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Infections of the Fascial Spaces of the Head and Neck in Children Robert F

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Infections of the Fascial Spaces of the Head and Neck in Children Robert F Infections of the Fascial Spaces of the Head and Neck in Children Robert F. Yellon, MD espite the availability of potent new antimicrobial agents condition that also may occur after infection of the parotid gland D for the treatment of bacterial infections of the upper or overlying skin or from adenitis of lymph nodes overlying the respiratory tract, cellulitis and abscesses of the fascial spaces of adjacent masseter muscle. Previously, infections of the buccal the head and neck still occur in children. Therefore, it is space in young children have been caused by hematogenously important to understand the anatomic, bacteriologic, and clini- disseminated Haemophilus influenzae type b, but such infections cal factors associated with infections of these sites and to select now are uncommon among properly immunized children. Infec- the best diagnostic and therapeutic modalities required for tion of the canine space results from a canine tooth root abscess optimal management of these infections. In addition to provid- that erodes through the anterior cortex of the maxilla. Infec- ing this information, this article presents data from a study of tions of the parotid space and submandibular gland space may head and neck space infections at the Children's Hospital of follow sialoadenitis or suppuration of lymph nodes in these Pittsburgh. In patients with immunodeficiencyor prior antibi- spaces or may result from calculi or tumors encroaching on the otic treatment, unusual clinical presentations and pathogens ductal system. may be found, making timely diagnosis and treatment even Infections of cystic hygromas and branchial apparatus rem- more critical. nants can spread into adjacent deep neck spaces. Infection of the carotid sheath may occur as a result of spread from infected adjacent deep neck spaces, suppurative adenitis, illicit intrave- Pathogenesis nous drug use, central venous catheter placement, and hyperco- Retropharyngeal space infections frequently originate as infec- agulable states. Infections of the deep neck space also may tions in the nose, paranasal sinuses, or nasopharynx that develop by contiguous extension from abscesses in the mediasti- subsequently spread to the retropharyngeal lymph nodes. Pha- num. ryngeal trauma also can lead to infection of the retropharyngeal and lateral pharyngeal spaces. Infection of or trauma to the tonsils, laryngotracheal complex, hypopharymx, or esophagus Bacteriology can result in visceral and pretracheal space infections. Tubercu- Between 1986 and 1992, 117 children (n = 78 cultures) with lous infection of the vertebral bodies (Pott's abscess), as well as infections of the fascial spaces of the head and neck space were nontuberculous infection, can cause prevertebral (retropharyn- observed at Children's Hospital of Pittsburgh. 1 Table 1 displays geal) space infections. the pathogens recovered from these infections. Gram-positive Adenotonsillitisis a source of infection of the lateral pharyn- aerobic pathogens, Streptococcuspyogenes (18%) and Staphylococcus geal space. Infection of the petrous apex may extend into the aureus (18%), were the most prevalent isolates. Anaerobic lateral phaIyngeal space. Bezold's abscess occurs when infection pathogens, including Bacteroides melaninogenicus (17%) (now Pre- in the mastoid tip erodes through the cortex; it is located in the votella melaninagenicus) and Veillonella species (14%), frequently area between the mastoid tip and mandible and may extend into were recovered also. Haemophilus parainJluenzae was reported in the lateral pharyngeal space. Of course, tonsillitis precedes 14% of cultures. Overall, gram-negative pathogens were present infection of the peritonsillar space, which, in turn, may extend in 17.9% of cultures. Beta-lactamase production by aerobic into the lateral pharyngeal space. Iatrogenic causes of infections pathogens was reported in 22% of cultures. A bacteriologic study of the lateral pharyngeal space include local anesthesia for in another series of 20 retropharyngeal abscesses in adults and tonsillectomy and superior alveolar nerve block. children disclosed a 30% prevalence of gram-negative organ- Infections of mandibular teeth and gingiva may cause isms. 2 Many abscesses are polymicrobial, and many of the infections of the mandibular, submandibular, masticator, pa- anaerobes also produce beta-lactamase.3,4 rotid, and lateral pharyngeal spaces. Infections of maxillary or Mycobacterium tuberculosis, atypical mycobacteria, 5 and Barton- mandibular teeth usually cause infection of the buccal space, a ella (formerly Rochilamaea) henselae (the causative agent of Cat- Scratch disease) also can infect cervical lymph nodes, resulting in significant adenopathy and occasional abscesses. Infections From the Department of Pediatric Otolarvngology, Children's Hospital of caused by atypical mycobacteria and B henselae6 tend to differ Pittsburgh and Department of Otola~yngology, Universityof Pittsburgh School of from the infections caused by the more common pyogenic Medicine, Pittsburgh,PA. Address correspondenceto Robert F. Yellon, MD, Department of Pediatric pathogens in that they usually follow a more indolent course, Otolaomgology, Children'sHospital ofPittsburgh, 3705 Fifth Ave, Pittsburgh,PA often without either fever or severe pain. The fever and 15213-2583. adenopathy associated with Kawasaki disease occasionally may Copyright 1998 by W.B. Saunders Company resemble bacterial infection of the neck space, but the disease 1045-1870/98/0901-001258.00/0 usually can be recognized by the typical associated mucocutane- 60 Seminars in Pediatric Infectious Diseases, Vol 9, No 1 (January), 1998:pp 60-69 .
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