Retropharyngeal infections in children. Treatment strategies and outcomes

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Abstract

Objective

To optimize the treatment of retropharyngeal infections in children.

Methods

Retrospective chart review of 101 consecutive pediatric cases of retropharyngeal infections referred to our center from January 2006 to July 2009.

Results

Two-thirds of patients were males. Their mean age was 52 months (range: 6–163). Upper airway obstruction was observed in three patients. In another child, the infection evolved towards a diffuse cervical cellulitis. Medical treatment was initially planned in 44% of patients. Failures requiring surgical drainage occurred in 18% of them. In 56% of cases, surgical treatment was immediately instigated. It failed in 16% of patients, requiring a second surgical drainage. There was no difference in the duration of fever and of hospital stay between patients initially treated medically or surgically. Both medical and surgical treatment failures were associated with longer durations of fever (p = 0.002, and p < 0.0001, respectively) and of hospital stay (p = 0.0006, and p = 0.0005, respectively). Some characteristics of CT-scan anomalies were correlated with treatment failure. A hypodense core surrounded by rim enhancement, with a largest long axis ≥20 mm, was more frequent in case of medical failure (p = 0.02). Surgical failure was associated with the same feature, but with a largest long axis ≥30 mm (p = 0.05).

Conclusions

The present study suggests that severe complications are rare in pediatric retropharyngeal adenitis, and that CT-scan is a useful tool to choose between medical and surgical treatment.

Introduction

Retropharyngeal infections in children are rare complications of upper respiratory tract infections. They consist of adenitis localized behind the posterior pharyngeal wall, or posterior and lateral to it, in the so-called posterior compartment of the parapharyngeal space [1]. Their course is usually uneventful [2] but complications might be encountered such as airway obstruction, cervical necrotizing fasciitis, mediastinitis, aspiration pneumonia, jugular thrombosis or aneurysm of the carotid artery [3].

Their management is still today a subject of debate, and particularly the choice between first line medical or surgical treatment. The aim of this study was to identify the risk factors and the consequences of treatment failures, in order to define an optimal protocol.

Section snippets

Patients

This retrospective chart review comprised of 101 consecutive pediatric cases of retropharyngeal infections referred to our center from January 2006 to July 2009. CT Scan confirmed diagnosis in all but one case (major dyspnea requiring urgent surgery).

Collected data

Charts were reviewed for demographic data and medical history, treatment received before hospitalization, clinical presentation, biological and bacteriological data, radiological evaluation, treatment, duration of fever, duration of hospitalization

Demographic data

Two-thirds of patients were males (67/34). Patient's ages ranged from 6 to 163 months (52 ± 34 months, mean ± S.D.). Seventy-seven percent of patients were under 6 years of age, and 91% were under 8. Children who underwent surgery as a first line treatment or after medical treatment failure were younger than medically treated patients (45.9 ± 29.5 months versus 62.4 ± 39.6 months; p = 0.02). No patient had any significant medical history.

Before admission

The delay between first symptom and hospitalization was 3.41 ± 2.1

Demographic data

In accordance with literature data [2], [3], [5], [6], we found a preponderance of male patients aged between 3 and 6 years. National northern American data published in 2003 (n = 1321) showed 63% of males and a mean age of 5.1 ± 4.4 years (mean ± S.D.) [7]. The fact that RPA becomes rarer in older children probably results from the progressive atrophy of retropharyngeal lymph nodes before puberty [8].

Symptoms

As Frances et al. [5] and Craig et al. [8] emphasized, neck stiffness and torticollis are the

Conclusions

This study is one of the largest series of pediatric RPAs with a homogeneous group of 101 patients treated over a period of 3.5 years in our center. Considering our data, as well as other published series, we recommend the treatment protocol summarized in Fig. 3.

Acknowledgement

We thank Dr. Fergal Glynn for his helpful comments on the paper.

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      No differences were found concerning the type of imaging exam between both groups and, for that, the former association cannot be simply explained by the surgical group being more prone to CT scan performance, with an increase identification of retropharyngeal abscesses. We hypothesize that the apprehension for complications, although rare, such as airway obstruction, cervical necrotizing fasciitis, mediastinitis and aspiration pneumonia, traditionally associated with retropharyngeal abscess formation, near to the “danger space of the neck”, was an important determinant for the need of surgery [12]. One study assessing surgical outcomes in children with acute SCL, suggested that larger “abscess pocket” of LNs may be a predictive factor for surgery, as it was more often found in surgical group patients, with no differences encountered in largest LN diameter [2].

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