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Figure 1.
Age-specific differences in infecting organisms of deep neck space abscesses.

Age-specific differences in infecting organisms of deep neck space abscesses.

Figure 2.
Age-specific differences in anatomic locations of deep neck space abscesses.

Age-specific differences in anatomic locations of deep neck space abscesses.

Figure 3.
Location-specific differences in infecting organisms of deep neck space abscesses.

Location-specific differences in infecting organisms of deep neck space abscesses.

Table 1. 
Presenting Signs, Symptoms, and Investigations by Age Group*
Presenting Signs, Symptoms, and Investigations by Age Group*
Table 2. 
Sensitivity of Organisms to Antibiotics Over Time*
Sensitivity of Organisms to Antibiotics Over Time*
Table 3. 
Sensitivity of Organisms to Antibiotics vs Previous Antibiotic Exposure*
Sensitivity of Organisms to Antibiotics vs Previous Antibiotic Exposure*
1.
Barratt  GEKoopmann  CFCoulthard  SW Retropharyngeal abscess: a ten-year experience. Laryngoscope.1984;94:455-463.
PubMed
2.
Brook  I Microbiology of abscesses of the head and neck in children. Ann Otol Rhinol Laryngol.1987;96:429-433.
PubMed
3.
Dodds  BManiglia  AJ Peritonsillar and neck abscesses in the pediatric age group. Laryngoscope.1988;98:956-959.
PubMed
4.
Gianoli  GIEspinola  TEGuarisco  JLMiller  RH Retropharyngeal space infection: changing trends. Otolaryngol Head Neck Surg.1991;105:92-100.
PubMed
5.
Har-El  GAroesty  JHShalla  ALucente  FE Changing trends in deep neck abscess. Oral Surg Oral Med Oral Pathol.1994;77:446-450.
PubMed
6.
Sethi  DSStanley  RE Deep neck abscesses: changing trends. J Laryngol Otol.1994;108:138-143.
PubMed
7.
Brook  IGober  AE Prophylaxis with amoxicillin or sulfisoxazole for otitis media: effect on the recovery of penicillin-resistant bacteria from children. Clin Infect Dis.1996;22:143-145.
PubMed
8.
Brook  IGober  AE Resistance to antimicrobials used for therapy of otitis media and sinusitis: effect of previous antimicrobial therapy and smoking. Ann Otol Rhinol Laryngol.1999;108:645-647.
PubMed
9.
Brook  IGober  AE Emergence of β-lactamase–producing aerobic and anaerobic bacteria in the oropharynx of children following penicillin chemotherapy. Clin Pediatr (Phila).1984;23:338-341.
PubMed
10.
Nagy  MPizzuto  MBackstrom  IBrodsky  L Deep neck infections in children: a new approach to diagnosis and treatment. Laryngoscope.1997;107:1627-1634.
PubMed
11.
Thompson  JWCohen  SRReddix  P Retropharyngeal abscess in children: a retrospective and historical analysis. Laryngoscope.1988;98:589-592.
PubMed
12.
Davidson  M Abscesses of the retropharyngeal spaces in adults. Laryngoscope.1949;59:1146-1170.
13.
Faden  HBrodsky  LWaz  MJStanievich  JBernstein  JMOgra  PL Nasopharyngeal flora in the first three years of life in normal and otitis-prone children. Ann Otol Rhinol Laryngol.1991;100:612-615.
PubMed
14.
Choi  SSVezina  LGGrundfast  KM Relative incidence and alternative approaches for surgical drainage of different types of deep neck abscesses in children. Arch Otolaryngol Head Neck Surg.1997;123:1271-1275.
PubMed
15.
Gidley  PWGhorayeb  BYStiernberg  CM Contemporary management of deep neck space infections. Otolaryngol Head Neck Surg.1997;116:16-22.
PubMed
16.
Tom  MBRice  DH Presentation and management of neck abscess: a retrospective analysis. Laryngoscope.1988;98:877-880.
PubMed
17.
Ungkanont  KYellon  RFWeissman  JLCasselbrant  MLGonzalez-Valdepena  HBluestone  CD Head and neck space infections in infants and children. Otolaryngol Head Neck Surg.1995;112:375-382.
PubMed
18.
Beck  AL The influence of the chemotherapeutic and antibiotic drugs on the incidence and course of deep neck infections. Ann Otol Rhinol Laryngol.1952;61:515-532.
19.
Tami  TAParker  GS Eikenella corrodens: an emerging pathogen in head and neck infections. Arch Otolaryngol.1984;110:752-754.
PubMed
20.
Nussinovitch  MFinkelstein  YAmir  JVarsano  I Group A β-hemolytic streptococcal pharyngitis in preschool children aged 3 months to 5 years. Clin Pediatr (Phila).1999;38:357-360.
PubMed
Original Article
February 2004

Age-, Site-, and Time-Specific Differences in Pediatric Deep Neck Abscesses

Author Affiliations

From the Departments of Otolaryngology, Wayne State University, Detroit, Mich (Dr Coticchia), Feinberg School of Medicine, Northwestern University, Chicago, Ill (Dr Getnick), and University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio (Ms Yun and Dr Arnold). The authors have no relevant financial interest in this article.

Arch Otolaryngol Head Neck Surg. 2004;130(2):201-207. doi:10.1001/archotol.130.2.201
Abstract

Objective  To clarify presentations, organisms, and locations of deep neck abscesses in children.

Design  Retrospective review.

Setting  Tertiary children's hospital. The study population comprised 169 patients younger than 19 years who were surgically treated for deep neck abscesses between 1989 and 1999.

Main Outcome Measure  Resolution of abscess.

Results  Neck mass (91%), fever (86%), cervical adenopathy (83%), poor oral intake (66%), and neck stiffness (59%) were common in all ages. Patients younger than 4 years, compared with patients 4 years or older, presented with agitation (50% vs 14%), cough (35% vs 14%), drooling (27% vs 12%), lethargy (46% vs 33%), oropharyngeal abnormalities (45% vs 60%), respiratory distress (5% vs 2%), retractions (5% vs 2%), rhinorrhea (53% vs 15%), stridor (4% vs 2%), and trismus (14% vs 53%). Children younger than 1 year were infected with Staphylococcus aureus (79%) vs group A streptococcus (6%). Children 1 year or older were infected with group A streptococcus (29%) vs S aureus (16%). Retropharyngeal or parapharyngeal regions were involved in children 1 year or older (49%) vs younger than 1 year (21%). Anterior or posterior triangles and submandibular or submental regions were involved in 39% and 36%, respectively, of children younger than 1 year vs 30% and 23%, respectively, of children 1 year or older. Retropharyngeal and parapharyngeal abscesses yielded group A streptococcus (34%) vs S aureus (11%). Anterior and posterior triangle abscesses yielded S aureus (35%) vs group A streptococcus (19%), as did submandibular and submental abscesses (42% vs 19%).

Conclusions  Abscesses in children younger than 1 year affected anterior or posterior triangles and submandibular or submental regions, yielding S aureus. Abscesses in children 1 year or older affected retropharyngeal or parapharyngeal regions, yielding group A streptococcus.

Although antimicrobial therapy has reduced the incidence of deep neck space abscesses, these infections remain an important clinical entity. While adults often have numerous localizing signs and symptoms, children with deep neck space abscesses tend to have a more subtle presentation in that they are seldom able to verbalize their symptoms or cooperate with the physical examination, and their oropharynx is frequently difficult to examine because of its small size.1 In an attempt to better characterize deep neck space abscesses in children, we compared the presenting signs and symptoms, infecting organisms, and anatomic locations of these infections across several pediatric age groups.

Another interesting aspect of deep neck space abscesses involves the relationship between anatomic location and infecting organism. Previous investigators2,3 noted that abscesses in proximity to the oropharynx often yield microflora that are indigenous to this region, while abscesses located at a site distant from the oropharynx tend to grow organisms indigenous to the skin.

In recent years, several reports have described changing trends in deep neck space abscesses over time.46 Differences in incidence, age at presentation, anatomic location, and infecting organism have most commonly been noted. The most crucial issue is perhaps increasing microbial resistance. In the present article, we analyzed resistance patterns of infecting organisms over time and related them to changes in incidence, anatomic location, and infecting organism in deep neck space abscesses. Previous antibiotic use is associated with higher recovery of resistant organisms7,8 and increased incidence of β-lactamase–producing bacteria.9 We compared resistance patterns in patients with and without previous antibiotic exposure.

METHODS

We performed a retrospective analysis of 169 patients younger than 19 years, who were surgically treated for deep neck space abscesses at Rainbow Babies and Children's Hospital, Cleveland, Ohio, between January l, 1989, and December 31, 1999. Patients with peritonsillar, dentoalveolar, preauricular, postauricular, external auditory canal, and facial abscesses were excluded. In addition, patients with superficial abscesses and patients with cellulitis who recovered with antibiotic therapy alone were exempted. Information regarding age, sex, race, admission date, predisposing factors, history of infection and antibiotic use, presenting signs and symptoms, laboratory and radiographic evaluations, treatment, operative findings, complications, and outcome was gathered and recorded. Anatomic location of abscesses was determined using operative findings and radiographic data. A positive lateral neck radiograph was defined by the presence of increased prevertebral soft tissue, and a positive computed tomographic scan of the neck was defined by the presence of a rim-enhancing mass.

RESULTS
GENERAL

A total of 169 children were treated surgically for deep neck space abscesses. Patients ranged in age from 2 months to 18 years, with a mean presenting age of 4.1 years. Of these patients, 44% were female; 56%, male; 43%, black; 54%, white; 1%, Hispanic; and 1%, biracial. One or more predisposing factors to development of a deep neck space abscess were present in 28% of patients, including premature birth, recent trauma to the head or neck, history of neonatal intensive care unit admission, congenital cyst, immunosuppression, history of sepsis, and other miscellaneous medical conditions, and 67% of patients had 1 or more recent (within 1 month of admission) or current infections of the ears, nose, or throat.

Patients were symptomatic for an average of 4.7 days before admission. The most common signs and symptoms were neck mass, fever, lymphadenopathy, poor oral intake, and neck stiffness. Positive lateral neck radiographs (91%) and positive computed tomographic scans of the neck (90%) were consistently found in this study. Of the 169 patients, 168 had data available regarding antibiotic treatment of their abscesses. Of these, 54% were receiving antibiotic treatment at the time of admission. Also, 91% received intravenous antibiotics during admission, followed by oral antibiotics after discharge (Table 1).

Of the 169 patients, 3 had neck abscesses in 2 different anatomic locations at the same time. Also, 43% of patients had infections of the retropharyngeal or parapharyngeal regions, 32% had infections of the anterior or posterior triangles, 25% had infections of the submandibular or submental regions, and 1% had infections of the parotid region. Pus was obtained in 91% of abscesses, and the volume was recorded in 66 cases (mean volume of pus was 7.3 mL). Cultures were obtained and available in all but 4 patients. Cultures yielded Staphylococcus aureus in 28% and group A streptococcus in 25% of patients, and there was no growth in cultures in 25% of patients. Of the 42 patients with no growth, 27 had no organisms and 11 had organisms on gram stain. Additionally, 25 patients had growth of 1 or more normal oropharyngeal flora, which were identified as "mixed growth consistent with normal throat flora" (n = 12), α-hemolytic streptococcus (n = 11), diphtheroid species (n = 4), and Neisseria species (n = 3). Anaerobes were cultured in 12 patients, including Eikenella corrodens (n = 5), "mixed anaerobes" (n = 3), Bacteroides fragilis (n = 1), Peptostreptococcus species (n = 1), Propionibacterium acnes (n = 1), and Propionibacterium granulosum (n = 1). The remaining cultures grew Streptococcus viridans (n = 10), coagulase-negative S aureus (n = 5), yeast/Candida albicans (n = 3), Enterococcus species (n = 2), Haemophilus influenzae (n = 2), Branhamella catarrhalis (n = 1), Klebsiella pneumoniae (n = 1), microaerophilic streptococcus (n = 1), micrococcus (n = 1), Mycobacterium avium complex (n = 1), Pseudomonas aeruginosa (n = 1), and Streptococcus pneumoniae (n = 1).

Patients had an average length of hospitalization of 5.4 days. One or more complications were noted in 40 patients, the most common of which were persisting abscess or reinfection requiring a second procedure (n = 28), intubation before or after incision and drainage (n = 12), and pneumonia (n = 2).

AGE-SPECIFIC DIFFERENCES IN DEEP NECK SPACE ABSCESSES

Patients younger than 4 years presented with agitation (50%), cough (35%), drooling (27%), lethargy (46%), positive physical signs on oropharyngeal examination (45%), respiratory distress (5%), retractions (5%), rhinorrhea (53%), stridor (4%), and trismus (14%). Patients 4 years or older presented with agitation (14%), cough (14%), drooling (12%), lethargy (33%), positive physical signs on oropharyngeal examination (60%), respiratory distress (2%), retractions (2%), rhinorrhea (15%), stridor (2%), and trismus (53%). In addition, patients younger than 4 years were symptomatic for an average of 4.5 days before admission, and patients 4 years or older were symptomatic for an average of 5.2 days before admission (Table 1).

Staphylococcus aureus was seen in 79% of children younger than 1 year vs 16% of children 1 year or older. In contrast, group A streptococcus was more frequently identified in 29% of children 1 year or older vs 16% for children younger than 1 year. Normal oropharyngeal flora was identified in 17% of children 1 year or older vs 6% in children younger than 1 year. Also, 28% of children 1 year or older and 12% of children younger than 1 year yielded no growth (Figure 1).

Retropharyngeal or parapharyngeal regions were involved in 49% of children 1 year or older and 21% of children younger than 1 year. Submandibular or submental regions were more frequently involved in 36% children younger than 1 year vs 23% children 1 year or older. Finally, anterior or posterior triangles were involved in 39% children younger than 1 year and 30% children 1 year or older (Figure 2).

LOCATION-SPECIFIC DIFFERENCES IN DEEP NECK SPACE ABSCESSES

Patients with retropharyngeal or parapharyngeal space abscesses were infected with group A streptococcus in 34% of cases vs 11% with S aureus. Anterior or posterior triangle abscesses yielded S aureus in 35% of children vs 19% with group A streptococcus. Submandibular or submental abscesses yielded S aureus in 42% of cases vs 19% with group A streptococcus. In addition, normal oropharyngeal flora were found in retropharyngeal or parapharyngeal space abscesses (32%), anterior or posterior triangle abscesses (2%), and submandibular or submental abscesses (2%). All locations yielded approximately a 25% no-growth result (Figure 3).

Different anatomic locations were also approached differently for surgical incision and drainage. Specifically, 100% of anterior and posterior triangle abscesses, 100% of submandibular and submental abscesses, and 100% of parotid abscesses were approached externally. Retropharyngeal and parapharyngeal abscesses were drained using both transoral (52%) and external (48%) approaches.

DIFFERENCES IN DEEP NECK SPACE ABSCESSES OVER TIME

During the first half of the study period, 30% of patients were infected with S aureus, 21% were infected with group A streptococcus, 13% were infected with normal oropharyngeal flora, and 29% had no growth. During the second half of the study period, 27% of patients were infected with S aureus, 27% were infected with group A streptococcus, 16% were infected with normal oropharyngeal flora, and 23% had no growth. During the first half of the study period, retropharyngeal or parapharyngeal regions were involved in 36% of cases, submandibular or submental regions were involved in 20% of cases, and anterior or posterior triangles were involved in 45% of cases. During the second half of the study period, retropharyngeal or parapharyngeal regions were involved in 47% of cases, submandibular or submental regions were involved in 28% of cases, and anterior or posterior triangles were involved in 26% of cases.

Antibiotic-sensitive results were obtained for S aureus (100%) and group A streptococcus (50%). During the first 5.5 years of the study, 100% of S aureus infections were sensitive to clindamycin and 80% were sensitive to oxacillin. During the second 5.5 years of the study, 90% of S aureus infections were sensitive to clindamycin, and 100% were sensitive to oxacillin. Almost all S aureus infections were resistant to penicillin and intermediately sensitive to sulfamethoxazole (Table 2).

ANTIBIOTIC SENSITIVITY VS PREVIOUS ANTIBIOTIC EXPOSURE

In patients without previous antibiotic exposure, S aureus infections were sensitive to clindamycin, erythromycin, and oxacillin (93%, 85%, and 91%, respectively). In patients with previous antibiotic exposure, S aureus infections were sensitive to clindamycin, erythromycin, and oxacillin (100%, 93%, and 100%, respectively). Almost all S aureus infections were resistant to penicillin and intermediately sensitive to sulfamethoxazole in both groups. Group A streptococcus infections were sensitive to erythromycin (86%) and tetracycline (86%) in patients without previous antibiotic exposure. This organism was sensitive to erythromycin (100%) and tetracycline (100%) in patients with previous antibiotic exposure (Table 3).

COMMENT

The average age of children presenting with deep neck space abscesses was 4.1 years, consistent with previous reports.10,11 The age distribution showed decreasing incidence with increasing age, also reported by Thompson et al.11 This may relate to immaturity of the immune system in infants and young children. One must remember, though, that deep neck space abscesses also affect adults, and it has been suggested that abscesses in adults are underreported in the literature.12 Also interesting in the present review was the high percentage of patients with predisposition for deep neck space abscesses (28%) and with infection of the ears, nose, or throat (67%). Infection of the ears, nose, or throat may spread to deep neck spaces by direct continuity or by lymphatic drainage to lymph nodes in these spaces.1 Most common in our study was upper respiratory tract infection, which was present in 49% of patients. Because nasopharyngeal carriage of middle ear pathogens increases significantly during respiratory illness,13 patients with upper respiratory tract infection in our study may have experienced a change in nasopharyngeal flora to more pathogenic or virulent organisms.

The presentation of deep neck space abscesses has been reported by other researchers.****{xref ref-type="bibr" rid="REF-OOA30014-10 REF-OOA30014-11 REF-OOA30014-14 REF-OOA30014-15 REF-OOA30014-16 REF-OOA30014-17"/> The findings in our study are in agreement with these authors, since we found neck mass, fever, lymphadenopathy, poor oral intake, neck stiffness, positive lateral neck radiograph, and positive computed tomographic scan of the neck to be the most common signs, symptoms, and investigations (Table 1).

In our review, the distribution of abscesses among the various spaces of the neck was 43% retropharyngeal or parapharyngeal, 32% anterior or posterior triangle, 25% submandibular or submental, and 1% parotid. These results both support and refute distributions cited in the literature. Submandibular or submental predominance was noted by Beck,18 although this report was published in 1952. More recently, Gidley et al15 and Ungkanont et al17 showed a predominance of retropharyngeal or parapharyngeal abscesses, while Tom and Rice16 noted anterior or posterior triangle abscesses to be most common. These differences may have resulted from smaller sample sizes or different age groups in previous studies, or they may represent changes in location of abscesses over time (see "Location-Specific Differences in Deep Neck Space Abscesses" below).

Most studies recognize S aureus and group A streptococcus as the predominant organisms in neck abscesses.2,10,15,17 However, the importance of anaerobes has recently been established.2 We identified 28% of patients with S aureus and 25% with group A streptococcus. Our "no growth" rate of 25% is consistent with other reports.10,15,16 Although smaller numbers of anaerobes were cultured, it is likely that organisms noted on Gram stain that did not grow when cultured also represented anaerobes. The most common anaerobe cultured was E corrodens, and the importance of this organism in head and neck infections has recently been noted by Tami and Parker.19 Because E corrodens is universally resistant to clindamycin, clinicians must be wary of empirically treating presumed anaerobic infections with this antibiotic. Additional organisms cultured in this study included normal oropharyngeal flora in 15% of patients. Other researchers have reported growth of these organisms from deep neck space abscesses.17

AGE-SPECIFIC DIFFERENCES IN DEEP NECK SPACE ABSCESSES

To our knowledge, presentations of deep neck space abscesses in different pediatric age groups have not been compared in prior studies. Patients younger than 4 years more frequently presented with agitation, cough, drooling, lethargy, respiratory distress, retractions, rhinorrhea, and stridor and less frequently with positive physical signs on oropharyngeal examination and trismus compared with patients 4 years or older. These results suggest that younger children have unique presentations of deep neck space abscesses that closely mirror signs and symptoms of viral upper respiratory tract infection (ie, agitation, cough, lethargy, and rhinorrhea). This may increase the difficulty of arriving at an accurate diagnosis, particularly for primary care practitioners outside of a tertiary care hospital. Even more disturbing is that younger patients are more likely to show signs and symptoms of airway compromise, which underlies the necessity of making an accurate diagnosis. Patients younger than 4 years also have a shorter duration of symptoms (4.5 days) compared with patients 4 years or older (5.2 days) (Table 1). This may suggest that the pathophysiologic mechanism of abscess progression is more rapid or fulminant in younger children.

Children younger than 1 year were more commonly infected with S aureus (79%) than with group A streptococcus (6%) (P<.001). On the other hand, children 1 year or older were more commonly infected with group A streptococcus (29%) than with S aureus (16%) (P = .07). Children 1 year or older more frequently had cultures that grew normal oropharyngeal flora than children younger than 1 year (17% vs 6%) (P = .17). Also of interest, children younger than 1 year were more likely to have positive culture results (88%) than children 1 year or older (72%) (Figure 1). Since children younger than 1 year had more subtle presentation and shorter duration of symptoms, it is less likely that they were started on oral antibiotic therapy prior to admission. This may explain the difference in positive culture results between children younger than 1 year and children 1 year or older. In addition, the paucity of group A streptococcus in deep neck space abscesses of children younger than 1 year is consistent with a report showing increased group A streptococcus carriage rates in older children.20 In fact, the present study demonstrated that carriage rates of group A streptococcus rose from 1.5% in children younger than 1 year to 17.5% in children aged 4 to 5 years.

Retropharyngeal or parapharyngeal involvement was more common in children 1 year or older (49%) vs children younger than 1 year (21%) (P = .008). Submandibular or submental involvement was more common in children younger than 1 year (36%) vs children 1 year or older (23%) (P = .17). Finally, anterior or posterior triangle involvement was more common in children younger than 1 year (39%) vs children 1 year or older (30%) (P = .42). Thus, children 1 year or older were more likely to develop deep neck space abscesses to the retropharyngeal or parapharyngeal lymph nodes, indicating that the primary infections in this age group may be arising from the oropharynx, tonsil, nasopharynx, and paranasal sinuses. Of note, retropharyngeal abscesses have historically been considered rare in older children and adults because lymph nodes in this space regress by the age of 5 years.14 However, our review shows significant numbers of retropharyngeal abscesses in older age groups. Sethi and Stanley6 found similar results, and they proposed that noninfectious causes are more important in older children and adults with retropharyngeal abscesses (Figure 2).

LOCATION-SPECIFIC DIFFERENCES IN DEEP NECK SPACE ABSCESSES

Patients with retropharyngeal or parapharyngeal space abscesses, who tended to be 1 year or older, were more likely infected with group A streptococcus (34%) vs S aureus (11%) (P = .007). Anterior or posterior triangle abscesses, which tended to occur in patients younger than 1 year, more commonly yielded S aureus (35%) vs group A streptococcus (19%) (P = .25). Submandibular or submental abscesses tended to occur in patients younger than 1 year and more commonly yielded S aureus (42%) vs group A streptococcus (19%) (P = .15) (Figure 3). All locations yielded approximately 25% no growth. Brook2 has previously concluded that abscess location is paramount in determining the infecting organism. Our results support this conclusion. It makes sense that group A streptococcus and normal oropharyngeal flora were more common in retropharyngeal and parapharyngeal abscesses because these organisms are found in the oropharynx. Similarly, one would expect S aureus to be more common in anterior and posterior triangle and submandibular and submental abscesses because this organism is a common skin contaminant and these regions are more distant from the oropharynx. That S aureus tended to be more common than group A streptococcus in anterior and posterior triangle and submandibular and submental abscesses is consistent with the findings of Dodds and Maniglia.3

DIFFERENCES IN DEEP NECK SPACE ABSCESSES OVER TIME

Using a regression analysis of the number of patients admitted with deep neck space abscesses per year, we found a slope of 1.25 (SE, 0.63) (P = .08). While the relationship of number of patients to year of admission was not statistically significant, the average number of patients treated per year more than doubled from the first half to the second half of the study period (n = 10.2-20.5). One explanation for the lack of statistical significance may be the large variability. That there may be an increase in the incidence of deep neck space abscesses over time is supported by Dodds and Maniglia.3 They performed a retrospective review on all children treated for neck abscesses at our institution between 1972 and 1987. They noted only 6 cases per year, and these included some patients with peritonsillar abscesses, which were excluded from our study. This apparent increase in incidence may represent an increase in the resistance or virulence of infecting organisms. However, we cannot conclude that there has been an increase in the incidence of deep neck space abscesses because we do not know the total number of admissions and consultations done by the otolaryngology service at our institution over these periods.

From the first half of the study period to the second half, the proportion of patients with S aureus dropped slightly (30% to 27%). The proportion of patients with group A streptococcus rose slightly (21% to 27%), as did the proportion with normal oropharyngeal flora (13% to 16%). There were also small changes in anatomic location over time. Retropharyngeal or parapharyngeal involvement became more common (36% to 47%), as did submandibular or submental involvement (20% to 28%). However, anterior or posterior involvement became less common (45% to 26%). In the past, researchers have described changes in infecting organism and abscess location over time. Beck18 demonstrated shifts in organism and location from the preantibiotic era to the postantibiotic era, and he emphasized the selective pressure that antibiotics place on nasopharyngeal flora. In addition, Thompson et al11 noted an increase in gram-negative and anaerobic organisms from 1950 to 1986. During the shorter study period in the present review, however, we identified no overwhelming trends.

Although other investigators have demonstrated an increased incidence of antibiotic resistance in patients with acute otitis media and otitis media with effusion, this trend was not noted. This may suggest that host susceptibility and immune response are more important variables than antibiotic resistance of the infecting organism in deep neck space abscesses. This would indicate that these patients would not necessarily benefit from broader-spectrum antibiotics to treat these infections.

ANTIBIOTIC SENSITIVITY VS PREVIOUS ANTIBIOTIC EXPOSURE

Staphylococcus aureus exhibited slightly lower levels of sensitivity to clindamycin, erythromycin, and oxacillin in patients without previous antibiotic exposure (93%, 85%, and 91%, respectively) vs patients with previous antibiotic exposure (100%, 93%, and 100%, respectively). Almost all S aureus infections were resistant to penicillin and intermediately sensitive to sulfamethoxazole in both groups. Group A streptococcus infections were slightly less sensitive to erythromycin and tetracycline in patients without previous antibiotic exposure (86% and 86%, respectively) vs patients with previous antibiotic exposure (100% and 100%, respectively) (Table 3).

Because several studies have shown previous antibiotic use to be associated with increased antimicrobial resistance,79 we expected patients with previous antibiotic exposure to be infected with more resistant organisms than patients without previous antibiotic exposure. However, resistance patterns were very similar between the 2 groups. It is interesting that these prior studies have focused on middle ear pathogens. Perhaps the pathogens responsible for deep neck space abscesses are not under the same microbial pressure as middle ear pathogens.

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Article Information

Corresponding author and reprints: James M. Coticchia, MD, Department of Otolaryngology, Wayne State University, 540 E Canfield, 5E-UHC, Detroit, MI 48201 (e-mail: jcoticch@med.wayne.edu).

Submitted for publication January 14, 2003; final revision received May 28, 2003; accepted June 25, 2003.

We gratefully acknowledge Mary Ann O'Riordan, MS, for statistical analysis of the data reported in this article.

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Barratt  GEKoopmann  CFCoulthard  SW Retropharyngeal abscess: a ten-year experience. Laryngoscope.1984;94:455-463.
PubMed
2.
Brook  I Microbiology of abscesses of the head and neck in children. Ann Otol Rhinol Laryngol.1987;96:429-433.
PubMed
3.
Dodds  BManiglia  AJ Peritonsillar and neck abscesses in the pediatric age group. Laryngoscope.1988;98:956-959.
PubMed
4.
Gianoli  GIEspinola  TEGuarisco  JLMiller  RH Retropharyngeal space infection: changing trends. Otolaryngol Head Neck Surg.1991;105:92-100.
PubMed
5.
Har-El  GAroesty  JHShalla  ALucente  FE Changing trends in deep neck abscess. Oral Surg Oral Med Oral Pathol.1994;77:446-450.
PubMed
6.
Sethi  DSStanley  RE Deep neck abscesses: changing trends. J Laryngol Otol.1994;108:138-143.
PubMed
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Brook  IGober  AE Prophylaxis with amoxicillin or sulfisoxazole for otitis media: effect on the recovery of penicillin-resistant bacteria from children. Clin Infect Dis.1996;22:143-145.
PubMed
8.
Brook  IGober  AE Resistance to antimicrobials used for therapy of otitis media and sinusitis: effect of previous antimicrobial therapy and smoking. Ann Otol Rhinol Laryngol.1999;108:645-647.
PubMed
9.
Brook  IGober  AE Emergence of β-lactamase–producing aerobic and anaerobic bacteria in the oropharynx of children following penicillin chemotherapy. Clin Pediatr (Phila).1984;23:338-341.
PubMed
10.
Nagy  MPizzuto  MBackstrom  IBrodsky  L Deep neck infections in children: a new approach to diagnosis and treatment. Laryngoscope.1997;107:1627-1634.
PubMed
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Thompson  JWCohen  SRReddix  P Retropharyngeal abscess in children: a retrospective and historical analysis. Laryngoscope.1988;98:589-592.
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Davidson  M Abscesses of the retropharyngeal spaces in adults. Laryngoscope.1949;59:1146-1170.
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Faden  HBrodsky  LWaz  MJStanievich  JBernstein  JMOgra  PL Nasopharyngeal flora in the first three years of life in normal and otitis-prone children. Ann Otol Rhinol Laryngol.1991;100:612-615.
PubMed
14.
Choi  SSVezina  LGGrundfast  KM Relative incidence and alternative approaches for surgical drainage of different types of deep neck abscesses in children. Arch Otolaryngol Head Neck Surg.1997;123:1271-1275.
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