Saturday, December 6, 2014

Deep neck infection and abscess in a 2-year-old girl

Today's case isn't bizarre in any way - actually it's quite typical - but I decided to post it because of the images. I'm not a doctor, so I don't get to see abscesses on radiographs on a regular basis.

For anyone with small children, this story might be a little scary. The 2-year-old girl in these photos has a deep neck infection and an abscess has already formed. She was admitted to hospital after two days of fever, and after five days of hospitalization, a mass began to be noticeable on the front of her chest despite antibiotic treatment. Chest radiography and computer tomography showed that pus had collected in the tissues above the sternum (see below). Antibiotic therapy was changed to stronger drugs - meropenem, clindamycin and vancomycin - and the abscess was surgically incised and drained, releasing twenty milliliters of pus. A culture of the exudate grew Streptococcus anginosus sensitive to vancomycin. The toddler recovered and was discharged home after spending 15 weeks in the hospital.

Chest radiography, which was normal on the referring day (a), shows air in the soft tissue (b) on the 5th day of admission (arrows). t: trachea. Contrast-enhanced computer tomography shows an inflammatory swelling of the soft-tissue (*) with large abnormal air collections (arrows) suggesting abscess formation (c), and spreading into the ianterior chest wall (d). There is also subcutaneous edema (+). Images from: Ozurekci et al. 2014

Deep neck infections often start as an isolated area of soft tissue inflammation adjacent to the primary source of infection: a carious tooth, the throat, salivary glands or middle ear. In the case described above, the child had recovered from an ear infection two weeks before the abscess began to form. There's no way of knowing whether this infection was the cause. In the hospital, the toddler was tested for immune disorders causing impaired immunity, but her immune system turned out to be normal.

All in all, this child had a lucky escape. In May 2013, I blogged about another little girl who, in a bizarre twist of fate, got hit by a soccer ball, came down with necrotizing fasciitis and didn't survive.

For non-queasy viewers - here's a very cool educational video showing the incision and drainage of a HUGE abscess under a patient's chin. Note that the patient is awake throughout the procedure. After squeezing out all the pus, the cavity is irrigated, then packed with sterile gauze. The cause of this purulent monstrosity was an infected carious tooth.



Ozsurekci Y, Oncel KE, Oguz B, Ayvaci FN, Kara A. (2014) Pre-Sternal Abscess associated with Deep Neck Infection. APSP J Case Rep. 5(3): 35. 

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