Management of Pediatric Head and Neck Infections in the Emergency Department

Points & Pearls Excerpt

• If there is a subperiosteal abscess noted on imaging for mastoiditis, consult otolaryngology to percutaneously drain the abscess.
• Consider intracranial extension of sinusitis in patients with periorbital and orbital swelling with persistent headache and emesis, vomiting and headache requiring admission, emesis for > 24 hours, altered level of consciousness, focal neurologic deficits, or signs of meningitis. Order a computed tomography (CT) scan of the orbits, sinuses, or brain to evaluate for abscess, osteomyelitis, or brain extension. Order a CT venogram or magnetic resonance venography to diagnose a potential sinus venous thrombosis.
• Ludwig angina is a clinical diagnosis and requires imaging only when there is clinical concern for airway compromise or an associated dental abscess.
• If it is clinically unclear whether the patient has a peritonsillar abscess or peritonsillar cellulitis, consider a 24-hour trial of antibiotics. An improvement in symptoms indicates peritonsillar cellulitis.
• A retropharyngeal abscess typically forms from suppurative adenitis of the retropharyngeal lymph nodes; however, it can occasionally form secondary to trauma from an ingested foreign body or instrumentation to the posterior oropharynx. Order a neck CT with contrast if there is a high clinical suspicion for a retropharyngeal abscess.

Most Important References

• * Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280. (Clinical guideline) DOI: 10.1542/peds.2013-1071
• * Novis SJ, Pritchett CV, Thorne MC, et al. Pediatric deep space neck infections in U.S. children, 2000-2009. Int J Pediatr Otorhinolaryngol. 2014;78(5):832-836. (Review) DOI: 10.1016/j.ijporl.2014.02.024
• * Woods CR, Cash ED, Smith AM, et al. Retropharyngeal and parapharyngeal abscesses among children and adolescents in the United States: epidemiology and management trends, 2003-2012. J Pediatric Infect Dis Soc. 2016;5(3):259-268. (Retrospective administrative data set review; 8918 patients) DOI: 10.1093/jpids/piv010
• * Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003;128(3):332-343. (Meta-analysis; 6794 patients) DOI: 10.1067/mhn.2003.93