Minimally invasive transoral catheter-assisted drainage of a danger-space infection.

Abstract

We report the case of a 3-year-old boy who was brought to the emergency department for evaluation of a prolonged upper respiratory infection and diminished neck movement. Computed tomography identified a unilocular abscess extending from the level of C2 inferiorly to the diaphragm at the level of the T9 vertebral body. We successfully treated this transcervical, transthoracic infection surgically via a transoral approach to the retropharyngeal abscess combined with catheter drainage and irrigation of the abscess cavity at a depth of 13 cm. At 25 months of follow-up, the patient exhibited no evidence of recurrent disease or postsurgical complications. In this article, we describe our minimally invasive technique for managing unusual deep-space neck infections in children.

Introduction

We describe a minimally invasive surgical technique used to manage an unusual deep-space neck infection (DSNI) in a pediatric patient. Our graduated approach allows for diagnosis, culture, and definitive treatment of a DSNI that might otherwise require significantly more extensive surgery.

Case report

A previously healthy 3-year-old boy was brought to the emergency department with a 1-week history of low-grade fever and symptoms of upper respiratory infection. He had also recently experienced difficulty making neck movements, and he began refusing to eat solid food.

Upon examination, the patient appeared to be in no distress. He was afebrile, and his vital signs were stable. Physical examination was notable only for 2+ tonsils without exudate, mild oropharyngeal erythema, and the absence of uvula deviation, posterior pharyngeal wall edema, or asymmetrical bulging. Laboratory evaluation revealed a white blood cell (WBC) count of 34,700/[mm.sup.3] with a left shift of 20 bands. Computed tomography (CT) of the neck and chest demonstrated a largely unilocular, low-density, rim-enhancing lesion that measured 3.3 x 1.5 cm in its greatest transverse dimension (figure). The lesion extended from the retropharyngeal space at the level of C2 inferiorly to the diaphragm at the level of the T9 vertebral body. Given the extent of the fluid collection, our differential diagnosis included a retropharyngeal abscess with danger-space extension along with an infection of a developmental anomaly, such as a foregut duplication cyst, lymphangioma, or thymic cyst. Beating in mind the location of the fluid collection as it extended from C2 inferiorly between the esophagus and descending aorta, we initially considered performing a combined transcervical and transthoracic procedure. However, given the morbidity of such a procedure, we instead chose to perform intraoral catheter-assisted drainage that would be diagnostic, less invasive, and potentially definitive in the treatment of this infection.

The patient was taken to the operating room, where he underwent transoral drainage of the danger-space abscess. A cruciate incision was made in the posterior wall of the oropharynx, and blunt dissection into the retropharyngeal space produced an enormous amount of purulent material. After appropriate cultures were sent, two catheters were carefully advanced over 13 cm into the depths of the abscess cavity. Saline was pumped through the first catheter while the second catheter suctioned fluid from the cavity. The catheters were slowly withdrawn and subsequently removed when the effluence became clear. At the conclusion of this procedure, the intraoral incision was left open to allow for continued drainage.

The patient remained intubated for airway protection for approximately 36 hours, and a nasogastric tube was placed. He was administered intravenous ampicillin, gentamicin, and clindamycin. A repeat CT confirmed the marked resolution of the infection, and the patient was extubated on postoperative day 2 without any airway difficulties. By postoperative day 3, the patient's WBC count had fallen to 11,300/[mm.sup.3], and the wound cultures grew group A beta-hemolytic streptococci sensitive to clindamycin. The nasogastric tube was removed on postoperative day 4, and the patient began a clear-liquid diet. After completing 7 days of IV antibiotics, the patient was discharged home with a 10-day course of oral clindamycin. Findings on follow-up examination 2 weeks later were unremarkable. At 25 months postoperatively, the patient exhibited no evidence of recurrence or surgical complications.

Discussion

DSNIs that necessitate surgery are not common in children, but when they occur, they are associated with a high rate of morbidity and mortality as a result of the spread of infection to surrounding spaces and airway obstruction. (1) This is particularly true of a retropharyngeal-space abscess, which is the second most common type of DSNI in children. This potential space extends from the skull base to the level of T1-T2, where the alar layer of the deep layer of the deep cervical fascia fuses with the anteriorly located visceral portion of the middle layer of the deep cervical fascia. (2) A median raphe divides the retropharyngeal-space contents into two chains of lymph nodes, which typically limits an abscess to a single compartment of the retropharyngeal space and produces the characteristic unilateral bulge in the posterior pharyngeal wall. (3)

The danger space was first described by Grodinsky and Holyoke in 1938 as the loose areolar tissue that extends from the skull base to the diaphragm between the alar and prevertebral divisions of the deep layer of the deep cervical fascia. (4)

In our patient, the midline location of the abscess, its contiguous spread to the diaphragm, and its rapid clinical progression were consistent with a danger-space abscess, and these conditions supported our surgical approach. Several authors have explored the use of minimally invasive methods of treating DSNIs, although in many of these case series, the authors failed to identify the particular anatomic space that was being addressed. Brodsky et al used office-based percutaneous needle aspiration to successfully treat 55.6% of pediatric neck abscesses identified on CT. (5) Interventional radiologists have shown that minimally invasive methods of percutaneous drainage with ultrasound guidance allowed for successful management without incision and drainage in 87% of patients with unilocular neck abscesses. (6) The location of the DSNI in our patient precluded percutaneous drainage. Most authors agree that DSNIs located medial to the great vessels should be treated with transoral drainage, and they strongly caution against sedating a young patient whose airway might be compromised by infection. (5)

Our approach achieved the goal of performing a minimally invasive procedure within the accepted standards for the surgical management of an abscess medial to the great vessels. Our use of catheters safely extended our reach into the lumen of the abscess cavity as it extended into the chest without the need for a thoracotomy. By approaching our patient's DSNI in a graduated fashion, we were able to gain access to the infection through an intraoral incision, obtain culture specimens, completely evacuate and irrigate the abscess cavity, and spare the patient the morbidities inherent in a combined transcervical and transthoracic external approach.

References

(1.) Flanary VA, Conley SF. Pediatric deep space neck infections: The Medical College of Wisconsin experience. Int J Pediatr Otorhinolaryngol 1997;38:263-71.

(2.) Paonessa DF, Goldstein JC. Anatomy and physiology of head and neck infections (with emphasis on the fascia of the face and neck). Otolaryngol Clin North Am 1976;9:561-80.

(3.) Nicklaus PJ, Kelley PE. Management ofdeep neck infection. Pediatr Clin North Am 1996;43:1277-96.

(4.) Grodinsky M, Holyoke EA. The fasciae and fascial spaces of the head, neck and adjacent regions. Am J Anat 1938;63:367-408.

(5.) Brodsky L, Belles W, Brady A, et al. Needle aspiration of neck abscesses in children. Clin Pediatr (Phila) 1992;31:71-6.

(6.) Yeow KM, Liao CT, Hao SP. US-guided needle aspiration and catheter drainage as an alternative to open surgical drainage for uniloculated neck abscesses. J Vasc Interv Radiol 2001;12: 589-94.

Robert T. Adelson, MD; Alan D. Murray, MD

From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, University of Miami (Fla.) School of Medicine (Dr. Adelson), and the Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas (Dr. Murray).

Reprint requests: Robert T. Adelson, MD, 1504 Bay Rd., #1014, Miami Beach, FL 33139. Phone: [phone]; fax: [phone]; e-mail: [e-mail]