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.

Changes in Otorhinolaryngologic Disease Incidences before and during the COVID-19 Pandemic in Korea.

This study aimed to investigate the change in the incidence and variance of otorhinolaryngologic diseases during the coronavirus disease 19 (COVID-19) pandemic. The entire Korean population (~50 million) was evaluated for the monthly incidence of 11 common otorhinolaryngologic diseases of upper respiratory infection (URI), influenza, acute tonsillitis, peritonsillar abscess, retropharyngeal and parapharyngeal abscess, acute laryngitis and bronchitis, stomatitis and related lesions, acute sinusitis, rhinitis, otitis media, and dizziness from January 2018 through March 2021 using the International Classification of Disease (ICD)-10 codes with the data of the Korea National Health Insurance Service. The differences in the mean incidence of 11 common otorhinolaryngologic diseases before and during COVID-19 were compared using the Mann-Whitney U test. The differences in the variance of incidence before and during COVID-19 were compared using Levene's test. The incidence of all 11 otorhinolaryngologic diseases was lower during COVID-19 than before COVID-19 (all p < 0.05). The variations in disease incidence by season were lower during COVID-19 than before COVID-19 for infectious diseases, including URI, influenza, acute tonsillitis, peritonsillar abscess, retropharyngeal and parapharyngeal abscess, acute laryngitis and bronchitis, acute sinusitis, and otitis media (all p < 0.05), while it was not in noninfectious diseases, including stomatitis, rhinitis, and dizziness. As expected, the incidences of all otorhinolalryngolgic diseases were decreased. Additionally, we found that seasonal variations in infectious diseases disappeared during the COVID-19 pandemic, while noninfectious diseases did not.

[Features of the clinic, diagnosis and treatment of parapharyngeal abscesses in children: analysis of 121 observations]. / Osobennosti kliniki, diagnostiki i lecheniya parafaringeal'nykh abstsessov u detei: analiz 121 nablyudeniya.

Parapharyngeal and retropharyngeal abscesses (PPA) in children are a rare pathology, for the diagnosis of which it is necessary to use additional instrumental examination methods. The tactics of treating patients remains a subject of discussion. OBJECTIVE: To analyze the features of the clinic, diagnosis and treatment of PPA in children. MATERIAL AND METHODS: According to the hospital database, a retrospective analysis of the medical histories of children discharged from the clinic with a diagnosis of "J39.0 Retropharyngeal and parapharyngeal abscess" was carried out in the period from 01.01.14 to 31.12.19. In all cases, the diagnosis was confirmed by computed tomography (CT) data with contrast enhancement. Complaints at the time of treatment, anamnesis and instrumental diagnosis data, clinical features of the course of the disease and the effectiveness of treatment were analyzed. RESULTS: 121 children were treated for PPA (average age 73±41 months; Me=52.5 months), which is 0.4% of all hospitalized in the otorhinolaryngological department, 0.7% of the number of emergency hospitalizations, 0.8% of the number of hospitalized children with pharyngeal diseases, and 8.3% of the number of patients with pharyngeal abscess. Abscesses were more often localized in the upper pharynx, at the level of the I-II cervical vertebrae (49.6% of all observations); abscesses were found least often in the pharyngeal space (5.8%), there was no statistically significant difference between the right-sided and left-sided location: 47.9% and 46.2%, respectively. Surgical treatment was performed in 98 (81%) patients in the presence of an abscess capsule or an abscess diameter of more than 2 cm according to CT; the remaining 23 (19%) children were treated conservatively. The opening of the abscess was performed endopharyngeal, in the case of a pronounced deep lateral location of the abscess and its proximity to large blood vessels - with access through the tonsillar niche after preliminary tonsillectomy (19.4% of those operated). CONCLUSION: The final diagnosis of parapharyngeal and retropharyngeal abscess can be established by contrast-enhanced computed tomography. Conservative treatment is indicated for a limited group of patients at the initial stages of the disease, most patients need surgical treatment.

Features associated with surgically significant abscesses on computed tomography evaluation of the neck in pediatric patients.

BACKGROUND: Neck-related chief complaints are common in the pediatric Emergency Department (ED), and although the incidence of pathology such as retropharyngeal abscesses is rare, the ability to rule out abscesses requiring surgical/procedural intervention is essential. However, there are no clear clinical guidelines regarding work-up and diagnosis in this population, possibly contributing to an excess use of potentially harmful and costly computed tomography (CT) imaging. OBJECTIVE: In this study we sought to identify historical, physical exam, and laboratory findings associated with surgically significant neck abscesses to better delineate CT neck imaging criteria. METHODS: We conducted a retrospective chart review of all patients ≤18 years presenting to a pediatric ED between 2013 and 2017 who underwent CT neck imaging. Surgically significant abscesses (SSAs) were defined as abscesses ≥2 cm, retropharyngeal abscesses (RPA), parapharyngeal abscesses (PPA), or peritonsillar abscesses (PTA). Historical factors, physical exam findings, laboratory results, demographics, and CT results were analyzed using univariate statistical analysis and regression models. RESULTS: A total of 718 patients received neck CTs and 153 SSAs were identified. In children younger than 6 years, factors associated with statistically significant increased odds of an SSA were reported throat pain (OR 1.18; 95% CI 1.05, 1.33), fussiness (OR 1.18; 1.01, 1.39), lethargy (OR 1.43; 1.07, 1.91), tonsillar enlargement (OR 1.17; 1.02, 1.34), C-reactive protein (CRP) > 10 (OR 1.22; 1.07, 1.40), and an ED visit within the preceding week (OR 1.18; 1.04, 1.33). In children older than 6 years, the factors associated with statistically significant increased odds of an SSA included current antibiotic use (OR 1.12; 1.02, 1.22) and a CRP >10 (OR 1.14; 1.03, 1.26). CONCLUSION: Some historical, physical exam, and laboratory findings are associated with SSAs, and while not definitive in isolation, may be beneficial additions to routine SSA assessment, as a supplement to clinical judgement regarding CT and observation decisions. This may potentially allow for the identification of patients requiring CT versus those who may not, and thus the opportunity to safely reduce the use of CT imaging in select patients.

Absceso retrofaríngeo. Revisión clínica de veinticinco años / Retropharyngeal Abscess. Clinical Review of Twenty-five Years

INTRODUCCIÓN: Los abscesos retrofaríngeos constituyen una entidad grave. Debido a su escasa frecuencia y a compartir sintomatología con otros procesos, constituyen un reto diagnóstico para el clínico, siendo esencial realizar un diagnóstico temprano para no demorar el tratamiento y evitar así complicaciones. OBJETIVOS: Conocer la epidemiología, etiopatogenia, manifestaciones clínicas, microorganismos más frecuentemente implicados, tipo de tratamiento realizado y morbimortalidad de los abscesos retrofaríngeos en un hospital terciario en 25 años. MATERIAL Y MÉTODOS: Se realizó un estudio retrospectivo descriptivo mediante la revisión de historias clínicas de todos los pacientes diagnosticados con absceso retrofaríngeo en un centro entre el 1 de enero de 1990 hasta el 31 de febrero de 2016. Treinta y tres pacientes diagnosticados con absceso retrofaríngeo durante dicho periodo fueron incluidos en nuestro estudio. De la historia clínica se recogieron diferentes variables que fueron agrupadas en las siguientes categorías: antecedentes personales, enfermedad actual, procedimientos diagnósticos realizados y tratamiento. RESULTADOS: La incidencia durante los años de estudio fue de 0,2 casos/100.000 habitantes/año. Los factores de riesgo más frecuentemente asociados fueron la diabetes de tipo II y la obesidad, siendo la impactación de un cuerpo extraño la etiología más frecuentemente encontrada (sobre todo, espina de pescado). Los síntomas/signos más frecuentes de presentación fueron la odinofagia y fiebre. La traqueotomía preventiva en el manejo inicial del paciente se realizó en nueve pacientes (27%). La complicación más frecuente fue la mediastinitis necrosante descendente. Se precisó un drenaje quirúrgico del absceso en 27 pacientes (82%), sobre todo con abordajes por vía externa (17 casos). Dos pacientes presentaron secuelas relacionadas con el tratamiento quirúrgico: una parálisis de cuerda vocal unilateral y un síndrome de Horner. No se objetivó mortalidad en los pacientes del estudio. CONCLUSIONES: Los abscesos retrofaríngeos deben ser considerados urgencias médico-quirúrgicas, ya que son susceptibles de producir complicaciones graves. Debemos prestar atención a los síntomas de alarma como son la odinofagia y el dolor cervical, asociado o no, disnea, estridor, trismus, rigidez cervical y síndrome febril. Los avances en procedimientos diagnósticos, terapéuticos y en los cuidados del paciente crítico han sido decisivos en la mejora del pronóstico y mortalidad de estos pacientes

INTRODUCTION: Retropharyngeal abscess is a serious condition. Its rare occurrence, thus sharing symptoms with other processes, make it a diagnostic challenge for the clinician. Therefore, it is critical to make an early diagnosis to prevent delaying treatment and avoid complications. OBJECTIVES: To gain knowledge of the epidemiology, pathogenesis, clinical manifestations, the most commonly implicated microorganisms, the type of treatment used, morbidity and mortality of retropharyngeal abscesses at a tertiary institution over the last 25 years. METHODS: A retrospective study was conducted by reviewing medical records of all patients diagnosed with retropharyngeal abscess in a single centre between 1 January 1990 and 31 February 2016. Thirty-three patients were included in our study. Data such as personal history, present illness, diagnoses and treatment procedures were collected from the medical records. RESULTS: The incidence during the years of study was 0.2 cases/100 000 inhabitants/year. Personal medical histories most often associated were alcoholism, smoking, diabetes and obesity. The most common aetiology found was impaction of a foreign body (especially fishbone). The most common presenting symptoms were odynophagia and neck pain accompanied by fever. Preventive tracheotomy was performed in the initial management of the patient in 9 cases (27%). The most frequent complication was descending necrotizing mediastinitis. Surgical drainage of the abscess was required in 27 patients (82%), especially with external approaches (17 cases). Two patients had sequelae: paralysis of unilateral vocal cord and Horner's syndrome. No mortality was observed in the patients of the study. CONCLUSION: Retropharyngeal abscesses must be considered medical-surgical emergencies as they are likely to produce serious complications. We must pay attention to the warning symptoms such as odynophagia and cervical pain, associated or otherwise with dyspnoea, stridor, trismus, and neck stiffness. Advances in diagnostic and therapeutic procedures together with advances in critical care have been a key factor in improving the prognosis and mortality of these patients

Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management.

INTRODUCTION: Tonsillectomy is a common surgical procedure performed chiefly for recurrent tonsillitis. The Scottish Intercollegiate Guidance Network (SIGN) introduced guidelines in 1998 to improve patient selection for tonsillectomy and reduce the potential harm to patients from surgical complications such as haemorrhage. Since the introduction of the guidance, the number of admissions for tonsillitis and its complications has increased. National Hospital Episode Statistics over a 20-year period were analysed to assess the trends in tonsillectomy, post-tonsillectomy haemorrhage, tonsillitis and its complications with reference to the guidance, procedures of limited clinical value and the associated costs and benefits. MATERIALS AND METHODS: A literature search was conducted via PubMed and the Cochrane Library to identify relevant research. Hospital Episode Statistics data were interrogated and relevant data compared over time to assess trends related to the implementation of national guidance. RESULTS: Over the period analysed, the incidence of deep neck space infections has increased almost five-fold, mediastinitis ten-fold and peritonsillar abscess by 1.7-fold compared with prior to SIGN guidance. Following procedures of limited clinical value implementation, the incidence of deep neck space infections has increased 2.4-fold, mediastinitis 4.1-fold and peritonsillar abscess 1.4-fold compared with immediately prior to clinical commissioning group rationing. The rate of tonsillectomy and associated haemorrhage (1-2%) has remained relatively constant at 46,299 (1999) compared with 49,447 (2009) and 49,141 (2016), despite an increase in the population of England by seven million over the 20-year period. DISCUSSION: The rise in admissions for tonsillitis and its complications appears to correspond closely to the date of SIGN guidance and clinical commissioning group rationing of tonsillectomy and is on the background of a rise in the population of the UK. The move towards daycase tonsillectomy has reduced bed occupancy after surgery but this has been counteracted by an increase in admissions for tonsillitis and deep neck space infections, sometimes requiring lengthy intensive care stays and a protracted course of rehabilitation. The total cost of treating the complications of tonsillitis in England in 2017 is estimated to be around £73 million. The cost of tonsillectomy and treating post-tonsillectomy haemorrhage is £56 million by comparison. The total cost per annum for tonsillectomy prior to the introduction of SIGN guidance was estimated at £71 million with tonsillitis and its complications accounting for a further £8 million.

Variation in the Management of Children With Deep Neck Infections.

BACKGROUND AND OBJECTIVES: Children with deep neck infections (DNIs) are increasingly being managed nonsurgically with intravenous antibiotics. Our objective was to examine variation in the management of children with DNIs across US children's hospitals. METHODS: We conducted a retrospective cohort study using the Pediatric Health Information System database. Children ≤12 years of age hospitalized for retropharyngeal or parapharyngeal abscesses from 2010 to 2018 were included. Hospital variation in management modality and imaging use was described. Temporal trends in management modality were assessed by using logistic regression. Medical management alone versus a combination of medical and surgical management was assessed, and the characteristics of children in these 2 groups were compared. The relationship between hospital rates of initial medical management and failed medical management was assessed by using linear regression. RESULTS: Hospitals varied widely in their rates of surgical management from 17% to 70%. The overall rate of surgical management decreased from 42.0% to 33.5% over the study period. Children managed surgically had higher rates of ICU admission (11.5% vs 3.2%; P < .001) and higher hospital charges ($25 241 vs $15 088; P < .001) compared with those managed medically alone. Seventy-three percent of children underwent initial medical management, of whom 17.9% went on to undergo surgery. Hospitals with higher rates of initial medical management had lower rates of failed medical management (ß = -.43). CONCLUSIONS: Although rates of surgical management of pediatric DNI are decreasing over time, there remains considerable variation in management across US children's hospitals. Children managed surgically have higher rates of resource use and costs.

A Nationwide Population-Based Study on the Incidence of Parapharyngeal and Retropharyngeal Abscess-A 10-Year Study.

This study aimed to investigate the annual incidence of parapharyngeal and retropharyngeal abscess (PRPA) based on 10-year population-based data. Patients with PRPA were identified from the Taiwan Health Insurance Research Database, a database of all medical claims of a randomly selected, population-representative sample of over two million enrollees of the National Health Insurance system that covers over 99% of Taiwan's citizens. During 2007-2016, 5779 patients received a diagnosis of PRPA. We calculated the population-wide incidence rates of PRPA by sex and age group (20-44, 45-64, and >64) as well as in-hospital mortality. The annual incidence rate of PRPA was 2.64 per 100,000 people. The gender-specific incidence rates per 100,000 people were 3.34 for males and 1.94 for females with a male:female gender ratio of 1.72. A slight increase in incidence rates among both genders over the study period was noted. Age-specific rates were lowest in the 20-44 age group with a mean annual incidence of 2.00 per 100,000 people, and the highest rates were noted in the age groups of 45-64 and >64 years with mean annual incidences of 3.21 and 3.20, respectively. We found that PRPA is common in Taiwan, males and older individuals are more susceptible to it, and incidence has increased in recent years.

Deep Neck Abscesses in Children: An Italian Retrospective Study.

BACKGROUND: Retropharyngeal and parapharyngeal abscesses (RPAs, PPAs) usually affect young children. Surgical drainage and/or antibiotic therapy are treatment of choice, but no specific guidelines exist. In order to reduce the risk of severe complications, appropriate diagnosis and therapy are necessary. The aims of the study were to review diagnosis and management of children with RPAs/PPAs and to compare surgical versus medical approach. METHODS: This is a multicenter retrospective study including all patients younger than 15 years admitted at 4 Italian pediatric hospitals of Florence, Padua, Rome, and Treviso, with International Classification of Diseases, Ninth Revision discharge diagnosis code of RPAs and PPAs, from January 1, 2008, to December 31, 2016. RESULTS: One hundred fifty-three children were included. The median age was 4.4 years, with overall male predominance. Heterogeneous signs and symptoms (fever, neck cervical, lymphadenopathy, pain, and stiff neck most frequently) and a large mixture of bacteria from pus cultures were detected. Computer tomography (66.7%) and magnetic resonance imaging (27.5%) were performed to confirm the presence of abscess. Fifty-one percent of abscesses were greater than 3 cm. Eighty-seven patients (56.9%) underwent surgery, and 66 (43.1%) were treated with antibiotics alone (mostly ceftriaxone, metronidazole, amikacin, and clindamycin) with median days of therapy of 26.5 days and length of therapy of 16.0 days of median. Median length of stay was 11 days. None had severe complications. Multivariate analysis indicated as independent predictive factors of surgery abscess of 3 cm or greater, high white blood cell count, and-most of all-the hospital of admission. CONCLUSIONS: Deep neck abscesses mostly affect patients in early childhood, with a combination of nonspecific signs and symptoms, and it still emerges as a heterogeneous approach in diagnosis and management of these infections. Thus, common shared protocols represent an essential tool in order to standardize care and improve patients' outcomes.

Deep Neck Space Involvement of Kawasaki Disease in the US: A Population-Based Study.

OBJECTIVES: To describe the rate and risk factors of deep neck space involvement of Kawasaki disease. STUDY DESIGN: We performed a retrospective analysis using the Kids' Inpatient Database from 2006, 2009, 2012, and 2016. Kawasaki disease and deep neck space involvement cases were identified using International Classification of Diseases codes among children aged <12 years. Demographic and outcome data of Kawasaki disease cases with and without deep neck space involvement were compared. RESULTS: Of 20 787 patients with Kawasaki disease, 0.6% (130 cases) had deep neck space involvement. On multivariable analysis, children aged ≥4 years (OR 8.41; 95% CI 3.79-18.7 in those aged 6-11 years), Asian or Pacific Islanders (OR 3.72; 95% CI 1.90-7.27), non-Hispanic black children (OR 2.39; 95% CI 1.34-4.28), and Northeast hospital region (OR 2.32; 95% CI 1.21-4.46) were associated with deep neck space involvement. Surgical drainage was performed in 21.7% of patients with deep neck space involvement. Deep neck space involvement was associated with longer hospital stay and greater costs. CONCLUSIONS: Approximately 0.6% of patients with Kawasaki disease present with deep neck space involvement in the US. Deep neck space involvement of Kawasaki disease occurs primarily in older (≥4 years old), non-white, non-Hispanic children. Deep neck space involvement is associated with operative procedures for presumed abscess, longer hospital stay, and greater costs. In caring for children with suspected deep neck space abscess, particularly when they are not responding to antibiotics, clinicians should evaluate them for the possibility of Kawasaki disease.

Tonsillectomy increases the risk of retropharyngeal and parapharyngeal abscesses in adults, but not in children: A national cohort study.

OBJECTIVES: The purpose of this study is to evaluate the risk of retropharyngeal and parapharyngeal abscesses (deep neck infection) after tonsillectomy in Koreans using national cohort data. METHODS: Using the national cohort study from the Korean Health Insurance Review and Assessment Service, participants who had undergone a tonsillectomy (5,299) and control participants (21,196) were selected and matched 1:4 (for age, sex, income, region of residence, and pre-operative upper respiratory infection visits). The Cox-proportional hazard model was used. A crude model and an adjusted model for age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia were used in this analysis. For the subgroup analyses, the participants were divided into 2 groups: children (≤ 14 years old) and adolescents and adults (≥ 15 years old). RESULTS: The adjusted hazard ratio of deep neck infection after tonsillectomy was 1.43 (95% confidence interval, CI = 1.18-1.72, P < 0.001). In subgroup analysis, this ratio was 1.12 (95% CI = 0.86-1.47, P = 0.390) in children and 1.87 (95% CI = 1.43-2.45, P < 0.001) in adolescents and adults. The crude hazard ratios were almost the same as the adjusted ratios. CONCLUSION: The risk of deep neck infection was higher in the tonsillectomy group. The subgroup analysis showed a similar finding in the adolescent and adult group but not in the child group.

Deep neck infections: review of 263 cases.

OBJECTIVES: In patients hospitalized due to deep neck infections (DNIs), to investigate the association between demographic parameters, etiology, and localization of abscesses and/or phlegmons, complications, comorbidities, treatment, and bacterial cultures. METHODS: We analyzed data of 263 patients that were hospitalized from January 1, 2012, to December 31, 2015, due to deep neck space phlegmons and/or abscesses. We performed statistical analysis with the SPSS 22.0 software; statistical significance was set p<0.05. RESULTS: Among the analyzed patients, dental infections were the most frequent, followed by acute phlegmonous pharyngitis. Submandibular space abscesses or phlegmons of the neck were the most frequent complications of these infections. Re-operation was performed in 19.8% of cases, and complications developed in 11% (mostly airway obstruction). DNI complications were less common in smokers than in non-smokers (OR=0.038, p=0.025). DISCUSSION: In our study, dental infections accounted for 70.6% of DNI cases. Thus, our study explains why odontogenic DNIs are the most common DNI type studied in the literature. Poor oral health and odontogenic infections should not be underestimated because they can lead to uncommon but lethal diseases such as descending necrotizing mediastinitis, which requires aggressive surgical treatment and is associated with a mortality rate of 10%-40% despite treatment. The complication developed in 11.4% of cases. In conclusion, oral health and hygiene contribute to DNI development.

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.

Serious tonsil infections versus tonsillectomy rates in Wales: A 15-year analysis.

INTRODUCTION Sore throat and tonsillitis place a significant burden on the National Health Service. National guideline criteria for gauging the severity of sore throat and tonsillitis have reduced the number of tonsillectomies performed, which is thought to have increased the rate of tonsil-related infections. METHODS Data was extracted from the prospective Patient Episode Database of Wales and analysed to determine the annual number of tonsillectomies for recurrent tonsillitis, adjusted for population changes. Admissions to acute hospitals for tonsillitis, peritonsillar abscess and deep neck space abscesses were also examined. RESULTS Between 1999 and 2014, hospital admissions for tonsillitis rose three-fold (r=0.968), while admissions for peritonsillar abscess rose by 48% (r=0.857) and retro or parapharyngeal abscess admissions also increased (r=0.709). In contrast, the number of tonsillectomies per 100,000 population gradually decreased (r=-0.16). There was a positive correlation between the incidence of tonsillitis and admissions for peritonsillar abscess (adjusted r2 0.631; p=0.015) and retropharyngeal abscess (adjusted r2 0.442; p=0.00254). There was a statistically significant negative correlation between the incidence of tonsillitis and the number of tonsillectomies performed (adjusted r2=-0.07; p=0.0235). CONCLUSIONS The significant rise in tonsillitis in Wales raises the question as to whether we should revisit the criteria for tonsillectomy. The perceived cost saving from limiting certain procedures should not prevent healthcare policymakers from considering all other evidence. The rise in peritonsillar, retropharyngeal and parapharyngeal abscess is alarming, as they are associated with significant morbidity and mortality.

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.

Retropharyngeal and Parapharyngeal Abscesses Among Children and Adolescents in the United States: Epidemiology and Management Trends, 2003-2012.

INTRODUCTION: The epidemiology and hospital course of children with retropharyngeal abscess (RPA) or parapharyngeal abscess (PPA) have not been fully described at the national level in the United States. METHODS: Pediatric discharges for PPA and RPA were evaluated by using the Kids' Inpatient Database from 2003, 2006, 2009, and 2012. Cases were identified by using International Classification of Disease, Ninth Revision, Clinical Modification codes 478.22 and 478.24 for PPA and RPA, respectively. Nationally representative incidence data were calculated by using weighted case estimates and US census data. Demographic and cost analyses were conducted by using unweighted analyses. RESULTS: There were 2685 hospital discharges for PPA and 6233 hospital discharges for RPA during the 4 study years combined. The incidence of RPA increased from 2.98 per 100 000 population among children <20 years old in 2003 to 4.10 per 100 000 in 2012. The incidence of PPA peaked at 1.49 per 100 000 in 2006. Incidences were highest among children <5 years old and boys in all age groups for PPA and RPA. Winter-to-spring seasonality also was evident for both. PPA was managed surgically in 58.1% of the cases, and RPA was managed surgically in 46.7%. Surgery was performed most often on the day of admission or the following day, was more frequent at teaching hospitals, and was associated with higher hospital charges. The mean hospital length of stay was longer for children who had surgery versus those who did not (4.4 vs 3.1 days [for PPA] and 4.8 vs 3.2 days [for RPA], respectively; both P < .001). The median charges for RPA and PPA were similar. The proportions of children with RPA or PPA covered by Medicaid increased during the study period. CONCLUSION: PPA and RPA represent relatively common male-predominant childhood infections with similar epidemiologies. The incidence of hospital discharges with a diagnosis of RPA increased during the study period. Substantial proportions of children with PPA or RPA are now managed without surgery. Surgical drainage was associated with higher hospital charges and longer lengths of stay.

Hospital discharge survey on 4,199 peritonsillar abscesses in the Veneto region: what is the risk of recurrence and complications without tonsillectomy?

The Veneto region's database of hospital discharge records was queried for ICD-9 codes corresponding to: peritonsillar abscess (PTA), PTA incision and drainage, tonsillectomy, pharyngeal-retropharyngeal abscess, cervical phlegmon, cervical abscess, and mediastinitis recorded from 1997 to 2006. All these codes were considered to identify cases of PTA recurrence and severe infectious complications occurring in conservatively treated patients. Among 4,199 patients whose PTA was incised and drained on admission to hospital, 1,532 were treated with tonsillectomy, while 2,667 were treated conservatively (without tonsillectomy). Abscess tonsillectomy was carried out almost exclusively in children (0-14 years of age), and only in 40 young and adult patients (0.95 %). The relapse rate after a single episode of PTA was 11.7 %, while potentially fatal complication occurred in 0.41 % of cases. Incidence of PTA hospital admission has remained stable in the considered period despite a 45 % reduction in the tonsillectomy rate. In conclusion, our data seem to show that conservative treatment for PTA is not associated with a significant risk of recurrence (and becomes minimal after 6-12 months), provided that patients have not suffered from previous PTA episodes.

The Public Health Impact of Pediatric Deep Neck Space Infections.

OBJECTIVE: There is little consensus about the best management of pediatric deep neck space infections (DNSIs) and limited information about the national disease burden. The purpose of this study is to examine the health care burden, management, and complications of DNSIs from a national perspective. STUDY DESIGN: Retrospective administrative data set review. SETTING: National pediatric admission database. SUBJECTS AND METHODS: Pediatric patients diagnosed with a parapharyngeal space and/or retropharyngeal abscess were identified from the 2009 KIDS' Inpatient Database. Patient demographic, hospital, and clinical characteristics were compared between patients who received surgical and nonsurgical management. All results for the analyses were weighted, clustered, and stratified appropriately according to the sampling design of the KIDS' Inpatient Database. RESULTS: The prevalence of DNSIs was 3444 in 2009, and the estimated incidence was 4.6 per 100,000 children. The total hospital charges were >$75 million. The patients who were drained surgically had a 22% longer length of stay (mean = 4.19 days) than that of those who were managed without surgery (mean = 3.44 days). Mean hospital charges for patients who were drained surgically were almost twice those of patients who were managed medically ($28,969 vs $17,022); 165 patients (4.8%) had a complication. RESULTS: There are >3400 admissions for pediatric DNSIs annually, and they account for a significant number of inpatient days and hospital charges. A randomized controlled trial of management may be indicated from a public health perspective.

Staphylococcus aureus retropharyngeal abscess in children.

A retrospective review of 33 patients comparing community-associated methicillin-resistant Staphylococcus aureus retropharyngeal abscess (RPA) with community-associated methicillin-susceptible S. aureus RPA from 2002-2013 at Texas Children's Hospital revealed most cases of S. aureus RPA have been due to community-associated methicillin-resistant S. aureus, which appears to be associated with a more complicated clinical course than RPA caused by community-associated methicillin-susceptible S. aureus.

National trends in retropharyngeal abscess among adult inpatients with peritonsillar abscess.

OBJECTIVES: To describe national trends in retropharyngeal abscess (RPA) complicating peritonsillar abscess (PTA) and to determine factors associated with RPA in patients with PTA. STUDY DESIGN: Cross-sectional analysis. SETTING: Nationwide Inpatient Sample, 2003-2010. SUBJECTS AND METHODS: PTA patients ≥18 years old, with or without RPA, were extracted according to ICD-9-CM codes. The cohort was analyzed with descriptive statistics and multivariate regression modeling to identify factors associated with RPA. RESULTS: Of the 91,647 (95% CI: 86,433-95,449) patients identified with PTA, 885 (1.0%) also had a concurrently coded RPA. The annual rate of concomitant RPA increased from 0.5% (95% CI: 0.3%-0.8%) to 1.4% (95% CI: 1.0%-2.0%) between 2003 and 2010 (P < .001). PTA patients with RPA more frequently underwent tonsillectomy (23.5% vs 11.1%), endotracheal intubation (7.1% vs 1.5%), and mechanical ventilation (13.2% vs 2.0%) than those without RPA (all P < .001). PTA patients with RPA were significantly older (41 vs 34 years old), had a longer hospital stay (6.4 vs 2.5 days), and had more procedures (2.5 vs 0.9) when compared to patients without RPA (all P < .001). Upon multivariate regression analysis, factors associated with RPA included the age groups of 40 to 64 years (odds ratio, 2.256; P < .001) and 65 and older (odds ratio, 2.086; P = .045). Median total charges for PTA inpatients with concomitant RPA were approximately $8700 greater (P < .001) when compared to patients with PTA alone. CONCLUSIONS: The incidence of RPA among adult inpatients with PTA is increasing, and patients with RPA have higher in-hospital resource utilization. Further studies may help validate factors predictive of RPA to enable prevention or earlier identification.