Antibiotic therapy for pediatric deep neck abscesses: A systematic review

Abstract

Objective

To evaluate the current evidence regarding the safety and efficacy of medical management for deep neck abscesses in children.

Data sources

Pubmed and Embase databases accessed 3/27/2012.

Review methods

An a priori protocol defining inclusion and exclusion criteria was developed to identify all articles addressing medical therapy of pediatric deep neck abscesses where details regarding diagnostic criteria, specifics of medical therapy and definitions of failure were presented. The search included electronic databases to identify candidate articles as well as a manual crosscheck of references. The level of evidence was assessed and data extracted by three authors independently. Data were pooled using a random effects model due to significant study heterogeneity.

Results

Eight articles met inclusion criteria. The overall level of evidence was grade C. There was significant heterogeneity among the studies (I² = 98.8%; p < .001). However, each article uniformly presented cases suggesting that medical therapy may be a viable alternative to surgical drainage in some patients. The pooled success rate of medical therapy in avoiding surgical drainage in children with deep neck infections was 0.517 (95%CI: 0.335, 0.700). When patients taken immediately to surgery were excluded and patients were placed on author defined medical protocols, the success rate increased to 0.951 (95%CI: 0.851, 1.051). Subgroup analysis by duration of intravenous antibiotic trial greater than 48 h demonstrated a pooled success rate of 0.740 (95%CI: 0.527, 0.953).

Conclusion

The current literature suggests medical management may be a safe alternative to surgical drainage of deep neck abscesses in children. However, the level of evidence lacks strength and further investigation is warranted.

Introduction

Deep neck abscesses in the pediatric population are relatively uncommon, however they carry the potential for serious morbidity and mortality [1]. Life threatening complications can develop rapidly and include airway compromise, dissemination of infection and spread into contiguous potential spaces that communicate with the mediastinum [2], [3].

Early diagnoses followed by prompt and appropriate treatment is crucial. Clinical symptoms vary and may be mistaken for other disease processes such as epiglottitis [3]. Predominate clinical features include trismus, dysphagia, neck pain, torticollis, painful neck mass, odynophagia, irritability, and fever [1], [2], [4]. Neurologic signs may develop if the sympathetic chain and cranial nerves IX–XII are involved [3], [5].

In children, retropharyngeal and parapharyngeal abscesses are the most commonly reported deep neck spaces involved and are often combined. Retropharyngeal abscesses occur either by direct penetrating trauma or through spread from a continuous area. Suppuration of lateral retropharyngeal lymph nodes often leads to abscess formation. Edema may develop within the retropharyngeal fat secondary to progression of an infection and cellulitis, which can make distinction between non-infectious and infectious fluid difficult [6]. Similarly, a majority of parapharyngeal abscesses arise from lymph nodes in the parapharyngeal space. Frequent origins of infection include odontogenic infections, pharyngitis, tonsillitis, otitis, mastoiditis, and parotitis [4], [7], [8].

Few studies exist specifically addressing the incidence of parapharyngeal and retropharyngeal abscesses in the pediatric population. While a decreased incidence in deep neck abscesses has been anecdotally observed, owed largely to improvements in antibiotics and better access to healthcare, recent reports have suggested an increased incidence [1], [3], [8]. Landers et al.’s analysis of the Kids’ Inpatient Database (KID) in 2003 revealed 1321 admissions for retropharyngeal abscesses, of which 563 (43%) patients had surgical drainage performed [9].

Traditional treatment of retropharyngeal and parapharyngeal abscesses, which developed prior to the advances in antibiotics and imaging involves early surgical incision and drainage [10]. Traditional external versus intraoral surgical approaches are predicated upon the location of the fluid collection primarily with respect to the great vessels and both have been presented as viable surgical techniques [8]. As such, imaging is a cornerstone in the evaluation of suspected deep neck space infections [3], [5], [11], [12], [13]. Commonly obtained studies include lateral neck radiographs, ultasonagraphy and contrast enhanced computed tomography (CT) [12], [14], [15]. Each modality has limitations, however the superior anatomical detail provided by CT has made this modality the preferred imaging technique [2], [7], [11], [12], [13], [16], [17].

One limitation of CT imaging is its specificity with regard to differentiating cellulitis versus abscess. Specificity of CT imaging in predicting purulence at the time of surgical incision has high variability and has been reported between 0% and 92% [8], [18]. While the standard CT criteria for diagnosing abscess is a homogenous area of low-attenuation with rim enhancement, this finding does not always correlate with surgical findings of pus [8]. Malloy et al. suggest that the finding of rim enhancement on CT represents a continuum between cellulitis and abscess and concluded that there is no significant correlation between rim enhancement and incidence of purulence at surgical drainage [19]. Kirse et al. study concluded that abscess wall scalloping was found to be more specific in predicting pus than rim enhancement [8]. Despite the poor specificity of this modality to differentiate abscess from cellulitis and lymphadenitis, it is commonly accepted that CT provides clinical utility in directing therapy [2], [5], [13], [20].

Surgical drainage for both retropharyngeal and parapharyngeal abscesses has been a topic of controversy in recent literature and numerous studies suggest conservative treatment with intravenous antibiotics together with close observation may represent an acceptable first line of therapy [1], [2], [3], [4], [5], [10], [12], [13], [14], [16], [17], [21], [22], [23]. Unfortunately there are no well-controlled trials confirming this hypothesis. With the advent of improved antibiotics and CT imaging, it seems plausible that an evidence based treatment algorithm using clinical findings and CT imaging could be developed that includes conservative treatment with intravenous antibiotics as an acceptable initial option [12], [23]. The primary objective of this review is to ascertain the evidence behind a conservative medical approach toward the management of pediatric deep neck abscesses.