ÇOCUKLARDA DERİN BOYUN ENFEKSİYONLARI; ÜÇÜNCÜ BASAMAK HASTANESİ VERİLERİ

Öz

AMAÇ: Derin boyun enfeksiyonları (DBE) boyun bölgesinin fasya tabakaları arasında kalan potansiyel boşluklarda gelişen enfeksiyonlardır. Selülit, miyozit gibi erken bulgulardan flegmon, apse gibi ilerlemiş DBE’ye doğru bir seyir izlenebilir. Geç tanı, hızlı progresyon ve hayatı tehdit edici komplikasyonlar nedeniyle DBE kritik önem taşır. Bu tanımlayıcı çalışmanın amacı hastalarımızın klinik ve laboratuvar özelliklerine dayanarak yedi yıllık DBE verilerimizi sunmaktır.
GEREÇ VE YÖNTEM: Çocuk Enfeksiyon Hastalıkları Kliniğinde DBE tanısıyla Ocak 2010 – Ocak 2017 tarihleri arasında yatırılarak izlenen 58 hastanın anamnez ve fizik muayene bulguları, laboratuvar ve görüntüleme sonuçları, medikal ve cerrahi tedavileri, klinik seyirleri geriye dönük olarak incelendi.
BULGULAR: Hastaların 30’u (%51,7) erkekti, yaş ortalaması 5,6±4,9 yıldı. En sık başvuru yakınması ve fizik muayene bulgusu boyunda şişlik (%96,5) olarak belirlendi. Vakaların %93’ünde C-reaktif protein yüksekliği, %89'unda lökositoz, %72'sinde sedimantasyon yüksekliği saptandı. Başvuru anında genel durum ve klinik bulgulara dayanarak ciddi DBE düşünülmeyen (=selülit aşaması) hastalara ultrasonografik görüntüleme yapıldığı (n=26), ciddi DBE düşünülen (=apse) hastalara bilgisayarlı tomografi (BT) çekildiği (n=28), BT cihazı arızalı ise manyetik rezonans görüntüleme yapıldığı (n=4) belirlendi. Apse izlenen hastalarda en sık yerleşimin parafarengeal bölge olduğu (%75) saptandı. Ultrasonografi bulgularına göre en sık submandibüler bölgenin (%46) tutulduğu görüldü. DBE gelişiminde en sık iki etiyolojik neden olarak akut tonsillofarenjit (%34) ve odontojenik nedenler (%10) saptandı, hastaların %51’inde etiyoloji bulunamadı. Hastaların ortalama hastanede kalış süresinin 9,7±5,9 gün olduğu; %55’inin intravenöz ampisilin sulbaktam, %43’ünün intravenöz klindamisin tedavisi aldığı görüldü. Yirmi iki (%38) hastanın medikal tedavi ile iyileştiği, 36 (%62) hastaya medikal tedavi yanında cerrahi drenaj uygulandığı, drenaj örneğinden alınan kültürde üremesi olan hasta sayısının 18 (%50) olduğu belirlendi. İki hastada (%3,4) havayolu obstruksiyonu ve mediastinit olmak üzere komplikasyon geliştiği, mortalite görülmediği saptandı.
SONUÇ: Boyunda şişlik-ağrı ve ateş yakınmaları olan çocuklarda DBE akla getirilmeli ve tonsiller, dental muayene dikkatli yapılmalıdır. Ciddi DBE şüphesi varlığında kontrastlı BT çekilmelidir ve apse saptanan hastalara cerrahi drenaj uygulanmalıdır. Havayolu açıklığını tehdit eden DBE çocuk hastalarda önemli morbidite ve mortalite nedeni olabilir. Erken tanı, uygun antibiyoterapi ve gerektiğinde cerrahi drenaj ile prognoz iyileştirilebilir.

Anahtar Kelimeler

• boyunda şişlik
• çocuk
• derin boyun enfeksiyonu
• drenaj
• parafarengeal apse

DEEP NECK INFECTIONS IN CHILDREN; DATA FROM A TERTIARY HOSPITAL

Öz

OBJECTIVE: Deep neck infections (DNIs) are the infections developing in potential spaces between the layers of deep servical fascia. Clinical course may progress from early manifestations such as cellulite, myositis to serious DNI such as phlegmon and abscess. DNIs have crucial importance because of delayed diagnosis, fast progression, and severe complications. In this descriptive study, we aimed to present our seven-year experience about pediatric DNIs based on the clinical and laboratory characteristic of our patients.
MATERIAL AND METHODS: Data of 58 hospitalized children who diagnosed with DNI between January 2010 and January 2017 in Pediatric Infectious Diseases Clinic were analysed retrospectively. Patients’ medical history and physical examination findings, laboratory and radiological imaging results, treatment modalities, and clinical courses were evaluated by reviewing medical records.
RESULTS: Thirty (51.7%) of the patients were male, average age was 5.6±4.9 years. The most common symptom and physical finding was neck swelling (96.5%). Rates of C-reactive protein elevation, leucocytosis, and sedimentation elevation were 93%, 89%, and 72% respectively. By considering clinical condition, ultrasound scan was performed on patients with nonserious DNI (=cellulite phase) (n=26), computed tomography scan was performed on patients with serious DNI (= abscess) (n=28), and magnetic resonance imagination was performed (n=4) if CT scanner is out of order. In patients with abscess formation parapharyngeal localization (75%) was the most common. According to ultrasound scan, submandibular involvement (%46) was the most frequent region. The most common two etiology were acute tonsillopharyngitis (34%) and odontogenic factors (10%), and unknown etiology rate was 51%. Average duration of hospitalization was 9.7±5.9 days, 55% of patients were treated with intravenous ampicillin-sulbactam whereas 43% were treated with intravenous clindamycin. Twenty-two (38%) patients healed with medical treatment. Surgical drainage was performed on 36 (62%) patients in addition to medical treatment. There were bacterial growths in 18 (50%) drainage material cultures. Two (3.4%) patients were complicated with airway obstruction and mediastinitis while there was no mortality.
CONCLUSIONS: Children with neck swelling and fever should be evaluated in terms of DNI, and also dental and tonsillar examinations should be done carefully. Contrast CT scan should be performed for pre-diagnosis of cases with serious DNI and surgical drainage should be performed in cases with abscess formation. DNIs threatening airway patency may cause severe morbidity and mortality, so early diagnosis, appropriate antibiotic therapy with or without surgical drainage may improve prognosis.

Anahtar Kelimeler

• neck swelling
• child
• deep neck infection
• drainage
• parapharyngeal abscess

Kaynakça

1. Eksioglu AS, Timur OM. Computed Tomography Findings in Deep Neck Infections in Children. Med Bull Haseki 2014;52:34-8.
2. Suehara AB, Goncalves AJ, Alcadipani FA, Kavabata NK, Menezes MB. Deep neck infections in children. J Microbiol Immunol Infect 2001;34:287-92.
3. Boscolo-Rizzo P, Marchiori C, Montolli F, Vaglia A, Da Mosto MC. Deep neck infections: a constant challenge. ORL J Otorhinolaryngol Relat Spec 2006;68:259-65.
4. Chow AW. Life-threatening infections of the head, neck, and upper respiratory tract. In: Hall JB, Schmidt GA, Wood LD (ed). Principles of critical care (2nd ed) New York: McGraw-Hill,1998: 887-94. 5. Unsal Tuna EE, Ozel E, Ozbek C, Ozdem C. Deep neck infection: analysis of 63 cases. Turk Arch Otolaryngol 2008;46:73-7.
5. Cengiz AB, Kara A, Kanra G, et al. Acute neck infections in children. Turk J Pediatr 2004;46:153-8.
6. Caglı S,Yuce I, Guney E. Deep Neck Infections: Results of 50 Cases Ercıyes Med J 2006;28:211-5.
7. Kaya EE, Tasar MA, Dallar Bilge Y. Evalution of Deep Neck Infections in Pediatric Patients. Turkish J Pediatr Dis 2012;6:197-205.
8. Huang TT, Liu TC, Chen PR, et al. Deep neck infection: analysis of 185 cases. Head Neck 2004;26:854-60.

9. Bottin R, Marioni G, Rinaldi R, et al. Deep neck infection: a present-day complication. A retrospective review of 83 cases (1998-2001). Eur Arch Otorhinolaryngol 2003;260:576-9.
10. Cmejrek RC, Coticchia JM, Arnold JE. Presentation, diagnosis, and management of deep-neck abscesses in infants. Arch Otolaryngol Head Neck Surg 2002;128:1361-4.
11. Tan PT, Chang LY, Huang YC, et al. Deep neck infections in children. J Microbiol Immunol Infect 2001;34:287-92.
12. Belet N, Tapısız A, Ucar Y, et al. Deep neck infections in children. J Pediatr Inf 2007;1:58-62.
13. Coticchia JM, Getnick GS, Yun RD, Arnold JE. Age-, site-, and time-specific differences in pediatric deep neck abscesses. Arch Otolaryngol Head Neck Surg 2004;130:201-7.
14. Yen CW, Lin CY, Tsao LY, et al. Children’s deep neck infections in central Taiwan. Acta Paediatr Taiwan 2007;48:15-9.
15. Tom MB, Rice DH. Presentation and management of neck abscess: a retrospective analysis. Laryngoscope 1988;98:877-80.
16. Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg 2006;13:889-93.
17. Huang CM, Huang FG, Chien YL, Chen PY. Deep neck infections in children. J Microbiol Immunol Infect 2017;50 (5):627-33.
18. Ridder GJ, Technau-Ihling K, Sander A, Boedeker CC. Spectrum and management of deep neck space infections: an 8-year experience of 234 cases. Otolaryngol Head Neck Surg 2005;133:709-14.
19. Wang LF, Tai CF, Kuo WR, Chien CY. Predisposing factors of complicated deep neck infections: 12-year experience at a single institution. J Otolaryngol Head Neck Surg 2010;39:335-41.
20. Rozovsky K, Hiller N, Koplewitz BZ, Simanovsky N. Does CT have an additional diagnostic value over ultrasound in the evaluation of acute inflammatory neck masses in children? Eur Radiol 2010;20:484-90.
21. Crespo AN, Chone CT, Fonseca AS, et al. Clinical versus computed tomography evaluation in the diagnosis and management of deep neck infection. Sao Paulo Med J 2004;122: 259-63.
22. Parhiscar A, Har-El G. Deep neck abscess: A retrospective review of 210 cases. Ann Otol Rhinol Laryngol 2001;110:1051-4.
23. Yen CW, Lin CY, Tsao LY, et al. Children’s deep neck infections in central Taiwan. Acta Paediatr Taiwan 2007;48:15-9.
24. Grisaru-Soen G, Komisar O, Aizenstein O, et al. Retropharyngeal and parapharyngeal abscess in childrendepidemiology, clinical features and treatment. Int J Pediatr Otorhinolaryngol 2010;74:1016-20.
25. Brook I. Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg 2004;62:1545-50.
26. Beck AL. The influence of the chemotherapeutic and antibiotic drugs on the incidence and course of deep neck infections. Ann Otol Rhinol Laryngol 1952;61:515-32.
27. Lee JK, Kim HD, Lim SC. Predisposing factors of complicated. deep neck infection: an analysis of 158 cases. Yonsei Med J 2007;48:55-62.
28. Baldassari CM, Howell R, Amorn M, et al. Complications in pediatric deep neck space abscesses. Otolaryngol Head Neck Surg 2011;144:592-5.
29. Suehara AB, Gonçalves AJ, Alcadipani FA, Kavabata NK, Menezes MB. Deep neck infection: analysis of 80 cases. Braz J Otorhinolaryngol 2008;74:253-9