FLEX February 2024

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D.K.C. Wong et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1810–1813

to review the management of deep neck abscesses in our institution and to identify characteristics that would predict successful non-operative management.

2. Methods

A retrospective chart review from January 2001 to August 2010 was initially performed: patients were identified by the admission diagnostic code and computerised records examined. Demograph ic data and details of investigations, microbiology, management and follow up were collected. Institutional review board approval was obtained (Northern X Ethics Committee; NTX/10/EXP/122, A+4824). Children up to age fifteen years with a diagnosis of RPA or PPA confirmed on cross-sectional imaging were included. Patients with deep neck cellulitis, abscesses due to mycobacteria, immuno compromised patients, and congenital cervical lesions were excluded. A case–control study of small deep space neck abscess ( 25 mm maximal diameter) was performed, comparing antibi otic treatment alone with antibiotics plus abscess drainage. For categorical variables, differences between groups were calculated by Fisher’s exact test. For continuous variables differences were determined by the parametric t -test or the non-parametric Wilcoxon rank sums test as appropriate. Multivariate analyses were undertaken using nominal logistic regression. 66 children were identified, 54 met the inclusion criteria. The reasons for exclusion were: deep neck cellulitis or lymphadenitis (four), no cross-sectional imaging (four), incorrectly coded (three), mycobacterium avium intracellular complex infection (one). Of the 54 patients, 38 were male (70%) and 16 were female (30%). The ethnic distribution of the study population and general Auckland population can be seen in Fig. 1. 41 (76%) were in the lower half of the New Zealand socio-economic scale. A non significant trend to increasing incidence over the 10-year study period was noted, and is shown in Fig. 2. The mean age was 4.75 years (SD 3.7, range 0.3–14 years) and the incidence decreased with age. There were 30 retropharyngeal abscesses (56%) and 24 parapharyngeal abscesses (44%). The most commonly recorded signs in the present review were restricted neck movements and neck swelling, while a bulging pharynx, trismus, drooling and shortness of breath were uncommon The characteristics of two groups with abscesses 25 mm or > 25 mm are shown in Table 1. More children with small abscesses were managed non surgically but there were no significant demographic or symptom differences between the groups. The hospital stay ranged from 1 to 11 days for all patients. The mean stay for patients undergoing surgery was 4 days, while for those with antibiotics alone was 5 days, a non-significant difference. There was no mortality in either group. 40 children (74%) were managed with a period of observation and antibiotic treatment for at least 24 h. 3. Results

Fig. 2. Annual incidence of deep space neck abscesses.

3.1. Antibiotic regime

The majority of children, 42 (78%) were treated with high dose intravenous Amoxicillin/Clavulanic acid 50 mg/kg eight-hourly, eight (15%) received medium or low dose antibiotics, four (7%) received a Cephalosporin with Flucloxacillin or Metronidazole. The management strategy of different abscess sizes is shown in Fig. 3. 3.2. Abscesses 25 mm diameter 27 children with abscesses 25 mm diameter on CT scan were categorised into two groups based on management received: intravenous antibiotics alone or incision and drainage with antibiotics. These groups are compared in Table 2. The children managed with antibiotics alone were significantly older ( p < 0.05) than those undergoing surgery. There was no significant difference in abscess size or clinical presentation between the groups. Four children underwent surgery on the day of admission, one following intubation/stabilization in the ICU for respiratory embarrassment, one due to a markedly bulging pharyngeal wall, the indications in two were not explicitly recorded. Thus 10 children underwent a period of antibiotic treatment prior to surgery. 9 (90%) had fever 38 8 C beyond 24 h of treatment compared with three (23%) in the non-surgical group ( p < 0.01). 8 (80%) had fever beyond 48 h compared with 3 (23%) in the non-surgical group ( p < 0.01). Other indications for surgery in this group included: multiple loculations on CT scan (three), mediastinal involvement (one). There was no difference in ages between the groups when the four children undergoing immediate (day 0) drainage were excluded. Overall, however the children with small abscesses requiring incision and drainage were significantly younger ( p < 0.05). 27 children had an abscess > 25 mm diameter on CT scan, four (15%) were successfully treated with high dose intravenous antibiotics alone. All responded quickly to antibiotics: only one child had a spike of fever on day 3 which settled and the rest remained afebrile during admission. 23 children underwent incision and drainage; the groups are compared in Table 3. 10 children underwent surgery on the day of admission leaving 13 for a period of observation with intravenous antibiotics, 10 were 3.3. Abscesses > 25 mm diameter

Table 1 Features of children with large and small deep space neck abscesses.