Retropharyngeal and parapharyngeal abscesses or phlegmons in children: Is there an association with adenotonsillectomy?

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Summary

Background

Retropharyngeal and parapharyngeal abscesses or phlegmons are relatively uncommon. Since the tonsils and adenoids are part of the lymphoid tissues of the nasopharynx and oral cavity, one may hypothesize that their removal would lead to an increased susceptibility to pharyngeal infections.

Objective

Determine whether there is an association with a history of adenotonsillectomy and the development of retro- and parapharyngeal abscesses/phlegmons.

Methods

A case–control study was performed. The charts of 180 children admitted to a tertiary care pediatric hospital between 1996 and 2006 were reviewed. The patients were age-matched to 180 children having visited the emergency department of the same hospital. The charts of these children were reviewed and used as controls.

Results

13.9% of children admitted with a retro- or parapharyngeal abscess or phlegmon had previously undergone an adenotonsillectomy as compared to only 2.2% of children in the control group. The calculated odds ratio was 7.10 (95% CI [2.52–19.93], p < 0.001).

Conclusion

In conclusion, the development of a retropharyngeal or parapharyngeal abscess or phlegmon is strongly associated with a history of adenotonsillectomy.

Introduction

Retro- and parapharyngeal abscesses/phlegmons are relatively uncommon infections that are most often encountered in children between 3 and 4 years old [1]. Possible complications include airway compromise, aspiration pneumonia, mediastinitis, invasion of contiguous structures and sepsis. In all cases, treatment consists of intravenous antibiotics with incision and drainage being reserved for the most severe cases or in cases unresponsive to antibiotherapy. The abscess or phlegmon is thought to occur as a consequence of an infection in the nasopharynx, sinuses or middle ear, which subsequently spreads to lymph nodes of the retro- or parapharyngeal space. Affected lymph nodes are located between the posterior pharyngeal wall and the prevertebral fascia for retropharyngeal abscesses, or between the lateral pharyngeal wall and the superficial layer of the deep cervical fascia for parapharyngeal abscesses. Abscess formation is the result of the progression from cellulitis to an organized phlegmon and subsequent maturation to an abscess.

Tonsils and adenoids are part of Waldeyer’s ring, a ring of lymphoid tissue in the nasopharynx and oral cavity. As this ring of lymphoid tissue is involved in the defence against airborne and alimentary organisms [2], one may hypothesise that adenotonsillectomy would result in the alteration of the humoral and cellular response of the immune system. This alteration in the immune system could potentially manifest itself as an increased susceptibility to the development of retro- or parapharyngeal abscesses or phlegmons.

We wished to evaluate whether there is an association between retro- and parapharyngeal abscess/phlegmon development and a history of adenotonsillectomy in the pediatric population.

Section snippets

Method

A retrospective case–control study of children admitted to a tertiary care pediatric hospital for a retro- and/or parapharyngeal abscess or phlegmon was conducted. The medical record of 180 children admitted with this diagnosis between January 1, 1996 and July 1, 2006 were reviewed. Information regarding age, gender, location of the collection, therapy, microbiology, season of hospitalization, duration of hospitalization and date and reason for previous adenotonsillectomy were recorded. The

Results

Table 1 summarizes the characteristics of the children admitted with a retro- and/or parapharyngeal abscess/phlegmon. The characteristics of our cases were comparable to those published in previous studies. Males were more often affected than females. Children presenting with a collection in the retro- or parapharyngeal spaces were more likely to have previously undergone an adenotonsillectomy. All children were treated with intravenous clindamycin, ceftriaxone, cefuroxime or

Discussion

In this study, we wished to determine whether there was an association between children developing a retro- or parapharyngeal abscess/phlegmon and a history of adenotonsillectomy. The calculated odds ratio for all children with abscesses/phlegmons was 7.10 and was highly statistically significant. Thus our hypothesis that adenotonsillectomy is associated with retro- and parapharyngeal abscesses/phlegmons is confirmed.

Although the association between tonsillectomy and retro- and parapharyngeal

Conclusion

This represents the first study looking at the association between a history of adenotonsillectomy and the development of retro- or parapharyngeal abscesses or phlegmons. Our results confirm our hypothesis that adenotonsillectomy is associated with the development of retro- and/or parapharyngeal abscesses or phlegmons. Nonetheless, the latter remain extremely rare in children with previous adenotonsillectomy and further studies are needed in order to better characterize this association.

Disclosure

Dr. Daniel is a speaker and has a clinical trial contract with Alcon Research Inc.

Acknowledgements

The authors would like to thank Dr. Melvin Schloss and Dr. Anthony Abela from the Montreal Children’s Hospital and Ste-Justine’s Hospital, respectively, for allowing us access to some of the patients’ data presented in this manuscript.

Melanie Duval participated in the design of the study, acquisition of the data, analysis and interpretation of the data, draft of the manuscript and gave final approval of the version to be published.

Sam Daniel participated in the design of the study, revision of

References (9)

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This study was presented at the American Society of Pediatric Otolaryngology Annual Meeting in May 2008.

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