificity of 65% (p=0.001, 95% CI 0.856-0.984). CONCLUSIONS: The clinical risk scale developed to predict advanced airway management in patients with a diagnosis of deep neck abscess may be applicable in our environment with high sensitivity and specificity. LEVEL OF EVIDENCE: IV.

Prognostic Factors for Retropharyngeal Abscess in Children Receiving Surgery or Antibiotic Therapy.

OBJECTIVE: Effective management of retropharyngeal abscess (RPA) may predicate upon identification of key patient characteristics. We analyzed characteristics and outcomes of pediatric patients with RPA to identify prognostic factors associated with successful surgical intervention. METHODS: A financial database was searched for pediatric otolaryngology patients with RPA from 2010 to 2021. Medical charts were reviewed for demographics, presenting history, physical examination, laboratory testing, imaging, surgical findings, and hospital course. Bivariate analyses were performed to identify potentially significant predictors of positive drainage. These variables were included in multivariate analysis of surgical outcomes. RESULTS: Of 245 total patients, 159 patients (65%) received surgery and 86 patients (35%) received antibiotics only. Patients with restricted cervical motion, neck swelling, and computed tomography (CT) cross-sectional area (CSA) >2 cm2 were more likely to receive surgery. Rim enhancement on CT imaging was associated with positive surgical drainage (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.16-5.74). However, no variables from clinical symptoms or physical exam were associated with positive drainage. Variables that approached significance were included in multivariate analysis, which revealed only rim enhancement predicted positive drainage (OR 2.57, 95% CI 1.13-5.83). The mean length of stay (LOS) was 2.6 versus 3.5 days (p < 0.001) for medical vs surgical treatment groups, respectively. CONCLUSION: Our study revealed a high success rate of medical management. Although patient characteristics and clinical features were not significant predictors of surgical outcomes, CT findings such as rim enhancement were strongly associated with positive surgical drainage. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:1955-1960, 2024.

Disparities in the Presentation and Management of Pediatric Retropharyngeal Abscess.

OBJECTIVES: Differences in management and outcomes of otolaryngologic diseases may reflect inequities driven by social determinants of health. This study aimed to investigate disparities in presentation and outcomes of retropharyngeal abscess (RPA) among 231 pediatric patients. METHODS: Medical records were searched for pediatric patients with RPA from 2010 to 2021. Charts were reviewed for demographics, clinical features, and treatment decisions. Area deprivation index (ADI) scores for patient zip codes were determined. Chi-square analysis independent samples t-test, and regression analyses were used to investigate associations between variables. RESULTS: Among patients presenting for RPA, Black patients were less likely to undergo surgical management than non-Black patients (53.2% vs. 71.6%, p = 0.009). Black patients had a lower rate of treatment with antibiotics prior to hospital admission (19.4% vs. 54.4%, p < 0.001). Among patients who received surgery, Black patients had higher cross-sectional abscess area on CT (6.4 ± 8.4 cm2 > vs. 3.8 ± 3.3 cm2 , p = 0.014), longer length of stay (5.4 ± 3.3 days vs. 3.2 ± 1.5, p < 0.001), and longer time between admission and surgery (2.3 ± 2.1 vs. 0.83 ± 1.1, p < 0.001). Increased ADI was correlated with increased rate of trismus. CONCLUSIONS: Lower rates of pre-admission antibiotics and larger abscess area on CT imaging among Black patients may suggest disparities in access to primary care, resulting in presentation to tertiary care at later stages of disease and higher rates of medical management trial prior to surgical intervention. LEVEL OF EVIDENCE: 3 (retrospective cohort study) Laryngoscope, 134:1907-1912, 2024.

The role of adjuvant systemic corticosteroid in pediatric retropharyngeal and parapharyngeal abscess.

OBJECTIVES: To evaluate the potential benefits of systemic corticosteroids as an adjuvant treatment for pediatric retropharyngeal abscess (RPA) and parapharyngeal abscess (PPA). METHODS: We retrospectively reviewed medical records of patients diagnosed with RPA and PPA who were admitted to Shenzhen Children's Hospital between January 2010 and January 2023. Data on demographic characteristics, clinical presentation, physical examination, laboratory data, use of corticosteroids, management, duration of hospital stay, need for surgical drainage, and complications were collected. Patients were divided into two groups: non-corticosteroid group (antibiotic only) and corticosteroid group (corticosteroid and antibiotic). RESULTS: A total of 111 patients were enrolled. There were 51 cases in non-corticosteroid group and 60 cases in corticosteroid group (10 cases received methylprednisolone and 50 cases received dexamethasone). There was no significant difference in sex, age, location of abscess, size of abscess and laboratory parameters at admission and discharge between the two groups. The surgical drainage rate was significantly lower in the corticosteroid group than in the non-corticosteroid group (p = 0.008). The hospital duration was also shorter in the corticosteroid group than in the non-corticosteroid group (p = 0.026). The hospitalization cost was significantly lower in the corticosteroid group than in the non-corticosteroid group (p = 0.000). CONCLUSION: The use of systemic corticosteroids along with antibiotics in children with RPA and PPA may reduce the need for surgical drainage, shorten hospital duration, and decrease hospitalization cost. Further studies are needed to confirm these findings and determine the optimal timing, duration, and route of administration of corticosteroids.

Descending necrotizing mediastinitis secondary to retropharyngeal abscess.

We report a case of descending necrotizing mediastinitis (DNM) in a 68-year-old male who presented in acute respiratory distress accompanied with anterior cervical neck swelling and pain with swallowing. Contrast enhanced computed tomography (CECT) of the neck demonstrated a large, peripherally enhancing retropharyngeal fluid and air collection that appeared to communicate with a fluid and air collection within the mediastinum. CECT of the chest demonstrated punctate foci of air and fat stranding along the anterior and superior mediastinum. Radiological evidence and the presence of necrosis on surgical debridement of the retropharyngeal abscess established the diagnosis of DNM. This case emphasizes the role of computed tomography (CT) in the diagnosis of DNM and demonstrates the utility of chest imaging in a high-risk patient who presents with a retropharyngeal abscess.

Emerging findings for the assessment and treatment of pediatric deep neck abscesses.

PURPOSE OF REVIEW: The purpose of this review is to summarize new literature regarding the description, diagnosis, and treatment of pediatric deep neck abscesses. RECENT FINDINGS: Providers should include multi-inflammatory syndrome in children (MIS-C) in a differential diagnosis in children suspected of having a retropharyngeal abscess. MRI may guide the proper management of children with deep neck abscesses by more accurately detecting free fluid compared to computed tomography imaging. Factors that may predict the need for surgical management include elevations in white blood cell counts and abscess size more than 3 cm. However, future investigation is necessary to establish consistent guidelines. Medical management is effective in many children, with a new study indicating success using a combination of cefotaxime and rifampicin. SUMMARY: Anatomical and age-related risk factors predispose children to the development of deep neck abscesses. Findings from recent studies may aid providers in making an accurate diagnosis and providing proper medical or surgical management of children with these infections.

Life-threatening complication of retropharyngeal abscess in an infant: a case report.

BACKGROUND: Deep neck space infections are uncommon in infants. Retropharyngeal abscess (RPA) is a deep space neck infection that can present with subtle signs and symptoms. Delay in diagnosis can lead to life-threatening complications. Here we describe life-threatening complication of retropharyngeal abscess. CASE PRESENTATION: We report a life-threatening complication of retropharyngeal abscess in 10-month old Asian infant weighing 8.2 kg. The patient presented with fever, right-sided neck swelling, hoarseness of voice, and respiratory distress. The clinical and radiological findings were suggestive of airway obstruction complicated by retropharyngeal abscess. The patient was urgently taken to the operating room and underwent (grade 3) intubation. After stabilization, the patient underwent endoscopic trans-oral incision and drainage, during which 5 cc pus was aspirated. Antibiotics were prescribed for 2 weeks following the procedure based on the sensitivity result of the pus culture. CONCLUSION: In retropharyngeal abscess, a delay in diagnosis can result in life-threatening complications. This report highlights the importance of prompt recognition of a threatened airway and the management of retropharyngeal abscess by emergency physicians. If an emergency physician suspects RPA with airway obstructions, the airway should be immediately secured in a secure environment by otolaryngologist and an anesthesiologist.

Retropharyngeal Abscess With Mediastinal Extension: A Case Series and Review of the Literature.

Deep neck infections are common in infants and occur in several anatomic subsites including the retropharyngeal space. Retropharyngeal abscesses are significant given their propensity for mediastinal extension and can have life-threatening sequelae. We present 3 cases of retropharyngeal abscess with mediastinal extension in infants. In one case, an incompletely vaccinated 10-month-old boy presented with cough, rhinorrhea, and fever. Despite antibiotic treatment, he developed Horner's syndrome and hypoxia. A computed tomography (CT) scan showed a C1-T7 retropharyngeal abscess. He underwent transoral incision and drainage and recovered fully. In another case, a 12-month old infant presented with 8 days of fever and neck pain. A CT scan showed a retropharyngeal collection extending to the mediastinum and right hemithorax. Transoral incision and drainage and video-assisted thoracoscopic surgery thoracotomy were performed for abscess drainage. He recovered fully with antibiotics. In the third case, an 8-month-old boy presented to the emergency room following several days of fever, lethargy, and decreased neck range of motion. A CT scan showed a large retropharyngeal abscess that required both transoral and transcervical drainage. His case was complicated by septic shock, yet the patient eventually made a full recovery.

Rare and unexpected cause for retropharyngeal abscess in an immunocompetent man: metastatic community-acquired methicillin-resistant Staphylococcus aureus infection.

Staphylococcus aureus causes clinical diseases ranging from mild skin infections to devastating conditions such as septic shock, endocarditis and osteomyelitis. S. aureus is a common cause of community-acquired bacteraemia. Prolonged bacteraemia may cause metastatic infection, manifesting as endocarditis, osteomyelitis and abscesses. A man in his 20s presented with a short-duration of fever and odynophagia. CT of the neck suggested a retropharyngeal abscess. Retropharyngeal abscesses are typically polymicrobial and caused by resident oral cavity flora. In the hospital, he developed shortness of breath and hypoxia. CT of the chest showed peripheral, subpleural nodular opacities raising suspicion for septic pulmonary emboli. Blood cultures demonstrated the growth of methicillin-resistant S. aureus The patient completely recovered with antibiotic therapy alone. This is a unique and rare presentation case of metastatic S. aureus bacteraemia, manifesting as a retropharyngeal abscess without any evidence of infective endocarditis on transoesophageal echocardiography.

Retropharyngeal abscess-like as an atypical presentation of Kawasaki disease: a case report and literature review.

BACKGROUND: Kawasaki disease (KD) is a systemic inflammatory condition primarily affecting young children. Although 90% of KD patients present with variable head and neck manifestations, especially cervical lymphadenopathy, peritonsillar, retropharyngeal and parapharyngeal involvement are uncommonly reported as initial manifestations of KD. CASE REPORT: Eight-year-old girl with prolonged fever, clinical and a radiological picture suggestive of retropharyngeal abscess, unresponsive to three changes in the antibiotic regimen and surgical drainage. The disease progressed with the development of additional signs and symptoms as non-purulent conjunctivitis (with uveitis), mucosal involvement (strawberry tongue and cracked lips), edema of her hands and feet, and arthritis. A diagnosis of Kawasaki disease was reached with complete remission after Intravenous Immunoglobulin (IVIG) treatment. In addition, we present a literature review of similar cases reported in the last thirty years. CONCLUSION: Kawasaki disease requires a high index of suspicion and awareness of unusual presentations. It should be kept in mind as one of the differential diagnosis of patients with febrile inflammation of the retropharyngeal and parapharyngeal spaces who do not respond to antibiotic treatment in the relevant clinical context.

Veillonella atypica causing retropharyngeal abscess: A rare case presentation.

Veillonella species are obligate anaerobes which are part of the human oral, gut and vaginal microbiota. The genus Veillonella consists of 16 characterized species. Very few infections due to Veillonella atypica have been reported till date. Here we present a case of retropharyngeal abscess due to this organism in a 55-year-old lady.

Treatments and outcomes of adult parapharyngeal and retropharyngeal abscess: 1882 cases from a Japanese nationwide database.

PURPOSE: Although parapharyngeal and retropharyngeal abscesses are potentially fatal deep neck abscesses, there is limited evidence for the treatment courses for adult patients with these abscesses. We aimed to describe the practice patterns and clinical outcomes of adult patients undergoing an emergency surgery for parapharyngeal or retropharyngeal abscesses using a nationwide database. MATERIALS AND METHODS: We identified patients aged ≥18 years who underwent emergency surgery for parapharyngeal (para group, n = 1148) or retropharyngeal (retro group, n = 734) abscesses from July 2010 to March 2020, using a nationwide inpatient database. We performed between-group comparisons of the baseline characteristics, treatment course, and outcomes. RESULTS: Compared with the retro group, the para group was more likely to be older (median, 66 vs. 60 years; P < 0.001) and have several comorbidities, such as diabetes (21 % vs 16 %; P = 0.010) and epiglottitis (33 % vs. 26 %; P = 0.002), except for peritonsillar abscess (14 % vs. 22 %; P < 0.001) and tonsillitis (2.1 % vs. 13 %; P < 0.001). Regarding intravenous drugs administered within 2 days of admission, approximately half of the patients received steroids, non-antipseudomonal penicillins, and lincomycins. The para group received more comprehensive treatments, such as tracheostomy, intensive care unit admissions, and swallowing rehabilitation, within total hospitalization than the retro group. Moreover, it demonstrated higher in-hospital mortality (2.7 % vs. 1.1 %; P = 0.017) and morbidity (16 % vs. 9.7 %; P < 0.001), and longer length of hospitalization than the retro group. CONCLUSION: The current nationwide study provided an overview of the characteristics, treatments, and outcomes for patients who underwent an emergency surgery for parapharyngeal or retropharyngeal abscess.

Bilateral Longus Colli Abscesses as a Complication of Advanced Bacterial Rhinosinusitis.

Known complications of acute bacterial rhinosinusitis include retropharyngeal abscess, cavernous sinus thrombosis, intracranial abscess, and associated sequelae. We describe the case of a patient with longus colli abscess formation resulting from acute pansinusitis, complicated by bilateral cavernous sinus thrombosis in the setting of concurrent viral pneumonitis, severe sepsis, and a large area cerebral infarction. The bilateral longus colli abscesses were drained via stereotactic image-guided endonasal sinus surgery, yielding Staphylococcus hominis in culture. The described disease progressed rapidly over a 2-week course amid the COVID-19 pandemic.