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Computed tomography in the evaluation of pediatric neck infections
Computed tomography in the evaluation of pediatric neck infections RALPH F. WETMORE, MD, FACS, SOROOSH MAHBOUBI, MD, FACR, and SUREYYA K. SOYUPAK, MD, Philadelphia, Pennsylvania
In children, infections involving both the superficial and deep neck spaces are common. Children so affected typically present with fever, neck mass, neck stiffness, and, occasionally, airway compromise. Radiologic modalities used in the evaluation of neck infections include plain lateral neck radiography, ultrasound, computed tomography, and magnetic resonance imaging. All these modalities have proved useful in the treatment of such infections, specifically the decision to perform incision and drainage. The charts of 66 patients—33 with superficial and 33 with deep neck infections—were analyzed with respect to symptoms, signs, computed tomography findings, and need for surgical intervention. Computed tomography was not particularly helpful in superficial neck infections with regard to the decision to perform surgical drainage; however, it did localize and demonstrate the extent of infection. In deep neck infections we found a 92% correlation between computed tomographic evidence of an abscess and surgical confirmation of one. Contrast-enhanced computed tomography remains an excellent tool in the treatment of neck infections in children. (Otolaryngol Head Neck Surg 1998;119:624-7.)
B
oth superficial and deep neck infections are common in children. The sinuses, ears, and pharynx are the most common sources of these infections, although trauma to the head and neck has become an increasingly common source of retropharyngeal infection.1 Although superficial neck infections rarely result in significant morbidity, they may have a significant impact on the patient’s family. Deep neck infections, on the other hand, do have From the Departments of Pediatric Otolaryngology and Radiology, Children’s Hospital of Philadelphia; and the University of Pennsylvania School of Medicine. Presented at the Annual Meeting of the Society of Ear, Nose and Throat Advances in Children, Cancun, Mexico, December 1995. Reprint requests: Ralph F. Wetmore, MD, Department of Pediatric Otolaryngology, Children’s Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA 19104. Copyright © 1998 by the American Academy of Otolaryngology– Head and Neck Surgery, Foundation, Inc. 0194-5998/98/$5.00 + 0 23/1/87030 624
a significant morbidity and, rarely, mortality, as reported in the literature. Airway obstruction, septicemia, rupture of an abscess into the pharynx and airway with subsequent aspiration, mediastinal extension of infection, jugular thrombosis, and carotid artery rupture are complications that have diminished in frequency since the onset of antibiotic therapy. Several radiologic modalities are helpful in identifying the location and extent of superficial and deep neck infections. Plain lateral neck radiography is useful in visualizing the retropharyngeal space when an abscess in that region is suspected. Ultrasound (US) and direct aspiration of pus can distinguish an abscess from a confluence of lymph nodes. Contrast-enhanced CT and MRI have become the standard of care in most institutions for the evaluation of patients with suspected abscesses of the head and neck. To assess the efficacy of CT in the management of both superficial and deep neck infections, we reviewed its use in pediatric patients. METHODS AND MATERIAL We retrospectively reviewed the outpatient and inpatient charts of children treated at the Children’s Hospital of Philadelphia for superficial and deep neck infections. Sixtysix such patients were identified as having been treated between May 1992 and May 1995. CT was correlated with the clinical signs and symptoms, the response to antibiotic therapy, and surgical findings, when surgery was performed. RESULTS
Of the 66 patients who were found to have had neck infections, 33 (50%) presented with superficial neck infections, defined as adenitis or an abscess not involving the deep fascial spaces of the neck. The remaining 33 patients (50%) presented with cellulitis or abscess of the retropharyngeal or parapharyngeal deep fascial spaces. Of the 33 patients with superficial infection, 16 (48%) were treated medically only (intravenous antibiotics) and 17 (52%) required surgical drainage in addition to antibiotic therapy. The demographic data of both groups are shown in Table 1. The sex and age distributions of both subgroups were similar. Mean age in children who underwent surgical drainage was younger, and the duration of hospital stay was slightly longer, but these differences were not significant. Fever was com-
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Table 1. Superficial neck infections (N = 33)
Features
Male/female (%) Age range Mean age (yr) Mean hospital stay (days)
Medical therapy alone (n = 16)
Medical and surgical therapy (n = 17)
69/31 2 mo–17 yr 5.7 6.4
71/29 3 mo–12 yr 3.6 7
Table 2. Deep neck infections (N = 33)
Features
Male/female (%) Age range Mean age (yr) Mean hospital stay (days)
Medical therapy alone (n = 20)
Medical and surgical therapy (n = 13)
65/35 1–7 yr 3.2 4
38/62 3 wk–7 yr 2.3 6.3
mon in most patients, and each presented with a neck mass. Complaints of neck stiffness were more frequent in the subgroup treated with antibiotics alone. In reviewing the CT scans of the 33 children with superficial infection, we found that most demonstrated a single focus of infection. A hypodense area was identified in approximately 80% of cases in both treatment groups. Contrast-enhanced CT showed no rim enhancement in those patients treated medically, whereas 24% of surgically treated patients had evidence of rim enhancement. Involvement of the skin and subcutaneous tissue was more common in the surgically treated group. Airway alteration was demonstrated in a small number of patients in each group. Both subgroups of superficially infected patients were treated with a variety of antibiotic regimens, including oxacillin, clindamycin, cephazolin, or a combination thereof. Blood and wound cultures were rarely obtained in the medically treated group. Wound cultures in the surgically treated patients were positive in 44% of cases; 25% grew coagulase-positive Staphylococcus species. α-Streptococcus, Enterococcus, and Klebsiella were also found. Of the 33 patients with deep neck infections, 27 cases (82%) involved the retropharyngeal space and 6 (18%) the parapharyngeal space. Twenty children (61%) were treated with intravenous antibiotics alone; 13 (39%) required combined medical and surgical therapy. The demographics of both subgroups are listed in Table 2; we noted little difference between subgroups, except for a sex difference that was not statistically significant. The subgroup that required combined therapy had a significantly longer duration of hospital stay. Little difference
Fig. 1. Contrast-enhanced CT scan of a superficial neck abscess in a 4-year-old boy. The abscess was drained through an external neck incision. A region of hypodensity (arrow) is surrounded by ring enhancement (arrowhead) and subcutaneous edema (clear arrow).
Fig. 2. Contrast-enhanced CT scan in a 2-year-old boy demonstrates a hypodense area (arrow) with slight ring enhancement (arrowhead) in the retropharynx. Surgical drainage yielded 10 mL of pus.
was found between subgroups with regard to presenting symptoms of fever, drooling, and neck stiffness. On the other hand, with regard to presence of a neck mass at the time of presentation, the surgical group had a statistically significantly greater incidence. As in the superficial-infection category, most children in both subgroups in the deep-infection category had a single focus of infection on CT scan. Demon-
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Fig. 3. Contrast-enhanced CT scan in a 5-year-old girl shows an area of hypodensity surrounded by ring enhancement (arrow). Deviation of the airway is also present (arrowhead). External and internal drainage of a parapharyngeal abscess was performed.
stration of subcutaneous involvement was more common in the combined-therapy subgroup, probably because of more extensive disease. As would be expected, the combined-therapy subgroup had a significant incidence of rim enhancement compared with those treated with antibiotics alone. We found a 92% correlation between CT-scan evidence of an abscess and surgical confirmation of one. Some alteration of the airway could be demonstrated on CT scan in both subgroups, with no difference between subgroups. In the deep-infection category, clindamycin was popular in both treatment groups, both alone and in combination with cephalosporins. Blood cultures were negative, whereas wound cultures were positive, usually for coagulase-positive Streptococcus or Group A βStreptococcus. DISCUSSION
Signs and symptoms of both superficial and deep neck infections remain consistent. Children with superficial neck infections typically presented with neck masses. Fever and other symptoms common to deep neck infections—drooling, neck stiffness, and fever— were not as common in our superficial-infection group. Deep neck infections, on the other hand, often involve a history of preceding illness and fever. Neck stiffness
Otolaryngology– Head and Neck Surgery December 1998
Fig. 4. Contrast-enhanced CT scan in a 3-year-old child with a retropharyngeal abscess demonstrates a region of hypodensity with surrounding ring enhancement (arrow).
was seen often enough that complaint of it should suggest a deep neck infection. A history of stridor or symptoms of respiratory distress was found in as many as 50% of patients in some series.1-3 Pathogens recovered from cultures of both superficial and deep neck infections tend to be gram-positive aerobes. Coagulase-positive Staphylococcus was found in approximately one quarter of both the superficial and deep subgroups. Other series have demonstrated the incidence of Staphylococcus to range from 18% to 83%.4-6 Staphylococcus has also been associated with neck infections that have followed an episode of neck trauma.1 Group A β-hemolytic Streptococcus was found in approximately one quarter of the deep neck infections, an incidence similar to that found in other series.5,6 Although anaerobic bacteria such as Bacteroides were not recovered in patients who underwent surgical drainage in this series, Gianoli et al.1 reported an incidence approaching 50%.1 As noted by Broughton,7 correlation of surgical cultures with blood and throat cultures is often low, a finding confirmed by our study. Although plain lateral neck radiography is not helpful in patients with superficial neck infections, it may be useful in the evaluation of deep neck infections, especially as a screening tool for retropharyngeal abscess. Because bulging of the retropharynx may occur during
Otolaryngology– Head and Neck Surgery Volume 119 Number 6
expiration, an inspiratory film is most reliable. In cases in which the lateral neck radiograph is inconclusive, fluoroscopy of the airway may be helpful in demonstrating widening of the retropharyngeal space.8,9 Plain lateral neck radiography is most specific for an abscess when a fluid-fluid level can be identified. With contrast-enhanced CT evaluation of children with superficial neck infection, only 24% of those infections treated surgically showed definite rim enhancement (Fig. 1). The decision to perform surgery in such cases was based on clinical findings—typically skin changes and palpable fluctuance. In the deep-infection category, the correlation was much greater— 92%—between surgical findings of an abscess and CTscan evidence of a hypodense region with surrounding rim enhancement (Figs. 2 through 4). This correlation compares favorably to those of other series comparing surgical and CT-scan findings.10-12 Lazor et al.10 showed 91% sensitivity but 60% specificity in a large series of children, and Holt et al.11 reported neither false positives nor false negatives in a smaller series. Healy,13 in analyzing a small series from Children’s Hospital of Buffalo, reported that CT scanning more accurately defined a neck abscess than did MRI or US. In addition to confirming the diagnosis of a neck abscess, CT scanning is helpful in localizing the abscess, making planning for surgery much easier. Several authors refute the value of CT scanning in the diagnosis of neck abscesses. Glasier et al.8 reported that US was more predictive of an abscess than CT scanning. Sichel et al.14 recently suggested that CT scanning is not helpful in the treatment of children with deep neck infections, although their study population was limited. Even in cases in which an abscess has been identified on CT, some authors favor medical management alone. Broughton cited eight cases of parapharyngeal space infections, including several with a frank abscess on CT, that were successfully treated with intravenous antibiotic therapy alone or in combination with CT-guided needle aspiration.7 Most authors, however, recommend surgical drainage of deep neck infections.5,6,9 CONCLUSION
Contrast-enhanced CT remains an important tool in the evaluation of both superficial and deep neck infec-
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tions. In cases of superficial infection, CT scanning does not appear to correlate well with surgical findings of an abscess but it is useful in localizing and determining the extent of infection. Presence of a deep neck abscess, as demonstrated by rim enhancement surrounding a hypodense region on contrast-enhanced CT, does appear to correlate well with surgical findings. In children in whom the severity of infection is evolving, repeated CT scan evaluation is crucial in the decision to intervene surgically. REFERENCES 1. Gianoli GJ, Espinola TE, Guarisco JL, et al. Retropharyngeal space infection: changing trends. Otolaryngol Head Neck Surg 1991;105:92-100. 2. Morrison JE, Pashley NRT. Retropharyngeal abscesses in children: a 10-year review. Pediatr Emerg Care 1988;4:9-11. 3. Thompson JW, Cohen SR, Reddix P. Retropharyngeal abscess in children: a retrospective and historical analysis. Laryngoscope 1988;98:589-92. 4. Brodsky L, Belles W, Brody A, et al. Needle aspiration of neck abscesses in children. Clin Pediatr 1992;31:71-6. 5. Hawkins DB, Austin JR. Abscesses of the neck in infants and young children: a review of 112 cases. Ann Otol Rhinol Laryngol 1991;100:361-5. 6. Ungkanont K, Yellon RF, Weissman JL, et al. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995;112:375-82. 7. Broughton RA. Nonsurgical management of deep neck infections in children. Pediatr Infect Dis J 1992;11:14-8. 8. Glasier CM, Stark JE, Jacobs RF, et al. CT and ultrasound imaging of retropharyngeal abscesses in children. AJNR Am J Neuroradiol 1992;13:1191-5. 9. Mahboubi S, Kramer S. The pediatric airway. J Thorac Imag 1995;10:156-70. 10. Lazor JB, Cunningham MJ, Eavey RD, et al. Comparison of computed tomography and surgical findings in deep neck infections. Otolaryngol Head Neck Surg 1994;111:746-50. 11. Holt GR, McManus K, Newman RK, et al. Computed tomography in the diagnosis of deep-neck infections. Arch Otolaryngol 1982;108:693-6. 12. Ravindranath T, Janakiraman N, Harris V. Computed tomography in diagnosing retropharyngeal abscess in children. Clin Pediatr 1993;32:242-4. 13. Healy GB. Inflammatory neck masses in children: a comparison of computed tomography, ultrasound, and magnetic resonance imaging. Arch Otolaryngol Head Neck Surg 1989;115: 1027-8. 14. Sichel JY, Gomori JM, Saah D, et al. Parapharyngeal abscess in children: the role of CT of diagnosis and treatment. Int J Pediatr Otorhinolaryngol 1996;35:213-22.
In children, infections involving both the superficial and deep neck spaces are common. Children so affected typically present with fever, neck mass, neck stiffness, and, occasionally, airway compromise. Radiologic modalities used in the evaluation of neck infections include plain lateral neck radiography, ultrasound, computed tomography, and magnetic resonance imaging. All these modalities have proved useful in the treatment of such infections, specifically the decision to perform incision and drainage. The charts of 66 patients—33 with superficial and 33 with deep neck infections—were analyzed with respect to symptoms, signs, computed tomography findings, and need for surgical intervention. Computed tomography was not particularly helpful in superficial neck infections with regard to the decision to perform surgical drainage; however, it did localize and demonstrate the extent of infection. In deep neck infections we found a 92% correlation between computed tomographic evidence of an abscess and surgical confirmation of one. Contrast-enhanced computed tomography remains an excellent tool in the treatment of neck infections in children. (Otolaryngol Head Neck Surg 1998;119:624-7.)
B
oth superficial and deep neck infections are common in children. The sinuses, ears, and pharynx are the most common sources of these infections, although trauma to the head and neck has become an increasingly common source of retropharyngeal infection.1 Although superficial neck infections rarely result in significant morbidity, they may have a significant impact on the patient’s family. Deep neck infections, on the other hand, do have From the Departments of Pediatric Otolaryngology and Radiology, Children’s Hospital of Philadelphia; and the University of Pennsylvania School of Medicine. Presented at the Annual Meeting of the Society of Ear, Nose and Throat Advances in Children, Cancun, Mexico, December 1995. Reprint requests: Ralph F. Wetmore, MD, Department of Pediatric Otolaryngology, Children’s Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA 19104. Copyright © 1998 by the American Academy of Otolaryngology– Head and Neck Surgery, Foundation, Inc. 0194-5998/98/$5.00 + 0 23/1/87030 624
a significant morbidity and, rarely, mortality, as reported in the literature. Airway obstruction, septicemia, rupture of an abscess into the pharynx and airway with subsequent aspiration, mediastinal extension of infection, jugular thrombosis, and carotid artery rupture are complications that have diminished in frequency since the onset of antibiotic therapy. Several radiologic modalities are helpful in identifying the location and extent of superficial and deep neck infections. Plain lateral neck radiography is useful in visualizing the retropharyngeal space when an abscess in that region is suspected. Ultrasound (US) and direct aspiration of pus can distinguish an abscess from a confluence of lymph nodes. Contrast-enhanced CT and MRI have become the standard of care in most institutions for the evaluation of patients with suspected abscesses of the head and neck. To assess the efficacy of CT in the management of both superficial and deep neck infections, we reviewed its use in pediatric patients. METHODS AND MATERIAL We retrospectively reviewed the outpatient and inpatient charts of children treated at the Children’s Hospital of Philadelphia for superficial and deep neck infections. Sixtysix such patients were identified as having been treated between May 1992 and May 1995. CT was correlated with the clinical signs and symptoms, the response to antibiotic therapy, and surgical findings, when surgery was performed. RESULTS
Of the 66 patients who were found to have had neck infections, 33 (50%) presented with superficial neck infections, defined as adenitis or an abscess not involving the deep fascial spaces of the neck. The remaining 33 patients (50%) presented with cellulitis or abscess of the retropharyngeal or parapharyngeal deep fascial spaces. Of the 33 patients with superficial infection, 16 (48%) were treated medically only (intravenous antibiotics) and 17 (52%) required surgical drainage in addition to antibiotic therapy. The demographic data of both groups are shown in Table 1. The sex and age distributions of both subgroups were similar. Mean age in children who underwent surgical drainage was younger, and the duration of hospital stay was slightly longer, but these differences were not significant. Fever was com-
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Table 1. Superficial neck infections (N = 33)
Features
Male/female (%) Age range Mean age (yr) Mean hospital stay (days)
Medical therapy alone (n = 16)
Medical and surgical therapy (n = 17)
69/31 2 mo–17 yr 5.7 6.4
71/29 3 mo–12 yr 3.6 7
Table 2. Deep neck infections (N = 33)
Features
Male/female (%) Age range Mean age (yr) Mean hospital stay (days)
Medical therapy alone (n = 20)
Medical and surgical therapy (n = 13)
65/35 1–7 yr 3.2 4
38/62 3 wk–7 yr 2.3 6.3
mon in most patients, and each presented with a neck mass. Complaints of neck stiffness were more frequent in the subgroup treated with antibiotics alone. In reviewing the CT scans of the 33 children with superficial infection, we found that most demonstrated a single focus of infection. A hypodense area was identified in approximately 80% of cases in both treatment groups. Contrast-enhanced CT showed no rim enhancement in those patients treated medically, whereas 24% of surgically treated patients had evidence of rim enhancement. Involvement of the skin and subcutaneous tissue was more common in the surgically treated group. Airway alteration was demonstrated in a small number of patients in each group. Both subgroups of superficially infected patients were treated with a variety of antibiotic regimens, including oxacillin, clindamycin, cephazolin, or a combination thereof. Blood and wound cultures were rarely obtained in the medically treated group. Wound cultures in the surgically treated patients were positive in 44% of cases; 25% grew coagulase-positive Staphylococcus species. α-Streptococcus, Enterococcus, and Klebsiella were also found. Of the 33 patients with deep neck infections, 27 cases (82%) involved the retropharyngeal space and 6 (18%) the parapharyngeal space. Twenty children (61%) were treated with intravenous antibiotics alone; 13 (39%) required combined medical and surgical therapy. The demographics of both subgroups are listed in Table 2; we noted little difference between subgroups, except for a sex difference that was not statistically significant. The subgroup that required combined therapy had a significantly longer duration of hospital stay. Little difference
Fig. 1. Contrast-enhanced CT scan of a superficial neck abscess in a 4-year-old boy. The abscess was drained through an external neck incision. A region of hypodensity (arrow) is surrounded by ring enhancement (arrowhead) and subcutaneous edema (clear arrow).
Fig. 2. Contrast-enhanced CT scan in a 2-year-old boy demonstrates a hypodense area (arrow) with slight ring enhancement (arrowhead) in the retropharynx. Surgical drainage yielded 10 mL of pus.
was found between subgroups with regard to presenting symptoms of fever, drooling, and neck stiffness. On the other hand, with regard to presence of a neck mass at the time of presentation, the surgical group had a statistically significantly greater incidence. As in the superficial-infection category, most children in both subgroups in the deep-infection category had a single focus of infection on CT scan. Demon-
626
WETMORE et al.
Fig. 3. Contrast-enhanced CT scan in a 5-year-old girl shows an area of hypodensity surrounded by ring enhancement (arrow). Deviation of the airway is also present (arrowhead). External and internal drainage of a parapharyngeal abscess was performed.
stration of subcutaneous involvement was more common in the combined-therapy subgroup, probably because of more extensive disease. As would be expected, the combined-therapy subgroup had a significant incidence of rim enhancement compared with those treated with antibiotics alone. We found a 92% correlation between CT-scan evidence of an abscess and surgical confirmation of one. Some alteration of the airway could be demonstrated on CT scan in both subgroups, with no difference between subgroups. In the deep-infection category, clindamycin was popular in both treatment groups, both alone and in combination with cephalosporins. Blood cultures were negative, whereas wound cultures were positive, usually for coagulase-positive Streptococcus or Group A βStreptococcus. DISCUSSION
Signs and symptoms of both superficial and deep neck infections remain consistent. Children with superficial neck infections typically presented with neck masses. Fever and other symptoms common to deep neck infections—drooling, neck stiffness, and fever— were not as common in our superficial-infection group. Deep neck infections, on the other hand, often involve a history of preceding illness and fever. Neck stiffness
Otolaryngology– Head and Neck Surgery December 1998
Fig. 4. Contrast-enhanced CT scan in a 3-year-old child with a retropharyngeal abscess demonstrates a region of hypodensity with surrounding ring enhancement (arrow).
was seen often enough that complaint of it should suggest a deep neck infection. A history of stridor or symptoms of respiratory distress was found in as many as 50% of patients in some series.1-3 Pathogens recovered from cultures of both superficial and deep neck infections tend to be gram-positive aerobes. Coagulase-positive Staphylococcus was found in approximately one quarter of both the superficial and deep subgroups. Other series have demonstrated the incidence of Staphylococcus to range from 18% to 83%.4-6 Staphylococcus has also been associated with neck infections that have followed an episode of neck trauma.1 Group A β-hemolytic Streptococcus was found in approximately one quarter of the deep neck infections, an incidence similar to that found in other series.5,6 Although anaerobic bacteria such as Bacteroides were not recovered in patients who underwent surgical drainage in this series, Gianoli et al.1 reported an incidence approaching 50%.1 As noted by Broughton,7 correlation of surgical cultures with blood and throat cultures is often low, a finding confirmed by our study. Although plain lateral neck radiography is not helpful in patients with superficial neck infections, it may be useful in the evaluation of deep neck infections, especially as a screening tool for retropharyngeal abscess. Because bulging of the retropharynx may occur during
Otolaryngology– Head and Neck Surgery Volume 119 Number 6
expiration, an inspiratory film is most reliable. In cases in which the lateral neck radiograph is inconclusive, fluoroscopy of the airway may be helpful in demonstrating widening of the retropharyngeal space.8,9 Plain lateral neck radiography is most specific for an abscess when a fluid-fluid level can be identified. With contrast-enhanced CT evaluation of children with superficial neck infection, only 24% of those infections treated surgically showed definite rim enhancement (Fig. 1). The decision to perform surgery in such cases was based on clinical findings—typically skin changes and palpable fluctuance. In the deep-infection category, the correlation was much greater— 92%—between surgical findings of an abscess and CTscan evidence of a hypodense region with surrounding rim enhancement (Figs. 2 through 4). This correlation compares favorably to those of other series comparing surgical and CT-scan findings.10-12 Lazor et al.10 showed 91% sensitivity but 60% specificity in a large series of children, and Holt et al.11 reported neither false positives nor false negatives in a smaller series. Healy,13 in analyzing a small series from Children’s Hospital of Buffalo, reported that CT scanning more accurately defined a neck abscess than did MRI or US. In addition to confirming the diagnosis of a neck abscess, CT scanning is helpful in localizing the abscess, making planning for surgery much easier. Several authors refute the value of CT scanning in the diagnosis of neck abscesses. Glasier et al.8 reported that US was more predictive of an abscess than CT scanning. Sichel et al.14 recently suggested that CT scanning is not helpful in the treatment of children with deep neck infections, although their study population was limited. Even in cases in which an abscess has been identified on CT, some authors favor medical management alone. Broughton cited eight cases of parapharyngeal space infections, including several with a frank abscess on CT, that were successfully treated with intravenous antibiotic therapy alone or in combination with CT-guided needle aspiration.7 Most authors, however, recommend surgical drainage of deep neck infections.5,6,9 CONCLUSION
Contrast-enhanced CT remains an important tool in the evaluation of both superficial and deep neck infec-
WETMORE et al.
627
tions. In cases of superficial infection, CT scanning does not appear to correlate well with surgical findings of an abscess but it is useful in localizing and determining the extent of infection. Presence of a deep neck abscess, as demonstrated by rim enhancement surrounding a hypodense region on contrast-enhanced CT, does appear to correlate well with surgical findings. In children in whom the severity of infection is evolving, repeated CT scan evaluation is crucial in the decision to intervene surgically. REFERENCES 1. Gianoli GJ, Espinola TE, Guarisco JL, et al. Retropharyngeal space infection: changing trends. Otolaryngol Head Neck Surg 1991;105:92-100. 2. Morrison JE, Pashley NRT. Retropharyngeal abscesses in children: a 10-year review. Pediatr Emerg Care 1988;4:9-11. 3. Thompson JW, Cohen SR, Reddix P. Retropharyngeal abscess in children: a retrospective and historical analysis. Laryngoscope 1988;98:589-92. 4. Brodsky L, Belles W, Brody A, et al. Needle aspiration of neck abscesses in children. Clin Pediatr 1992;31:71-6. 5. Hawkins DB, Austin JR. Abscesses of the neck in infants and young children: a review of 112 cases. Ann Otol Rhinol Laryngol 1991;100:361-5. 6. Ungkanont K, Yellon RF, Weissman JL, et al. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995;112:375-82. 7. Broughton RA. Nonsurgical management of deep neck infections in children. Pediatr Infect Dis J 1992;11:14-8. 8. Glasier CM, Stark JE, Jacobs RF, et al. CT and ultrasound imaging of retropharyngeal abscesses in children. AJNR Am J Neuroradiol 1992;13:1191-5. 9. Mahboubi S, Kramer S. The pediatric airway. J Thorac Imag 1995;10:156-70. 10. Lazor JB, Cunningham MJ, Eavey RD, et al. Comparison of computed tomography and surgical findings in deep neck infections. Otolaryngol Head Neck Surg 1994;111:746-50. 11. Holt GR, McManus K, Newman RK, et al. Computed tomography in the diagnosis of deep-neck infections. Arch Otolaryngol 1982;108:693-6. 12. Ravindranath T, Janakiraman N, Harris V. Computed tomography in diagnosing retropharyngeal abscess in children. Clin Pediatr 1993;32:242-4. 13. Healy GB. Inflammatory neck masses in children: a comparison of computed tomography, ultrasound, and magnetic resonance imaging. Arch Otolaryngol Head Neck Surg 1989;115: 1027-8. 14. Sichel JY, Gomori JM, Saah D, et al. Parapharyngeal abscess in children: the role of CT of diagnosis and treatment. Int J Pediatr Otorhinolaryngol 1996;35:213-22.