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International Journal of Pediatric Otorhinolaryngology 76 (2012) 1810–1813

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International Journal of Pediatric Otorhinolaryngology

jo ur n al ho m ep ag e: ww w.els evier .c om /lo cat e/ijp o r l

To drain or not to drain – Management of pediatric deep neck abscesses: A case–control study

Danny K.C. Wong, Colin Brown, Nikki Mills, Patrick Spielmann, Michel Neeff*

Department of Paediatric Otolaryngology, Starship Children’s Hospital, Auckland, New Zealand

A R T I C L E I N F O

A B S T R A C T

Article history: Received 23 June 2012 Received in revised form 29 August 2012 Accepted 3 September 2012 Available online 22 October 2012

Optimal management of deep neck abscesses has been the subject of debate for more than a century: surgical drainage has been the mainstay of treatment, but recently many centres have reported successful non-operative management in selected cases. Objectives: Our objective was to review the management of deep neck abscesses in our institution and to identify characteristics that would predict successful non-operative management. Methods: A retrospective chart review from January 2001 to August 2010 was performed. Children up to age fifteen years with a CT-confirmed diagnosis of retropharyngeal or parapharyngeal abscess were included. A case–control study of small deep space neck abscesses ( 25 mm maximal diameter) was performed, comparing antibiotic treatment alone with antibiotics plus abscess drainage. Results: 54 children met the inclusion criteria, of whom half had abscesses 25 mm diameter. Younger children within the group with smaller abscesses were more likely to need surgical drainage ( p < 0.05). Of 13 children requiring operative management, ten underwent a period of antibiotic treatment and observation prior to surgery, eight (80%) had fever beyond 48 h compared with three (23%) in the non surgical group ( p < 0.01). 27 children had an abscess > 25 mm diameter on CT scan, four (15%) of whom responded quickly to antibiotics and were managed non-operatively, while the rest underwent surgery. There were no significant differences between the surgical and non-surgical group characteristics with larger abscesses. Conclusion: High dose intravenous antibiotics are an effective treatment for deep space neck abscesses and may obviate the need for surgical drainage, particularly in smaller abscesses. Children who do not respond quickly to antibiotics are more likely to require surgery to achieve resolution. Children with larger abscesses may respond to antibiotic therapy alone but should be closely observed. A trial of high dose intravenous antibiotics in stable children with close observation is warranted as first line treatment, especially for small deep space neck abscesses. 2012 Elsevier Ireland Ltd. All rights reserved.

Keywords: Parapharyngeal abscess Retropharyngeal abscess Antibiotic

1. Introduction

select group can be treated and will resolve without requiring surgical drainage with intravenous antibiotics alone. Several authors have reported successful non-operative management in select groups: Sichel et al. successfully treated six children with parapharyngeal space abscesses with intravenous antibiotics alone [1] and Grisaru-Soen et al. [2] reported 20 children (over half of the case series) successfully treated with antibiotics. Hoffmann et al. [3] successfully treated 36 of 44 (82%) children with a retro pharyngeal abscess with antibiotics and McClay et al. [4] reported successful non-operative management in ten of eleven clinically stable children. By way of contrast, several authors [5,6] advocate immediate surgical drainage, citing shorter hospital stay, false negative imaging findings and the serious (occasionally fatal) sequelae of abscess rupture. A trial of antibiotic treatment in stable patients appears a desirable strategy because of false positive CT scans and occasional negative neck explorations. Our objective was

Deep space neck abscesses, retropharyngeal (RPA) and para pharyngeal (PPA) abscesses can be serious sequelae of upper respiratory tract infections. They can result in local, regional and systemic complications, including airway obstruction, mediasti nitis, jugular vein thrombophlebitis, cranial nerve dysfunction, cervical osteomyelitis, meningitis and death [1]. Optimal manage ment of deep neck abscesses has been the subject of debate for more than a century: surgical treatment has been the mainstay of treatment, with improved outcomes since the introduction of antibiotics in the 1940s. There has been debate as to whether a

* Corresponding author. Tel.: +64 9 3072800. E-mail address: MichelN@adhb.govt.nz (M. Neeff).

0165-5876/$ – see front matter 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2012.09.006