International Journal of Pediatric Otorhinolaryngology 76 (2012) 1647–1653

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Antibiotic therapy for pediatric deep neck abscesses: A systematic review§,§§

Peter N. Carbone a, Gregory G. Capra b,*, Matthew T. Brigger b
a
Naval Medical Center San Diego, Department of Anatomic Pathology, San Diego, CA, United States
b
Naval Medical Center San Diego, Department of Otolaryngology – Head and Neck Surgery, San Diego, CA, United States

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To evaluate the current evidence regarding the safety and efficacy of medical management for
Received 3 May 2012 deep neck abscesses in children.
Received in revised form 27 July 2012 Data sources: Pubmed and Embase databases accessed 3/27/2012.
Accepted 28 July 2012
Review methods: An a priori protocol defining inclusion and exclusion criteria was developed to identify
Available online 23 August 2012
all articles addressing medical therapy of pediatric deep neck abscesses where details regarding
diagnostic criteria, specifics of medical therapy and definitions of failure were presented. The search
Keywords:
included electronic databases to identify candidate articles as well as a manual crosscheck of references.
Deep neck abscess
Retropharyngeal abscess
The level of evidence was assessed and data extracted by three authors independently. Data were pooled
Parapharyngeal abscess using a random effects model due to significant study heterogeneity.
Pediatric Results: Eight articles met inclusion criteria. The overall level of evidence was grade C. There was
Airway significant heterogeneity among the studies (I2 = 98.8%; p < .001). However, each article uniformly
Computed tomography presented cases suggesting that medical therapy may be a viable alternative to surgical drainage in some
Surgical management patients. The pooled success rate of medical therapy in avoiding surgical drainage in children with deep
Antibiotic management neck infections was 0.517 (95%CI: 0.335, 0.700). When patients taken immediately to surgery were
excluded and patients were placed on author defined medical protocols, the success rate increased to
0.951 (95%CI: 0.851, 1.051). Subgroup analysis by duration of intravenous antibiotic trial greater than
48 h demonstrated a pooled success rate of 0.740 (95%CI: 0.527, 0.953).
Conclusion: The current literature suggests medical management may be a safe alternative to surgical
drainage of deep neck abscesses in children. However, the level of evidence lacks strength and further
investigation is warranted.
Published by Elsevier Ireland Ltd.

1. Introduction features include trismus, dysphagia, neck pain, torticollis, painful

neck mass, odynophagia, irritability, and fever [1,2,4]. Neurologic
Deep neck abscesses in the pediatric population are relatively signs may develop if the sympathetic chain and cranial nerves IX–
uncommon, however they carry the potential for serious morbidity XII are involved [3,5].
and mortality [1]. Life threatening complications can develop In children, retropharyngeal and parapharyngeal abscesses are
rapidly and include airway compromise, dissemination of infection the most commonly reported deep neck spaces involved and are
and spread into contiguous potential spaces that communicate often combined. Retropharyngeal abscesses occur either by direct
with the mediastinum [2,3]. penetrating trauma or through spread from a continuous area.
Early diagnoses followed by prompt and appropriate treatment Suppuration of lateral retropharyngeal lymph nodes often leads to
is crucial. Clinical symptoms vary and may be mistaken for other abscess formation. Edema may develop within the retropharyngeal
disease processes such as epiglottitis [3]. Predominate clinical fat secondary to progression of an infection and cellulitis, which
can make distinction between non-infectious and infectious fluid
difficult [6]. Similarly, a majority of parapharyngeal abscesses arise
§
from lymph nodes in the parapharyngeal space. Frequent origins of
The views expressed in this article are those of the authors and do not
necessarily reflect the official policy or position of the Department of the Navy, the
infection include odontogenic infections, pharyngitis, tonsillitis,
Department of Defense, nor the U.S. Government. otitis, mastoiditis, and parotitis [4,7,8].
§§
Accepted for presentation at the American Academy of Otolaryngology – Head Few studies exist specifically addressing the incidence of
and Neck Surgery Annual Meeting, Boston, MA, September 2010. parapharyngeal and retropharyngeal abscesses in the pediatric
* Corresponding author at: Naval Medical Center San Diego, Department of
population. While a decreased incidence in deep neck abscesses
Otolaryngology – Head and Neck Surgery, 34800 Bob Wilson Drive, San Diego, CA
92134, United States. Tel.: +1 619 532 9600; fax: +1 619 532 6808.
has been anecdotally observed, owed largely to improvements in
E-mail address: gregory.capra@med.navy.mil (G.G. Capra). antibiotics and better access to healthcare, recent reports have

0165-5876/$ – see front matter . Published by Elsevier Ireland Ltd.

http://dx.doi.org/10.1016/j.ijporl.2012.07.038
1648 P.N. Carbone et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1647–1653

suggested an increased incidence [1,3,8]. Landers et al.’s analysis of March 27, 2012 and published after 1947. Both keywords and
the Kids’ Inpatient Database (KID) in 2003 revealed 1321 medical subject headings (MESH) search strategies were used
admissions for retropharyngeal abscesses, of which 563 (43%) based on the following terms ‘‘retropharyngeal abscess,’’ ‘‘para-
patients had surgical drainage performed [9]. pharyngeal abscess,’’ ‘‘pharyngeal diseases,’’ ‘‘neck,’’ ‘‘abscess,’’
Traditional treatment of retropharyngeal and parapharyngeal ‘‘bacterial infection,’’ ‘‘deep neck infection,’’ ‘‘surgical drainage,’’
abscesses, which developed prior to the advances in antibiotics and ‘‘antibiotic therapy,’’ ‘‘infant,’’ ‘‘children,’’ ‘‘adolescent,’’ and
imaging involves early surgical incision and drainage [10]. ‘‘computed tomography.’’ Article titles and abstracts were then
Traditional external versus intraoral surgical approaches are reviewed to determine their relevance based on the stated
predicated upon the location of the fluid collection primarily with inclusion criteria. Full-text articles were retrieved from those
respect to the great vessels and both have been presented as viable deemed eligible by abstract review and were screened by each
surgical techniques [8]. As such, imaging is a cornerstone in the author independently. Manual crosschecks of the references were
evaluation of suspected deep neck space infections [3,5,11–13]. performed to further locate pertinent studies. Each selected article
Commonly obtained studies include lateral neck radiographs, was assigned a level of evidence by each author using guidelines
ultasonagraphy and contrast enhanced computed tomography published by Centre for Evidence-Based Medicine (www.cebm.-
(CT) [12,14,15]. Each modality has limitations, however the net). An evidence table was constructed to display and analyze
superior anatomical detail provided by CT has made this modality results. Conflict resolution was achieved collectively by all three
the preferred imaging technique [2,7,11–13,16,17]. authors after discussion and mutual agreement.
One limitation of CT imaging is its specificity with regard to The primary outcome was the binary measure of resolution of a
differentiating cellulitis versus abscess. Specificity of CT imaging in deep neck abscess with parenteral antibiotics in children who had
predicting purulence at the time of surgical incision has high documented rim enhancement of a deep neck hypodensity on CT.
variability and has been reported between 0% and 92% [8,18]. Children who were effectively treated without undergoing surgical
While the standard CT criteria for diagnosing abscess is a management were considered successes.
homogenous area of low-attenuation with rim enhancement, this A limited meta-analysis and pooling of the data was performed
finding does not always correlate with surgical findings of pus [8]. using a random effects model given the heterogeneity of the source
Malloy et al. suggest that the finding of rim enhancement on CT data. Standard error was estimated as the inverse of sample size.
represents a continuum between cellulitis and abscess and Potential publication bias was evaluated using funnel plot
concluded that there is no significant correlation between rim techniques in the method of Egger. All analyses were performed
enhancement and incidence of purulence at surgical drainage [19]. using STATA IC version 10.1, College Station, TX. For all analyses,
Kirse et al. study concluded that abscess wall scalloping was found the null hypothesis was rejected with a probability less than 0.05.
to be more specific in predicting pus than rim enhancement [8]. Pooled data results were generated for the following analysis
Despite the poor specificity of this modality to differentiate abscess groups:
from cellulitis and lymphadenitis, it is commonly accepted that CT
provides clinical utility in directing therapy [2,5,13,20]. (1) all children presenting with documented rim enhancement of a
Surgical drainage for both retropharyngeal and parapharyngeal deep neck hypodensity on CT.
abscesses has been a topic of controversy in recent literature and (2) children with documented rim enhancement of a deep neck
numerous studies suggest conservative treatment with intrave- hypodensity on CT who were initially provided a trial of
nous antibiotics together with close observation may represent an intravenous antibiotic treatment, excluding those taken for
acceptable first line of therapy [1–5,10,12–14,16,17,21–23]. immediate surgical drainage.
Unfortunately there are no well-controlled trials confirming this (3) all children with documented rim enhancement of a deep neck
hypothesis. With the advent of improved antibiotics and CT hypodensity on CT when an adequate trial of intravenous
imaging, it seems plausible that an evidence based treatment antibiotic treatment was defined as greater than 48 h.
algorithm using clinical findings and CT imaging could be
developed that includes conservative treatment with intravenous 3. Results
antibiotics as an acceptable initial option [12,23]. The primary
objective of this review is to ascertain the evidence behind a The primary medical literature search resulted in 302 potential
conservative medical approach toward the management of articles (Fig. 1). 13 additional articles were further identified from
pediatric deep neck abscesses. manual reference cross-checks. Screening of these titles resulted in
127 articles for abstract review. 25 papers were then selected for
2. Methods full article screening to determine whether or not they met
inclusion criteria. Eight articles met inclusion criteria
This study is exempt from formal review per our institutional [2,3,5,10,12,14,17,22]. Table 1 summarizes the general findings
review board. Prior to accessing the medical literature, a priori of the selected articles. Publication dates were between 1992 and
article inclusion criteria were developed for article selection. 2009. One article was prospective in design and seven were
Inclusion criteria were developed that sought to identify all papers retrospective. The overall level of evidence was grade C.
presenting a series of children with deep neck abscesses in the Sample sizes ranged from 4 to 27 patients. Antibiotic regimens
parapharyngeal or retropharyngeal space that (1) underwent a CT varied among the studies, however all medical treatment regimens
examination prior to treatment with reported findings, (2) were clinically appropriate. Although outcome measures were
received a documented inpatient intravenous antibiotic regimen, variable for each study, sufficient detail was available to extract the
and (3) the clinical response to the antibiotic regimen was data required for this systematic review. The duration of
documented or could be clearly inferred. Exclusion criteria were intravenous antibiotic therapy before determination of success
defined as: (1) papers that did not involve children under the age of or failure of medical therapy ranged from 24 h to 72 h.
18, (2) single case reports, (3) the presence of immunocompro- When all patients including those that underwent immediate
mised patients, and (4) the article was not available in the English surgery were included in the analysis, there was significant
language. heterogeneity among the studies (I2 = 98.8%; p < .001). However,
The medical literature was accessed using MEDLINE and each article uniformly presented cases suggesting that medical
EMBASE medical databases to search for articles indexed as of therapy may be a viable alternative to surgical drainage in some
 P.N. Carbone et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1647–1653 1649

Idenficaon
Records idenfied through Addional records from manual
database searching reference crosscheck
(n = 302) (n = 13)

Arcles selected for Records excluded

Screening

abstract review (n = 102)

(n = 127)

Full-text arcles excluded

• Greater than 18 yo
Full-text arcles assessed • Single case reports
Eligibility

for eligibility • Immunocompromised

(n = 25) paents
• Non-English arcle
(n = 17)
Included

Studies included in
quantave synthesis
(meta-analysis)
(n = 8)

Fig. 1. Flow diagram displaying results of systematic search strategy.

patients. When patients undergoing immediate surgical proce- 4. Discussion

dures were excluded, the interstudy heterogeneity decreased
significantly (I2 = 0%; p = .672). The pooled success rate of medical The goal of this review was to determine the level of evidence
therapy in avoiding surgical drainage in children presenting with supporting empiric antibiotic therapy in the management of
CT documented rim enhancement of a deep neck hypodensity was pediatric deep neck space abscesses. Each of the studies documents
0.517 (95%CI: 0.335, 0.700) (Fig. 2). When children taken cases of successful management with intravenous antibiotics. In an
immediately to surgery were excluded and patients who were era when antibiotics and radiographic technology have advanced,
deemed appropriate for conservative therapy by each author’s there is mounting data suggesting that non-operative approaches
clinical criteria, the success rate increased to 0.951 (95%CI: 0.851, may be acceptable treatment alternatives in selected deep neck
1.051) (Fig. 3). Subgroup analysis by duration of intravenous abscesses. However, the overall quality of the data is a relatively
antibiotic trial greater than 48 h demonstrated a pooled success poor grade C due to level 4 studies being reported. Given the low
rate of 0.740 (95%CI: 0.527, 0.953) (Fig. 4). Unfortunately, the data level of data quality, this primary goal of this manuscript is to
available precluded further subgroup analysis particularly with report the available data in an accessible format. Limited
relation to specific CT findings, mean duration of admission, type of metanalytic techniques were performed to assess summary
antibiotic therapy and age. estimates of the success rate of medical therapy for deep neck
A qualitative review of each article specifically addressing space abscesses in the setting of a clear CT diagnosis and antibiotic
complications of both medical therapy and surgical therapy therapy algorithms. The pooled analysis supports the notion that
demonstrated relatively few reported adverse outcomes. No conservative treatment of suspected deep neck abscesses with
complications of significant disease progression resulting in intravenous antibiotics is viable in various clinical scenarios of CT
mediastinitis, septicemia, airway obstruction or neurovascular documented abscesses.
decline were reported. Of the children who underwent surgical Surgical management for children has traditionally been the
management, several instances of multiple surgical procedures treatment of choice, as Johnston et al. suggest, in part because of
were reported and one child was reported to have a postoperative poor access to care, poor radiographic technology, late diagnoses,
Horner syndrome that resolved after 3 months [17]. and the associated morbidity and mortality from deep neck
Publication bias is a concern given the high level of success abscesses [23]. Some clinicians also argue that medical therapy
reported for medical therapy. As such, quantitative methods of alone is not sufficient to completely treat deep neck abscesses [20].
assessing publication bias were undertaken. Unfortunately, the However, the morbidity of surgical approaches including the need
small size of each individual study severely limits the strength for anesthesia, postoperative scarring risk and complications such
of the quantitative technique of Egger. Funnel plots (not shown) as neurovascular injury should be considered in seeking medical
of the various patient groups were inconclusive, and one therapeutic alternatives. Benefits of medical management include
must be wary of a potential publication bias in the positive avoidance of iatrogenic injury to cranial nerves or great vessels,
direction. while potentially not appreciably changing the duration of
 1650
Table 1
Evidence table.

First author/year Study design CEBM level N CT criteria Exclusion criteria Significant findings Complications Overall conclusion

Pelaz AC, 2009 Retrospective 4 7 Lucency located in the No exclusion criteria 7/7 (100%) were successfully None reported Intravenous antibiotic
parapharyngeal or specified treated with antibiotics treatment with steroids is a safe
retropharyngeal space with alternative to surgical drainage
ring enhancement in cases of a localized abscess
McClay JE, 2003 Retrospective 4 11 Rim enhancement around a Clinically unstable or 10/11 (90.9%) were successfully None reported In clinically stable children,
hypodensity measuring > 1 cm airway compromise treated with antibiotics abscesses diagnosed on CT

P.N. Carbone et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1647–1653

in every dimension scans using strict radiographic
criteria can be effectively
treated with IV antibiotics
alone
Craig FW, 2003 Retrospective 4 27 Radiologic report Posttraumatic 17 children underwent early None reported Some patients with
interpretation abscesses were I&D. 10/10 children were retropharyngeal abscess can be
excluded successfully treated with treated without surgery
antibiotics
Sichel JY, 2002 Prospective 4 11 Lucency in parapharyngeal Evidence of extension 5 children underwent None reported IV antibiotic treatment is a
space with ring enhancement of infection into other immediate I&D. 6/6 (100%) good alternative to surgical
in all patients spaces. No airway were successfully treated with drainage in cases with localized
compromise or septic antibiotics parapharyngeal infections in
shock the pediatric population
Zahara JN, 2002 Retrospective 4 4 Not specified No exclusion criteria 2/4 (50%) were successfully None reported CT is the most informative
specified treated with intravenous diagnostic tool and should be
antibiotics carried out upon suspicion
Flanary VA, 1997 Retrospective 4 14 Rim enhancement or air-fluid Patients with 12 underwent immediate I&D, Two surgical patients Patients in whom the airway is
level peritonsillar abscesses, 2/2 (100%) were successfully required a second not compromised may be
a history of trauma or a treated with antibiotics surgery and one treated with close observation
history of malignancy developed a post- and broad spectrum antibiotics.
were excluded. operative Horner’s Children under the age of 36
Medically treated syndrome months should be aggressively
children had an abscess managed
less than 1 cm in
diameter
Nagy M, 1997 Retrospective 4 14 Rim enhancement around a Patients with 11 children underwent early One surgical patient CT scan is an essential part in
hypodensity measuring > 1 cm peritonsillar abscesses, I&D. 3 children were required a second the evaluation of a child with
in every dimension superficial neck successfully treated with procedure suspected deep neck infection.
abscess, and Ludwig’s antibiotics Intravenous antibiotics are the
angina were excluded first-line medical treatment in
cases of cellulitis or abscess,
especially those with volumes
estimated to be <2000 mm3
Broughton RA, Retrospective 4 7 All patients had a round or oval No exclusion criteria 7/7 (100%) were successfully None reported Selected children with
1992 cystic lesion within the specified treated with antibiotics apparent abscess formation, as
parapharyngeal region determined by CT scan, may not
require surgical drainage
 P.N. Carbone et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1647–1653 1651

Fig. 2. Forest plot of the random effects model of the success rate of intravenous antibiotic therapy in all children presenting with documented rim enhancement of a deep
neck hypodensity on CT demonstrating a pooled success rate of 52% (95%CI: 33%, 70%). The effect size (success rate) estimate with confidence intervals is presented for each
study. The overall pooled estimate based on study weight is represented by the diamond at the bottom of the figure.

hospitalization or morbidity rates directly related to infection No clear complications of medical therapy and few complica-
[2,23,24]. tions of surgical therapy were reported in this review. No child was
A concern raised against conservative management is the reported to have progressed to neurovascular complications or
progression of the disease process and subsequent increased emergent loss of their airway. While the sample size remains small,
morbidity or mortality necessitating close observation for clinical this is an encouraging finding.
deterioration. Although not suitably addressed in this review, It should be noted that none of the articles discuss which, if any,
several reports have failed to identify a difference in hospital stay of the patients with a rim enhancing lesion on CT that went to
duration for children treated surgically or medically. A potential surgery as first-line treatment may have been treated successfully
additional concern in the current state of increasing antibiotic with conservative management. As such, no significant conclu-
resistance is the risk of not tailoring therapy to cultured organisms sions are reached in any of the articles as to which patients were
and thus potentially contributing to overall resistance patterns. more likely to fail conservative treatment. Two articles report

Fig. 3. Forest plot of the random effects model of the success rate of intravenous antibiotic therapy excluding children undergoing immediate surgery demonstrating a pooled
success rate of 95% (95%CI: 85%, 100%). The effect size (success rate) estimate with confidence intervals is presented for each study. The overall pooled estimate based on study
weight is represented by the diamond at the bottom of the figure.
1652 P.N. Carbone et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1647–1653

Fig. 4. Forest plot of the random effects model of the success rate of intravenous antibiotic therapy in all children with documented rim enhancement of a deep neck
hypodensity on CT when an adequate trial of intravenous antibiotic treatment was defined as greater than 48 h demonstrating a pooled success rate of 74% (95%CI: 53%, 95%).
The effect size (success rate) estimate with confidence intervals is presented for each study. The overall pooled estimate based on study weight is represented by the diamond
at the bottom of the figure.

failures of conservative management. McClay et al. report one concerns for airway obstruction, septicemia or further complica-
failure out of 11 patients, in which the patient had another abscess tions of deep neck abscesses. Symptoms of airway obstruction are
(submandibular) and unspecified signs clinical decline [10]. Zahara highly variable and subject to differential interpretation by
et al. report two failures (2/4) of conservative management that clinicians. Furthermore, in series where patients underwent
went on to surgical drainage, however specific details are not immediate surgical drainage, there is certainly selection bias as
described [22]. the children who underwent medical management generally had
This systematic review supports notion that conservative less severe disease.
therapy may be safely be used to manage deep neck abscesses In conclusion, data proposing medical therapy as an alternative
in children in the absence of airway distress or neurovascular to surgical intervention in deep neck abscesses is available but
compromise, but clearly shows that the available data is not robust limited in quality. In cases where medical therapy is coupled to CT
or well defined. However, the overall variability of the patient findings, intravenous antibiotics appear to be a reasonable
populations and consistent findings by each reviewed article’s alternative to immediate surgical incision and drainage in children
authors suggest that the conclusions are reliable and generalizable. with uncomplicated deep neck abscesses. Unfortunately, at this
Although surgery is considered the gold standard, it is not without time, recommendations beyond using the surgeon’s clinical
risk to the patient due to the complexity of regional anatomy. judgment regarding the clinical picture and surgical accessibility
Medical therapy offers a potential alternative that may be to determine the maximal severity of children who may be treated
successful in avoiding future surgical drainage. Given these medically is lacking. Therefore, further research is crucial to
findings, it seems reasonable to conclude that empiric antibiotics determine the appropriate selection of patients with deep neck
can be considered a first line therapy when treating deep neck abscesses who may be best served by a conservative therapeutic
infections in the pediatric population while reserving surgery for approach.
cases of failed medical therapy, large abscesses, or when a high risk
of morbidity is inevitable. However, the supporting data has References
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