FLEX February 2024

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

Table 2 Abscesses of 25 mm diameter. Abscess 25 mm on CT

Antibiotics alone

Surgical intervention

Significant difference?

13

14

N

Age mean (SD)

5.72 (SD 3.3)

3.66 (SD 2.3)

p < 0.05, 1 tailed t -test

Sex

11 male, 2 female

11 male, 3 female

Mean abscess size (SD, range) Fever after 24 h of iv Abs? Fever after 48 h of iv Abs?

16.7 (SD 4 mm, range 6–22 mm)

17.6 (SD 4.8 range 9–25 mm)

n/s

4 (31%) 3 (23%)

9/10 (90%) 8/10 (80%)

p = 0.005 (chi2) p = 0.004 (chi2)

Mean duration of hospital stay. Bed stays?

5.2

4.94

n/s

Table 3 Abscesses > 25 mm diameter.

Abscess > 25 mm on CT

Antibiotics alone

Surgical intervention

Significant difference?

4

23

N

Age mean (SD)

4.7 (SD 2.96)

4.49 (SD 4.62)

n/s

Sex

3 male, 1 female

13 male, 10 female

Mean abscess size (SD, range) Fever after 24 h of iv Abs? Fever after 48 h of iv Abs?

46 mm (SD 16, range 27–70 mm)

37 mm (SD 9.8, range 29–50 mm)

n/s

1/4 (25%) 1/4 (25%)

7/13 (54%) 6/10 (60%)

n/s, p = 0.3 n/s, p = 0.24

Mean duration of hospital stay. Bed stays?

5

4.9 days

n/s

who required surgery. Four children with large abscesses were also successfully managed non-operatively, there were no significant differences between the groups with large abscesses but the numbers were small.

observed for > 48 h. There was no significant difference between the surgical and non-surgical groups. One child with a CT scan suggestive of a neck abscess had a negative neck exploration (a false positive rate in this series of 2.7%). She was returned to theatre 4 days later and an abscess was successfully drained.

4.1. Clinical features

3.4. Microbiology

We acknowledge the limitations of a retrospective study as an inaccurate method to comment on the presence of particular symptoms at presentation as record keeping may be suboptimal thus we do not present a detailed analysis. Several symptoms or signs prompted early surgical intervention in our cohorts: airway compromise, severe neck immobility, a bulging pharyngeal wall, mediastinitis, meningitis, multiple abscesses and significant medical co-morbidities. These clinical findings are also reported in previous studies [2,5,7–9]. Deep neck abscesses behave differently in children than adults: typically arising from necrotic lymph nodes and thus enclosed in a rind of inflammatory tissue rather than merely bounded by fascial planes. Thus mediastinal spread is rare in children but if suspected or confirmed should be an indication for prompt surgical drainage [5]. Page et al. [9] performed logistic regression analysis of symptoms and signs to identify positive predictors for the presence of pus: duration of symptoms > 2 days prior to admission and fluid collection > 2 cm 3 on CT scan were the only positive findings. A posterior pharyngeal bulge had an odds ratio of 4.1 for the presence of pus but was marginally statistically non-significant ( p = 0.051). There is no high quality evidence to suggest that any particular symptom, clinical sign or combination thereof is a reliable predictor for the presence of pus or the need for surgical intervention. Although some studies [10] advocate the use of lateral neck X rays to detect pharyngeal or retropharyngeal swellings, it is impossible to determine the presence, size or exact location of an abscess, furthermore massive deep neck abscesses can be missed in the presence of a normal lateral neck X-ray [11]. CT scanning is the most commonly employed modality to identify a deep space neck abscess but reported sensitivity levels vary between 63% and 95% and specificity levels from 45% to 65% [7,9,12,13]. Some reports of successful non-operative management have concentrated on imaging characteristics: Hoffmann et al. [3] reported that a hypodense core and rim enhancement with a long 4.2. Radiologic features

Bacterial culture results from swabs taken intra-operatively were positive in 17 (46%) patients (Table 4). Of these most grew Streptococcus pyogenes or Staphylococcus aureus . Two patients grew a methicillin-resistant S. aureus .

4. Discussion

Of the 27 patients with small abscesses 13 were successfully managed conservatively. These were significantly older and responded more quickly to intravenous antibiotics than those

Fig. 3. Management strategy compared with abscess size.

Table 4 Microbiology of deep neck abscesses (of 37 patients undergoing surgery).

%

Organism

N

13

35

Streptococcus pyogenes Staphylococcus aureus Streptococcus viridans

3 1

8 3

No growth

18

49

No microbiology results

2

5