Retropharyngeal and parapharyngeal infections in children: the Toronto experience

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Summary

Objective

: To review the Hospital of Sick Children, Toronto's experience of the diagnosis and management of retropharyngeal and parapharyngeal infections with particular emphasis on the role of computed tomography (CT) imaging in diagnosing the presence of an abscess.

Methods

: A retrospective analysis of all patients diagnosed with retropharyngeal and parapharyngeal infections from 1987 to 1999 was performed. Demographic data, presenting symptoms, season of presentation, management and complications were reviewed. The CT scans of 27 patients who underwent surgical treatment were retrospectively examined by two neuroradiologists who were blinded to the patient's history and outcome. The sensitivity, specificity and predictive values for the specific features and overall assessment were calculated.

Results

: Fifty-four children were identified. There were 46 retropharyngeal infections, 6 parapharyngeal infections and 2 patients had both retropharyngeal and parapharyngeal infections. All patients were treated with parenteral antibiotics. Thirty-seven patients underwent surgical drainage and in 27 there was a positive finding of pus. The retrospectively assessed CT scans of the 21 patients who underwent surgery were found to have a sensitivity of 81% in detecting an abscess by CT scan but the specificity was 57%. There were four complications including mediastinitis, aspiration pneumonia, internal jugular vein thrombosis and common carotid artery aneurysm. All patients recovered but abscess recurred in five patients.

Conclusion

: Not all patients with retropharyngeal and parapharyngeal abscesses require surgery. Whilst CT scans are helpful in diagnosing and assessing the extent of these infections they are not always accurate in detecting an abscess. A decision to drain an abscess should therefore not be made based solely on the CT findings.

Introduction

Retropharyngeal and parapharyngeal infections in children are rare conditions but carry significant potential mortality and morbidity. Early diagnosis is necessary to prevent the development of complications. However, because of their relative infrequency, variability in presenting symptoms and lack of physical signs, they present a diagnostic challenge to emergency physicians, paediatricians and otolaryngologists to whom these children present. In addition, the management of these infections is also controversial in particular the timing of when to intervene surgically. These controversies have previously been highlighted in a survey of members of the American Society of Paediatric Otolaryngologists on their current practice of the diagnosis and management of retropharyngeal abscesses [1].

In this study, the experience at the Hospital for Sick Children, Toronto, in managing children with retropharyngeal and parapharyngeal infections is reviewed, in particular how patients present, the means of diagnosis, how they were managed and what complications occurred. The accuracy of computed tomography (CT) scanning in making a diagnosis is evaluated.

Section snippets

Methods

A retrospective chart review of 54 patients diagnosed with a retropharyngeal or parapharyngeal infection over 11 years (1987–1999) was performed. Patients with symptoms indicating an inflammatory process in the retropharyngeal and or parapharyngeal area and confirmatory radiological findings (either a lateral neck X-ray or CT scan) were included. In those patients who had a CT scan, a dynamic bolus CT scan was performed utilizing 2.5–3 cc per kg of non-ionic contrast material [Omnipague 300].

Results

Fifty-four cases of retropharyngeal and parapharyngeal infections were identified over the 11 year period. There were 46 retropharyngeal infections, 6 parapharyngeal infections and 2 patients had both retropharyngeal and parapharyngeal infections. Of the 54 children, there was a predominance of boys who comprised two-thirds of the population group (male n = 36; female n = 18). The incidence with age is shown in Fig. 1. The mean age at presentation was 5.4 years (range 0.4–17.9 years) and 66% were

Sensitivity and specificity of CT scanning

A positive diagnosis of an abscess by the finding of pus at surgery was made in 21 patients (Table 4). Six patients who had CT scans underwent surgery and were found to have no pus. The sensitivity, specificity and predictive values of CT scanning in detecting an abscess looking at the overall assessment and specific features including the presence of a complete enhancing rim and lucency with respect to CSF is given in Table 5.

Discussion

In the current study, infections of the retropharyngeal and parapharyngeal spaces were more frequent in younger children with two-thirds occurring under the age of 6 years. This age incidence is similar to other series. It has been postulated that younger children are more likely to develop infections in this area because of the presence of lymph nodes that run in a paramedian chain in the retropharyngeal space and which spontaneously regress after 5 years [3], [4]. We found a strong

Conclusion

Retropharyngeal and parapharyngeal infections present a diagnostic and management challenge. Presenting symptoms can be variable but most patients will have a sore throat and fever associated with a neck mass and torticollis.

The diagnosis is confirmed by imaging studies including an initial lateral neck X-ray followed by CT scanning. CT scans have a high sensitivity in detecting an abscess but a low specificity. Airway complications may occur in which case immediate surgical drainage is

Acknowledgements

We gratefully acknowledge Dr. W. Crysdale, Dr. J. Friedberg and Dr. V. Forte for allowing us to report on their patients. We also thank Derek Stephens, Biostatistician at The Hospital for Sick Children for his advice on the statistical analysis.

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