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

Table 5 Antibiotic use reported in recent series.

Type of antibiotic used

Location

Author, year

Clindamycin, Amoxicillin/Clavunate, Ceftriaxone Ampicillin/Sulbactam, Clindamycin Clindamycin, Cefuroxime Metronidazole Ampicillin/Sulbactam, Clindamycin

Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel

Grisaru-Soen et al., 2010 Nathan Page et al., 2008

St. Louis Hospital Atlanta, USA

St. Georges Hospital, Toronto, Canada Primary Children’s Medical Centre, UT, USA Children’s Hospital of Dallas, TX, USA Hadassah Medical Centre, Jerusalem, Israel

Daya et al., 2005

Craig and Shunk, 2003 McClay et al., 2003 Sichel et al. 2002 Dawes et al., 2002 Kirse and Roberson, 2001

Clindamycin, Cefuroxime Amoxcillin/Clavulanate

3rd generation cephalosporin, cloxacillin + metronidazole

Sydney Children’s Hospital, New South Wales, Australia

Ampicillin/Sulbactam, Clindamycin

Children’s Mercy Hospital, Kansas City, USA

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 in older children.

axis 20 mm was more common in children who required drainage after a period of medical management and recommend surgery if these characteristics are present. Abscess size has been shown to be an important predictor of treatment modality. Page et al. [9] reported 89% of patients with an abscess > 2.0 cm 2 in cross sectional area had pus confirmed at surgery compared with 65% of patients with an abscess < 2.0 cm 2 but the criteria to offer surgery to patients with smaller abscess were not presented. In the present study patients were statistically more likely to have successful conservative management when abscesses were < 2.5 cm (Fig. 3). Successful non-operative management relies on accurate audit of local pathogenic bacteria and modification of antibiotic regimes. Amoxicillin provides coverage of most common aerobic organisms found in deep neck abscesses, however over two thirds of S. aureus may produce beta-lactamase, which is broken down by Clavulanic acid. Higher doses of Amoxicillin result in higher plasma concentrations at day 3 in the treatment of respiratory infections [14]. To lengthen the mean intravenous concentration time, a 30– 40 mg/kg/dose of Amoxicillin has been used with excellent tolerance [15]. 50 mg/kg/day of Amoxicillin in two or four daily doses has been administered, yielding comparable efficacies and few adverse effects [16]. We report success with high doses of Amoxicillin/Clavulanic acid, a regime which finds support in the literature [17] and is used in other tertiary pediatric centres worldwide. Table 5 lists the recently published antibiotic regimes for deep space neck infections. A trend towards increasing incidence has been observed in other Pediatric Otolaryngology Centers. Early recognition and diagnosis of deep neck abscesses due to improved access to CT scans has been cited as a reason for this apparent rise [2,5,9] rather than an actual increase in incidence. This in turn would imply that some deep neck abscesses were previously undiagnosed and successfully treated with antibiotics alone, supporting an initial trial of non-operative management. Younger children with small abscesses appeared more likely to require surgical drainage than older children with similarly sized abscesses, although numbers were small. This may be due involvement of retropharyngeal lymph nodes, which are thought to involute with increasing age [8]. This area requires more investigation with a larger, prospectively studied cohort. 4.3. Antibiotic regime

Acknowledgements

The authors in this study would like to thank Mr. Peter Reid of the Children’s Research Centre at Starship Children’s Hospital for his statistical advice on this study and other members of the Department of Paediatric Otolaryngology, Starship Children’s Hospital for their input.

References

[1] J.-Y. Sichel, I. Dano, E. Hocwald, A. Biron, R. Eliashar, Nonsurgical management of parapharyngeal space infections: a prospective study, Laryngoscope 14 (2002) 906–910. [2] G. Grisaru-Soen, O. Komisar, O. Aizenstein, M. Soudack, D. Schwartz, G. Paret, Retropharyngeal and parapharyngeal abscess in children: epidemiology, clinical features and treatment, Int. J. Pediatr. Otorhinolaryngol. 74 (2010) 1016–1020. [3] C. Hoffmann, S. Pierrot, P. Contencin, M.-P. Morisseau-Durand, Y. Manach, V. Couloigner, Retropharyngeal infections in children. Treatment strategies and outcomes, Int. J. Pediatr. Otorhinolaryngol. 75 (2011) 1099–1103. [4] J.E. McClay, A.D. Murray, T. Booth, Intravenous antibiotic therapy for deep neck abscesses defined by computed tomography, Arch. Otolaryngol. Head Neck Surg. 129 (2003) 1207–1212. [5] D.J. Kirse, D.W. Roberson, Surgical management of retropharyngeal space infec tions in children, Laryngoscope 111 (2001) 1413–1422. [6] L.C. Dawes, R. Bova, P. Carter, Retropharyngeal abscess in children, ANZ J. Surg. 72 (2002) 417–420. [7] H. Daya, S. Lo, B.C. Papsin, A. Zachariasova, H. Murray, J. Pirie, et al., Retro pharyngeal and parapharyngeal infections in children: the Toronto experience, Int. J. Pediatr. Otorhinolaryngol. 69 (2005) 81–86. [8] F.W. Craig, J.E. Schunk, Retropharyngeal abscess in children: clinical presentation utility of imaging, and current management, Pediatrics 111 (2003) 1394–1398. [9] N. Page, E. Bauer, J. Lieu, Clinical features and treatment of retropharyngeal abscess in children, Otolaryngol. – Head Neck Surg. 138 (2008) 300–306. [10] C. Boucher, D. Dorion, C. Fisch, Retropharyngeal abscesses: a clinical and radio logic correlation, J. Otolaryngol. 28 (1999) 134–137. [11] V. Uzomefuna, F. Glynn, T. Mackle, J. Russell, Atypical locations of retropharyngeal abscess: beware of the normal lateral soft tissue neck X-ray, Int. J. Pediatr. Otorhinolaryngol. 74 (2010) 1445–1448. [12] M.J. Courtney, M. Mahadevan, A. Miteff, Management of paediatric retrophar yngeal infections: non-surgical versus surgical, ANZ J. Surg. 77 (2007) 985–987. [13] M. Nagy, M. Pizzuto, J. Backstrom, L. Brodsky, Deep neck infections in children a new approach to diagnosis and treatment, Laryngoscope 107 (1997) 1627–1634. [14] I. Brook, Current management of upper respiratory tract and head and neck infections, Eur. Arch. Otorhinolaryngol. 266 (2008) 315–323. [15] W. Fonseca, K. Hoppu, L.C. Rey, J. Amaral, S. Qazi, Comparing pharmacokinetics of amoxicillin given twice or three times per day to children older than 3 months with pneumonia, Antimicrob. Agents Chemother. 47 (2003) 997–1001. [16] F. Daschner, U. Behre, A. Dalhoff, Prospective clinical trial on the efficacy of amoxicillin administered twice or four times daily in children with respiratory tract infections, J. Int. Med. Res. 9 (1981) 274–276. [17] I. Brook, Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses, J. Oral Maxillofac. Surg. 62 (2004) 1545–1550.

5. 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