Deep Neck Space Infections In Infants At A Tertiary Referral Centre: A Case Review

Moyo, Charles

Deep Neck Space Infections In Infants At A Tertiary Referral Centre: A Case Review

Thesis / Dissertation

2023

Abstract

Background: Persistent upper respiratory tract infections in infants can lead to retropharyngeal lymphadenitis. If untreated, they can progress to deep neck space infections (DNSI). Objective: To review surgical management of DNSI in infants, and to determine optimum timing of surgical drainage, and sequelae thereof. Methods: A retrospective study of infants presenting with DNSI, was conducted at Red Cross War Memorial Children's Hospital, Cape Town, between May 2018 to March 2022. Medical folders were reviewed, data collected included demographics, clinical presentation, investigations, management, and post-operative course. Ethics approval was obtained prior to commencement. Results: Six children with DNSI were identified, aged between 3-12 (average 6.7) months. None had any preceding comorbidities; 2/6 (33%) children incidentally tested positive for Covid-19; 4/6 (67%) had preceding URTI, 3/4 (75%) having commenced antibiotics prior to presentation. Common clinical findings were neck swelling in 5/6 (83%) and fever in 6/6 (100%); stridor in 4/6 (67%) and dysphagia in 3/6 (50%). The average white cell count (WCC) was 21.5 (range 12.6-34.3) *109 /L. 3/6 infants had measured procalcitonin levels between 0.23-2.74 (average 1.10) ng/ml. DNSI was identified on CT imaging in all cases in the following deep spaces: retropharyngeal 6/6 (100%); parapharyngeal 4/6 (67%); superior mediastinum 5/6 (83%); anterior cervical 2/6 (33%); posterior mediastinum 1/6 (17%) and paratracheal 1/6(17%). Abscess size of more than 3cm with airway displacement was seen in all cases. 5/6 (83%) infants underwent surgical intervention within 24hours of presentation. Delayed surgical intervention in 1/6 (17%) resulted in “antibioma” formation and delayed surgical drainage. Methicillin sensitive staphylococcus aureus (MSSA) was cultured in 5/6 (83%) cases; no organisms were identified in the remaining case. 5/6 (83%) were managed post-operatively in the ICU for 3-9 (average 5.8) days. Empiric intravenous therapy was commenced in all cases, namely, Co-Amoxiclav (4/6) and Piperacillin/Tazobactam (2/6). Amikacin was additionally administered in 1 case for presumed nosocomial respiratory infection prior to DNSI management. Culture-directed therapy modified treatment to Cephalexin/Flucloxacillin in 2/6 cases. Neck drains were removed after an average of 2.8 (range 1-6) days when output was minimal. Duration of hospital stay was 13 (range 5-19) days. There were no mortalities. Conclusion: DNSI is a rare but serious complication of progressive retropharyngeal lymphadenitis resulting from non-resolving or worsening URTIs in infants. This was observed in all six cases. Typical presentation includes neck swelling, fever, and airway compromise often requiring prompt airway management with source control. Recommended management includes CT imagining of head, neck and chest to determine extent of spread, appropriate intravenous antibiotics, and prompt surgical drainage. Medical therapy alone can risk antibioma formation, with inevitable surgical clearance of sepsis.

Keywords

General Surgery

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