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Children with Deep Space Neck Infections: Our Experience with 178 Children
Jeffrey Cheng and Lisa Elden
Otolaryngology -- Head and Neck Surgery 2013 148: 1037 originally published online 21 March 2013
DOI: 10.1177/0194599813482292

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Original ResearchPediatric Otolaryngology
Children with Deep Space Neck
Infections: Our Experience with
178 Children
Jeffrey Cheng, MD1, and Lisa Elden, MD1,2
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. To identify clinical features associated with unsuc-
cessful medical therapy in children with deep space neck
infections (DSNIs).
Study Design. Consecutive case series with chart review.
Setting. Tertiary-care, academic childrens hospital.
Subjects and Methods. One hundred seventy-eight pediatric
patients treated for retropharyngeal or parapharyngeal
infections between July 1, 2007, and May 23, 2012.
Results. Median age was 34.5 months (2.9 years; range,
2-142 months); two-thirds were male. Increased surgical
drainage was found in children age 15 months (P = .002)
and for abscesses .2.2 cm (P = .0001). Risk factors associ-
ated with increased likelihood of medical therapy failure
included age 51 months, intensive care unit admission, and
computed tomography findings consistent with abscess size
.2.2 cm. Methicillin-resistant Staphylococcus aureus infec-
tions were found more often in younger children, with the
highest incidence in those 15 months of age (P = .001). All
children had resolution of infection.
Conclusion. Deep space neck infections in children can often
be successfully managed with medical therapy alone, but life-
threatening complications may occur. We recommend that
young patients be managed cautiously.
Keywords
parapharyngeal infection, retropharyngeal infection, pedia-
tric, deep space neck infection
Received November 16, 2012; revised January 30, 2013; accepted
February 21, 2013.
I
nfections of the deep neck spaces (DSNIs) in children
are not uncommon, especially involving the parapharyn-
geal and retropharyngeal areas. They often present with
a prodromal illness with upper respiratory tract symptoms,
with or without fever, which progresses to include decreased
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Otolaryngology
Head and Neck Surgery
148(6) 10371042
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2013
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DOI: 10.1177/0194599813482292
http://otojournal.org
oral intake, neck pain, swelling of the cervical lymph nodes,
and limitations in neck range of motion with or without tris-
mus, which may be associated with either a deep neck
space cellulitis or abscess formation.1
A number of authors have presented evidence for an initial
trial of medical treatment with empiric intravenous antibiotic
therapy, reserving surgery for those cases that fail to clini-
cally improve or to secure a compromised airway. Johnston
et al2 concluded from their experience with 32 children
treated for parapharyngeal and retropharyngeal infections,
including cellulitis and abscesses, that an initial trial of intra-
venous antibiotics may not adversely affect the clinical out-
come and may obviate the need for surgical intervention.
Likewise, other authors support the use of medical therapy
alone, concluding that 51% to 100% of pediatric patients
with these infections have been successfully treated without
surgery, even when computed tomography (CT) findings
were suggestive of abscess and not cellulitis.3,4 Factors that
have been reported to be associated with severe infections
and complicated clinical courses include the presence of
airway obstruction and multiple abscess sites.5
As evidence in the literature suggests, most children with
DSNIs have been successfully managed medically and may
avoid surgery. Our objective was to report and examine our
own experience and outcomes and to identify clinical fea-
tures in children who were more likely to have resolution of
their infections with medical therapy compared with those
who underwent surgical drainage (immediate or delayed).
Methods
We performed a consecutive case series review of pediatric
patients aged 2 months to 12 years diagnosed with and
treated for infections of the parapharyngeal or retropharyn-
geal space between July 1, 2007, and May 23, 2012.
1
Division of Pediatric Otolaryngology, The Childrens Hospital of
Philadelphia, Philadelphia, Pennsylvania, USA
2
Department of OtorhinolaryngologyHead and Neck Surgery, Perelman
School of Medicine at the University of Pennsylvania, Philadelphia,
Pennsylvania, USA
Corresponding Author:
Jeffrey Cheng, MD, Division of Pediatric Otolaryngology, The Childrens
Hospital of Philadelphia, One Wood Center, 34th Street and Civic Center
Blvd, Philadelphia, PA 19104 USA.
Email: chengj1@email.chop.edu
1038
Table 1. Clinical features of the patients.
Sex, No. (%)
Female
Male
Age, mo, median 6 SD (range)
ICU admission, No. (%)
WBC at presentation, mean 6 SD
Length of hospital stay, d, median 6 SD
Surgery, No. (%)
CT performed, No. (%)
Maximum dimension abscess on CT, cm, median 6 SD (range)
Abbreviations: CT, computed tomography; ICU, intensive care unit; WBC, white blood cell count.
Evaluable patients were identified by querying billing
records for the International Classification of Diseases,
Ninth Revision (ICD-9) codes: 478.21 (cellulitis of pharynx
or nasopharynx), 478.22 (parapharyngeal abscess), 478.24
(retropharyngeal abscess), and 478.25 (edema of pharynx or
nasopharynx). To identify patients with parapharyngeal or
retropharyngeal space infections to be included in the study,
we reviewed their charts for clinical symptoms of a deep
neck space infection, including fever, neck or throat pain,
torticollis, or neck mass, and/or CT or magnetic resonance
imaging (MRI) findings of infection or abscess in the deep
neck spaces and required admission to our hospital for
treatment.
We chose to exclude patients in the neonatal period (day
of life 60) because those patients who present with a feb-
rile illness are usually managed using a different paradigm
directed to a fever of unknown origin and are unlikely to
have deep space neck infections. All patients were initially
treated with intravenous antibiotic therapy upon hospital
admission. The patients were classified according to 3 dif-
ferent treatment outcomes: immediate surgical drainage,
delayed surgical drainage, and treatment with medical ther-
apy alone. Delayed surgical drainage was defined as any
patient who was admitted and for at least a 24-hour period
of intravenous antibiotic therapy. We did not have a stan-
dardized protocol for immediate surgical intervention. The
decision for surgery was reserved for the judgment of indi-
vidual physicians. The main outcome measure was resolu-
tion of infection, abscess, or cellulitis, depending on which
of the 3 interventions were used to treat the infection.
Microbiology cultures were obtained from specimens
collected in surgical patients in the operating theater.
Culture specimens were gathered from swabs of the wound
and sent for aerobic and anaerobic wound cultures, accord-
ing to the standard collection guidelines followed at The
Childrens Hospital of Philadelphia.
The following independent variables were examined uni-
variately, using a logistic regression model: age, sex, white
blood cell count (WBC) at presentation, intensive care unit
(ICU) admission, CT findings of complete abscess forma-
tion (defined by the presence of a hypolucent mass with
complete rim enhancement on CT or MRI), and the
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OtolaryngologyHead and Neck Surgery 148(6)
62 (34.8)
116 (65.2)
34.5 6 30.7 (2-142)
27 (15.2)
19.3 6 8.9 (4.2-57.8)
4.0 6 5.0 (1.0-54.0)
60 (33.7)
163 (92.1)
2.4 6 1.5 (0.7-7.2)
maximum dimension, axial or craniocaudal, of abscess for-
mation. In addition, a comparison of outcomes was per-
formed for those patients who underwent delayed surgery
and those who were successfully treated with medical ther-
apy alone. Statistical significance was set and reported at a
P value \.05, unless otherwise noted, and otherwise indi-
cated, 2-tailed.
A Wilcoxon rank sum test for difference was performed
to identify differences in length of stay depending on sex,
treatment (surgical or medical), and, if treated surgically,
immediate or delayed. A Spearman correlation was used to
examine if there was an association between age and length
of stay. Statistical significance was set and reported at a
P value \.05, unless otherwise noted, and otherwise indi-
cated, 2-tailed.
A logistic regression analysis was used to analyze the rela-
tionship between age and methicillin-resistant Staphylococcus
aureus (MRSA) infection.
Institutional review board (IRB) approval from The
Childrens Hospital of Philadelphia was obtained prior to
the initiation of the study (IRB 12-009401).
Results
A total of 178 patients were identified. A summary of the clin-
ical features of the patient cohort can be found in Table 1.
Nineteen patients (10.7%) underwent immediate surgical drai-
nage, and 159 (89.3%) patients were initially treated medically
with parenteral antibiotic therapy. Of those children in the
medical management cohort, 118 (66.3%) were successfully
managed without surgery. In the other 41 (23.0%), the
patients clinical symptoms did not improve after a minimum
of 24 hours (including symptoms such as persistent fever,
ongoing pain, trismus, or neck stiffness). In some instances,
repeat imaging studies were done, and either because of the
patients failure to clinically improve or because new imaging
findings had shown progression of the infection, the patient
eventually underwent delayed surgical drainage. All patients
had successful resolution of their infections.
The median length of stay for all patients was 4.7 days
(range, 1-54 days). The hospital stay was shorter for medi-
cally treated patients compared with those who underwent
surgical drainage (P \ .0001). Of those patients treated
Cheng and Elden 1039

Table 2. Univariate analysis for patient risk factors associated with length of hospital stay.
n Median Longest length of stay (days) P Value

Surgery \.0001
No 118 3.0 7.0
Yes 60 5.5 53.0
Sex .790
Female 62 4.0 21.0
Male 116 4.0 53.0
Surgery group .085
Delayed surgery 41 6.0 52.0
Immediate surgery 19 4.0 29.0
Correlation
P Value
Age, mo 178 0.14 .066

Table 3. Clinical features associated with children who underwent surgical drainage.
Odds Ratio (95% CI) P Value

Male sex 1.24 (0.64-2.40) .528

WBC at presentation 1.02 (0.99-1.06) .222
ICU admission 13.08 (4.63-36.95) \.0001
CT findings of complete rim enhancement 5.22 (2.58-10.56) \.0001
Age 15 mo 3.08 (1.53-6.20) .002
Greatest dimension on CT (.2.2 cm) 12.96 (4.11-40.90) \.0001

Abbreviations: CI, confidence interval; CT, computed tomography; ICU, intensive care unit; WBC, white blood cell count.

surgically, immediately or delayed, no difference in the
average length of stay was observed (P = .085), and the
length of stay was only weakly correlated with age (P =
.066) (Table 2).
Computed tomography imaging was obtained in 163
(91.6%) patients. Of the 160 imaging reports that were avail-
able, 72 (45%) demonstrated complete rim enhancement or
near-total rim-enhancing lesion consistent with early abscess
formation, and 15 (20.8%) underwent immediate surgical
drainage. Of those remaining cases, 32 (44.4%) were man-
aged successfully with parenteral antibiotics, and the other 25
patients (34.7%) underwent delayed surgical drainage.
The surgical approaches for drainage included transoral,
external (requiring a cervical incision), combined transoral
and external, and interventional radiology-guided needle
drainage in 47 (78.3%), 9 (15.0%), 3 (5.0%), and 1 (1.7%)
cases, respectively. The locations included parapharyngeal,
retropharyngeal, and combined in 19 (31.7%), 34 (56.7%),
and 7 (11.7%) children, respectively. Fifty-five of the 60
surgical patients (91.7%) had complete resolution of symp-
toms after initial incision and drainage. Clinical features of
the children associated with those who underwent surgery
can be found in Table 3. Children 15 months of age and
those with an abscess size .2.2 cm were found to have
undergone surgery more often (P = .002 and P \ .0001,
respectively).
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Risk factors were examined for patients treated with
delayed surgery compared with those patients successfully
treated with medically therapy alone, and the results are
summarized in Table 4. Sex and WBC at presentation were
not significantly associated with failure of medical therapy.
Univariate analysis demonstrated that younger age 51
months, WBC .20.7, ICU admission, CT findings with
complete abscess, and abscess size .2.2 cm were all signif-
icantly associated with unsuccessful medical therapy (P =
.036, P = .023, P \ .0001, P = .001, and P = .0002,
respectively).
Microbiology cultures were available only in those
patients who underwent surgical drainage. In all patients, an
attempt was made to obtain an intraoperative wound culture.
In 53.3% (32/60), an identifiable organism was cultured;
only 4 cases were polymicrobial (6.7%). The most com-
monly isolated pathogens identified were MRSA, beta-
hemolytic streptococcus group A, and methicillin-sensitive S
aureus. Others that were reported included Haemophilus influ-
enza, Streptococcus milleri, Enterobacter, and Klebsiella. The
MRSA cultures were sensitive to clindamycin and trimetho-
prim/sulfamethaxozole in all but 1 case, which demonstrated
resistance to clindamycin and sensitivity to trimethoprim/sul-
famethaxozole. Younger age was associated with MRSA
infection (P \ .0001), with the greatest risk in those patients
15 months of age (P = .001) (Table 5).
1040 OtolaryngologyHead and Neck Surgery 148(6)

Table 4. Comparison of delayed surgical group (medical treatment failures) and those successfully treated with medical therapy alone.
Odds Ratio (95% CI) P Value

Male sex 1.11 (0.52-2.33) .792

ICU admission 9.35 (3.05-28.65) \.0001
CT findings of complete rim enhancement 3.47 (1.63-7.37) .001
Age 51 mo 2.36 (1.06-5.25) .036
WBC at presentation (.20.7) 2.46 (1.13-5.03) .023
Greatest dimension on CT (.2.2 cm) 11.00 (3.09-39.20) .0002
Abbreviations: CI, confidence interval; CT, computed tomography; ICU, intensive care unit; WBC, white blood cell count.

Table 5. Logistic regression model analyzing relationship between CT. He was discovered to have had a cerebrovascular acci-
age and MRSA infection. dent (CVA). Both children were very young, aged 8 and
Odds Ratio (95% CI) P Value 4 months, respectively.
In the 3 patients successfully managed with medical ther-
Age, mo 0.88 (0.80-0.96) .004 apy alone, recurrence and/or persistence of clinical symp-
Age 15 mo 46.22 (5.31-402.49) .001 toms resulted in readmission for continued parenteral
antibiotics 1 day after discharge from the hospital in 2 chil-
Abbreviations: CI, confidence interval; MRSA, methicillin-resistant dren, and 1 childs clinical course was complicated by inter-
Staphylococcus aureus.
nal jugular vein thrombosis requiring anticoagulation.

Table 6. Summary of complications, resulting from DSNI.
Second drainage procedure required
Readmission for IV antibiotic therapy
Sepsis with CVA
Sepsis
Postoperative complications
Internal jugular vein thrombus
Total
Abbreviations: CVA, cerebrovascular accident; DSNI, deep space neck
infection; IV, intravenous.
Complications from DSNI, summarized in Table 6,
occurred in 12 (6.7%) children; 9 were treated surgically,
either immediate or delayed, and in 3, the patients were
treated with medical therapy alone. In the surgical group, 5
patients required a second drainage procedure (1-30 days
later), 4 had their infection initially approached transorally,
and 1 had an initial transcervical approach. One child
required readmission 8 days postoperatively for ongoing
clinical symptoms, which resolved with intravenous antibio-
tic therapy, and 1 had an unexpected ICU stay postopera-
tively to monitor new obstructive airway events and oxygen
desaturations. The 2 other patients who underwent surgery
had serious sequelae related to DSNI; both had sepsis. One
child was treated with surgery immediately, but the other
patient presented with additional mental status changes and
underwent delayed surgery as he had to be medically stabi-
lized and no discrete, infectious collection was identified on
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Discussion
Deep space neck infections are not uncommon in children.
n
Over nearly a 5-year time period, we averaged about
35 cases per year, which required hospital admission. We
5 sought to examine the outcomes and clinical features of this
3 large cohort of pediatric patients with retropharyngeal and
1 parapharyngeal infections. Complications related to DSNI
1 were uncommon (6.7%), primarily readmissions for further
1 intravenous antibiotic therapy or second drainage proce-
1 dures. Life-threatening complications of DSNI were rare in
12 our experience, only in 4 children (2.2%). Close clinical
monitoring and vigilance are required in determining which
children may benefit from early surgery, especially in those
children who have clinical features more likely to be associ-
ated with negative outcomes.
Our results support the findings of previous authors, in
that a significant proportion of the patients, about two-thirds
of our cohort of patients, were successfully treated with med-
ical therapy.6-8 Furthermore, almost half (44.4%) of the chil-
dren in our series with CT findings consistent with abscess
formation were able to be managed with antibiotics alone.
However, the success of antibiotic therapy in treating frank
abscesses may be overestimated, as diagnostic inaccuracies
are known to occur when using CT to differentiate between
abscess and cellulitis.9-11 Similar to other studies, we experi-
enced that CT findings alone should not guide the decision
for surgical drainage.10,12,13 Other clinical factors should also
be considered. Our experience has indicated that younger
patients (15 months of age) and those who had CT imaging
findings of a rim-enhancing lesion consistent with abscess
formation and size .2.2 cm more often underwent surgical
drainage. Hoffmann et al14 also observed similar results in
their series of patients and found that abscess size 20 mm
was associated with medical treatment failures.
Cheng and Elden
The MRSA infections were disproportionately found in
children 15 months. All of our MRSA isolates were sensi-
tive to trimethoprim/sulfamethoxazole and in only 1 case
(7.1%) resistant to clindamycin. Abdel-Haq et al15 also
observed similar results with increased rates of MRSA
infection in younger children, but none were resistant to
clindamycin. As such, clindamycin should be considered an
initial empiric intravenous antibiotic therapy for retrophar-
yngeal and parapharyngeal infections in young children
until other microbiology sensitivity results are available.
Clindamycin is superior to trimethoprim/sulfamethoxazole
empiric coverage because of its broader antimicrobial activ-
ity against Streptococcus, Staphylococcus, and anaerobes,
which are commonly found in pediatric DSNI.
Our results were also corroborated by previous findings
that when surgical drainage is undertaken, a transoral
approach is often effective in treating most abscesses.16 The
relationship of the primary abscess collection to the great
vessels often dictated our surgical approach, with those
medial amenable to a transoral approach, and if laterally
positioned, then an external approach is taken. Length of
hospital stay was similar in the immediate and delayed sur-
gery groups, as also reported by Johnston et al.2 We
observed that in 2 patients (1 surgically treated and 1
medically treated), recurrence was seen up to 1 month
postoperatively, so we also recommend clinical follow-up
as an outpatient to ensure the complete resolution of
infection.
We also wanted to investigate and analyze if there were
any differences in clinical features between those patients
who underwent delayed surgical drainage compared with
those patients who were successfully treated with medical
therapy alone. Age, sex, and WBC on admission were not
significantly associated with successful medical therapy
alone. However, younger children 51 months, those who
were admitted to the ICU, and those who had CT findings
of abscess formation .2.2 cm were significantly associated
with failure of medical treatment alone and delayed surgical
drainage. These factors may be considered in stratifying
those patients who may successfully be treated with medical
therapy alone.2,5,14 Even when surgical drainage was
delayed, we did not find a statistically significant increase
in the length of hospital stay, and thus it seems that a trial
period of medical management was not detrimental. Most of
our children who had complicated clinical courses were of a
very young age (3, 4, and 8 months).
Based on our reported clinical outcomes and those in the
literature, it appears that an upfront trial of intravenous anti-
biotics and guarded surveillance for children with DSNI
who are clinically stable, are older (.15 months of age),
and have smaller abscesses (2.2 cm) may be successful
without surgery. Younger children in our study had a higher
incidence of MRSA infection, most often clindamycin sensi-
tive. Polymicrobial infections and those resistant to clinda-
mycin were less often encountered in our patients. Those
children treated with an initial trial of medical therapy who
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1041
fail to show significant clinical improvement and/or fail to
defervesce should eventually undergo imaging and managed
accordingly. In our experience, patients who were more
likely to respond to medical therapy alone demonstrated sig-
nificant clinical improvement within the first 48 to 72 hours
after initiating parenteral antibiotic therapy. Close follow-up
is also important, as recurrence or the need for a second
drainage procedure may be necessary, which occurred in 8
(4.5%) of our patients.
We recognize that our study is limited by its retrospective
nature. Some selection bias exists in our study because our
cohort of patients was composed of acutely ill patients admit-
ted to a tertiary-care childrens hospital for parenteral antibio-
tics and/or surgery. Furthermore, some bias may have
complicated the interpretation of the data because the pres-
ence or absence of rim formation on cross-sectional ima-
ging was determined from either author review of the
images or extracted from the dictated radiologists reports.
Also, as a result of the type of study we conducted, we
could not eliminate our institutional bias, and there was no
standardization or protocol to determine which child
should undergo immediate surgical drainage. Our surgeons
may have preferentially operated on those children who
were younger and who had larger abscesses. The timing
for surgical intervention may have also been influenced
partly by operating room availability and surgeon prefer-
ence. However, we were able to identify specific patient
clinical features that were more likely to be associated
with surgery. Another factor that should be considered is
location of infections that are near the skull base. These
lesions appear to be rare, as we encountered only 1 case,
but can be notoriously difficult to access through a trans-
oral and/or external surgical approach. For these types of
infections, consultation with an interventional radiologist
who may be able to perform needle-guided aspiration
rather than open drainage may be advisable.
Conclusion
Deep space neck infections in children can often be success-
fully managed with medical therapy alone. Life-threatening
complications can occur in rare cases. We recommend that
very young patients be managed cautiously. Methicillin-
resistant S aureus involvement was highly associated with
younger age, especially those 15 months, and clindamycin
should be considered for initial empiric antibiotic therapy.
Acknowledgments
We thank Rachel Hammond for her contribution to the statistical
analysis.
Author Contributions
Jeffrey Cheng, conception and design, acquisition and interpreta-
tion of data, drafting of the manuscript, and final approval; Lisa
Elden, conception and design, critical revision of manuscript, and
final approval.
1042
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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