Management of Pediatric Head and Neck Infections in the Emergency Department (Infectious Disease CME and Pharmacology CME)

Table of Contents

 

Early diagnosis and urgent management of pediatric head and neck infections is critical for preventing complications and optimizing outcomes. Due to complex head and neck anatomy, diagnosing pediatric head and neck infections can be challenging. This issue reviews presenting signs and symptoms of pediatric head and neck infections, discusses when diagnostic studies are indicated, and offers evidence-based recommendations for management. Conditions reviewed include mastoiditis, sinusitis, Ludwig angina, peritonsillar abscess, retropharyngeal abscess, Lemierre syndrome, and acute suppurative thyroiditis. You will learn:

Common causes of serious head and neck infections

How the patient’s age can help guide the diagnosis

Common history and physical examination findings for each of the head and neck infections

When diagnostic studies are indicated, and which are recommended over others

Common pathogens that cause each of the head and neck infections

Evidence-based recommendations for antibiotic management and when surgical intervention is needed

Which patients can be managed as outpatients, which should be admitted, and which will need intensive care unit management

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Anatomy, Etiology, and Pathophysiology
   1. Head Infections
      1. Mastoiditis
      2. Sinusitis
      3. Ludwig Angina
   2. Deep Neck Infections
      1. Peritonsillar Abscess
      2. Retropharyngeal Abscess
      3. Lemierre Syndrome
      4. Acute Suppurative Thyroiditis
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
      1. Mastoiditis
      2. Sinusitis
      3. Ludwig Angina
      4. Peritonsillar Abscess
      5. Retropharyngeal Abscess
      6. Lemierre Syndrome
      7. Acute Suppurative Thyroiditis
   2. Physical Examination
      1. Mastoiditis Physical Examination Findings
      2. Sinusitis Physical Examination Findings
      3. Ludwig Angina Physical Examination Findings
      4. Peritonsillar Abscess Physical Examination Findings
      5. Retropharyngeal Abscess Physical Examination Findings
      6. Lemierre Syndrome Physical Examination Findings
      7. Acute Suppurative Thyroiditis Physical Examination Findings
9. Diagnostic Studies
   1. Mastoiditis Testing
   2. Sinusitis Testing
   3. Ludwig Angina Testing
   4. Peritonsillar Abscess Testing
   5. Retropharyngeal Abscess Testing
   6. Lemierre Syndrome Testing
   7. Acute Suppurative Thyroiditis Testing
10. Treatment
    1. Mastoiditis Treatment
    2. Sinusitis Treatment
    3. Ludwig Angina Treatment
    4. Peritonsillar Abscess Treatment
    5. Retropharyngeal Abscess Treatment
    6. Lemierre Syndrome Treatment
    7. Acute Suppurative Thyroiditis Treatment
11. Special Considerations
    1. Congenital Anomalies as Underlying Causes for Deep Neck Infections
12. Controversies and Cutting Edge
    1. Ultrasound-Guided Diagnosis and Needle Aspiration of Peritonsillar Abscess
    2. Use of Corticosteroids for Treatment of Peritonsillar Abscess
    3. Tonsillectomy in the Setting of Peritonsillar Abscess
    4. Anticoagulation in Lemierre Syndrome
13. Disposition
14. Summary
15. Time- and Cost-Effective Strategies
16. Risk Management Pitfalls for Head and Neck Infections
17. Case Conclusions
18. Clinical Pathway for Management of Pediatric Head and Neck Infections in the Emergency Department
19. Tables and Figures
    1. Table 1. History and Physical Examination Findings for Pediatric Head and Neck Infections
    2. Table 2. Common Pathogens and Treatment for Pediatric Head and Deep Neck Infections
    3. Figure 1. Mastoiditis Complicated by Postauricular Abscess With Proptosis
    4. Figure 2. Child with Elevated Floor of the Mouth in Ludwig Angina
    5. Figure 3. Right-Sided Peritonsillar Abscess With Uvula Deviation to the Left
    6. Figure 4. Intraoperative Videolaryngoscopy Showing Bulging of the Posterior Pharyngeal Wall Obstructing the Larynx and Pyriform Sinuses
    7. Figure 5. Bilateral Anterior Neck Swelling in Acute Suppurative Thyroiditis
    8. Figure 6. Computed Tomography Scan of Left-Sided Acute Suppurative Thyroiditis
    9. Figure 7. Ultrasound Measurement of the Distance from the Tonsillar Surface to the Carotid Vessel, Peritonsillar Abscess Medial to Carotid
    10. Figure 8. Ultrasound Views of Peritonsillar Abscess Before and After Aspiration
20. References

Abstract

Head and neck infections can spread to nearby structures, compromising the airway and progressing to life-threatening events. Pediatric head and neck infections can be difficult to recognize; emergency clinicians must know the signs and symptoms of head and neck infections for early diagnosis and urgent management in order to prevent complications and decrease hospitalization rates. This issue reviews presenting signs and symptoms of pediatric head and neck infections, discusses when diagnostic studies are indicated, and offers evidence-based recommendations for management. Conditions reviewed include mastoiditis, sinusitis, Ludwig angina, peritonsillar abscess, retropharyngeal abscess, Lemierre syndrome, and acute suppurative thyroiditis.

Case Presentations

A previously healthy 2-year-old girl is brought to the ED by her mother for noisy breathing and limited neck movement. The patient had fever to 39°C (102.2°F) for 2 days and a week of rhinorrhea prior to the onset of fever. The mother says the girl has been drooling for the past day. The girl's physical examination is notable for an anxious-appearing toddler with a temperature of 39°C, heart rate of 195 beats/min, blood pressure of 90/60 mm Hg, respiratory rate of 60 breaths/min, and oxygen saturation of 89%. You note stridor at rest, with supraclavicular and subcostal retractions. The girl refuses to look toward her right side. You put the child on a nonrebreather and prepare for intubation. Given the child’s symptoms, you are highly concerned that she may have an infectious process causing significant airway obstruction. With this concern, you have some trepidation in managing her airway and start to consider who to call in order to prevent any further complications, and which airway adjuncts to use when managing this difficult airway…

A 15-year-old boy with history of type 1 diabetes and poor dentition comes in via EMS. The boy is drooling and has trismus. His voice is so hoarse that all of his medical information is obtained through his mother. For the past 2 weeks he has been experiencing some pain from his left second and third mandibular molars, which has gotten progressively worse. For the past 2 days, he has had fever to 40°C (104°F), rigors, and has been sleeping more than usual. Today he awoke with an enlarged tongue, drooling, and a hoarse voice, which prompted them to come to the ED. His vital signs are notable for fever to 40°C, heart rate of 120 beats/min, blood pressure of 100/55 mm Hg, respiratory rate of 30 breaths/min, oxygen saturation of 95%, and a finger-stick glucose level of 600 mg/dL. On physical examination, you note an adolescent boy in moderate distress who is continuously expectorating sputum, with elevation of the floor of the mouth and fullness and crepitus of the bilateral submandibular area. You also note inspiratory stridor with mild supraclavicular retractions. You are concerned he is septic, with significant airway compromise, and you immediately place him on a nonrebreather, order laboratory tests, give IV fluids, and administer broad-spectrum antibiotics. You are concerned about his significant upper airway obstruction and wonder if you should prepare for a surgical airway…

A 6-year-old boy with acute lymphoblastic leukemia who was recently hospitalized for chemotherapy is brought to the ED by his parents for left-sided anterior neck swelling and a fever on the day of the visit to 38.5°C (101.3°F). He also is complaining of left ear pain and a left-sided occipital headache. Prior to discharge from the oncology floor, his last absolute neutrophil count was 800 cells/mm³. The child appears to be in moderate distress, with a temperature of 38.5°C, heart rate of 140 beats/min, blood pressure of 100/65 mm Hg, respiratory rate of 35 breaths/min, and oxygen saturation of 95%. He has left anterior neck swelling in the area of the left hemi-thyroid, with overlying erythema, fluctuance, and tenderness to palpation. The area of swelling measures approximately 3 cm by 4 cm. You note mild inspiratory stridor and supraclavicular retractions. You worry that he is septic, and the current respiratory symptoms are a sign of impending airway compromise. He is therefore placed on a nonrebreather, his subcutaneous port is accessed, and laboratory studies are drawn. He receives IV fluids and is started on broad-spectrum antibiotics. You wonder what the best imaging modality would be to further characterize the infection and what would be the best way to prepare to manage this child’s airway…

Introduction

Many children present to the emergency department (ED) with signs and symptoms of upper respiratory infections (URIs). Of this population of patients, a small subset may have potential complications that can be missed yet require early recognition and management by the emergency clinician. Due to complex head and neck anatomy, diagnosing pediatric head and neck infections can be challenging.¹ There are also very limited data on proper management. If these infections are not diagnosed and treated in a timely manner, they may progress to deep neck spaces. According to a retrospective study in the United States, not only is there variable management for children with deep space neck infections, but > $75 million dollars were spent on hospital admissions. Deep space neck infections can result in airway compromise and mediastinitis, both of which are associated with increased mortality rates. There are currently no randomized trials studying optimal management for these infections.² This issue of Pediatric Emergency Medicine Practice reviews the symptoms, evaluation, and management of pediatric mastoiditis, sinusitis, Ludwig angina, peritonsillar abscess, retropharyngeal abscess, Lemierre syndrome, and acute suppurative thyroiditis.

Critical Appraisal of the Literature

An online literature search was performed using the PubMed and Ovid MEDLINE^® databases. Search terms included: pediatric head and neck infections, mastoiditis, pediatric sinusitis, Ludwig’s angina, retropharyngeal abscess, peritonsillar abscess, Lemierre syndrome, and suppurative thyroiditis. A total of 185 articles were identified, and 170 were chosen for inclusion. Overall, there are limited high-quality data for evaluation and treatment of the pathologies discussed in this issue. The majority of the included articles were retrospective chart reviews, several were case reports, and there were limited meta-analyses found. Of the 170 included articles, there were 9 randomized trials examining current management and diagnosis of some of the 7 pathologies discussed in this issue. The most recent American Academy of Pediatrics (AAP) guideline entitled, “Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years” was reviewed,³ and 4 clinical guidelines focusing on acute sinusitis and peritonsillar abscesses were also reviewed.^3-6

Risk Management Pitfalls for Head and Neck Infections

1. “The child had difficulty breathing, so I decided to secure the airway on my own.”

Attempting to secure the airway of a child with a retropharyngeal abscess, Ludwig angina, or a large acute suppurative thyroiditis without the assistance of the anesthesia or otolaryngology team places the patient at high risk for fatal complications. Examination and airway management should be performed in a controlled setting (eg, the operating room), with the proper difficult airway devices.

7. “My 7-year-old patient with an elevated floor of the mouth, erythema, and tenderness started having stridor. I decided to start him on oxygen by face mask and sent him to the floor for further management.”

Patients with Ludwig angina and stridor or any sign of respiratory distress require prompt airway management and ICU monitoring. These patients usually require intubation and, if there is significant airway obstruction, even a cricothyroidotomy.

9. “The patient had completed a 14-day course of antibiotics for acute suppurative thyroiditis 2 months ago and came back with a suddenly inflamed and tender thyroid gland. On chart review from his last admission, no direct laryngoscopy, CT scan of the neck with contrast, or barium esophagography was found.”

After resolution of the acute inflammatory period, anatomic imaging should be performed to rule out any defect that increases the risk of recurrent acute suppurative thyroiditis infections. If an anatomic abnormality is identified, it should be removed promptly to prevent future infections or complications.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are highlighted.

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