Retropharyngeal and parapharyngeal infections in children: the Toronto experience
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.
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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.
References (13)
- et al.
Retropharyngeal abscess management in children: current practices
Otolaryngol. Head Neck Surg.
(1999) - et al.
Ligation of the common carotid artery for the management of a mycotic pseudoaneurysm of an extracranial internal carotid artery. A case report and review of the literature
Int. J. Pediatr. Otorhinolaryngol.
(1995) - et al.
Correlation between computed tomography and surgical findings in retropharyngeal inflammatory processes in children
Int. J. Pediatr Otorhinolaryngol.
(1999) - et al.
Head and neck space infections in infants and children
Otolaryngol. Head Neck Surg.
(1995) - et al.
Contemporary management of deep neck space infections
Otolaryngol. Head Neck Surg.
(1997) - et al.
Comparison of computed tomography and surgical findings in deep neck infections
Otolaryngol. Head Neck Surg.
(1994)