NAPLES, Fla.—Certain serious childhood head and neck infections tend to occur in particular sites by age, according to research presented here at the meeting of the Southern Section of the Triological Society.
Exactly why that should occur remains controversial, said John M. Schweinfurth, MD, Associate Professor of Otolaryngology and Communicative Sciences at the University of Mississippi Medical Center in Jackson.
“Head and neck infections are not random occurrences base on exposure alone: host factors are clearly important,” he said. “Given the lack of correlation with school age, the results cannot be explained on the basis of exposure alone.”
T-Cells, Immune Response Key
Dr. Schweinfurth suggested that further study of the role of certain types of viral infections, T-cell activation, and overall immune system response is warranted to figure out why some severe infections occur early and others occur late.
“We did find significant age differences by site,” Dr. Schweinfurth said. He said the differences by age reached significance at the p < .001 level.
“These findings are not completely explained by exposure to infectious agents. A better understanding of signaling that occurs between T-cells in response to infection may provide a better explanation of this process,” he said.
The host immune response is likely the most important determinant of the development of an abscess.
That understanding is now being studied by several scientists, he said. He suggested that abscesses development has been associated with interleukin-8 and -17, and can also be stimulated by Zwitterionic bacterial polysaccharides—all of which affect the T-cell response.
“The aggregation and migration of sensitized T-cell lymphocytes may be responsible for the progression in site incidence of severe infections of the head and neck with age,” Dr. Schweinfurth said. “Patterns identified in the present study are cause for further investigation.”
He suggested that host factors may also be involved, including a genetic disposition to tonsillitis and how T-cells respond to infection in early infancy. Viral infection may play a role as well. Epstein-Bar virus (EBV) can cause lymphadenitis which results in secondary abscess formation in young children due to intense, local inflammation.
Study Protocols
He looked specifically at the incidence of abscesses in these children. An abscess can be described as an intense, localized immune response characterized by recruitment of many polymorphonuclear leukocytes to a restricted side, inflammation, and a locally compromised circulation. The host immune response is likely the most important determinant of the development of an abscess. Its formation is an immune response to the products of a bacterial cell.
“The aggregation and migration of sensitized T-cell lymphocytes may be responsible for the progression in site incidence of sever infections of the head and neck with age.” – —John M. Schweinfurth, MD
“We used an epidemiological approach to determine if we could identify a pattern of development of these infections and if there was a pattern to the risk factors associated with abscesses in a pediatric population,” he said.
A nonparametric Kruskal-Wallis test was used to identify significant differences in the age distributions among the diagnosis groups. A Bonferroni, pairwise comparison procedure was used for comparing the average age of first onset of severe head and neck infections. A chi-square test was used to identify any significant association between season of the year and disease.
In his study, Dr. Schweinfurth identified a total of 1,010 severe head and neck infections cases among patients aged 3 months to 18 years during a five-year period. He noted the differences in age distributions of those infections and the average age of the first onset of the infection.
The most frequent abscess seen was the periapical abscess.
Results Reveal Age, Site Clusters
He found 133 cases of cellulitis and abscesses of the neck—and 59 of those cases occurred during the first year of life. The mean age of occurrence was 5.4 years, but only in one year after the first year of life were there more than 10 such infections recorded in the pediatric population.
On the other hand, cases of peri-tonsillar abscesses were rare before the child was 10 and increased dramatically during the teen years, with 26 of the 81 cases of this infection occurring at age 18. More than five cases a year were seen by children aged 11, 14, 16, 17, and 18. The mean age for this infection was 13.1 years. “A potential explanation may come from the observation that Epstein-Bar virus (EBV) causes more severe infections in the tonsils of adolescents compared to younger children. The abscess is a secondary occurrence from intense local inflammation.”
Dr. Schweinfurth’s hospital recorded 73 cases of pharyngitis and tonsillitis, with most of the cases clustering before age 7. The mean was 6.4 years.
The study found 11 cases of parapharyngeal abscess, all in children 12 years of age or younger. Four of those cases occurred in children 7 to 8 years of age. The mean was 5.8 years.
He scrutinized 92 cases in which pediatric patients had combined peri-tonsillar and parapharyngeal abscesses. Those cases again peaked at the older end of the age spectrum, with 42 of the cases occurring in children ages 15 to 18 years. In contrast, less than 10 of these cases were recorded in children under the age of 5 years. The mean was 12.2 years.
Retropharyngeal abscess appears to be an illness that occurs early in a child’s life, Dr. Schweinfurth’s research revealed. Of the 27 cases of this lesion seen at the hospital, 10 occurred in the child’s first two years of life and 7 more occurred during years 3 to 4. The mean was reached at 3.4 years.
Some Infections Span Age Spectrum
In a number of cases, the periapical abscess, an infection originating in the root of a tooth, was most frequent. His institution recorded 398 of these serious infections, most of them occurring before the child reached age 8. The mean was 7.7 years. The most frequent time for these cases to appear was in the fourth and fifth year of life—with more than 45 cases occurring in each of those years. More than 25 cases occurred in years 2, 3, and 6. However, this infection was seen about 10 times each year of age across the pediatric spectrum.
There were 285 cases of facial cellulitis seen in the pediatric unit, with 48 cases seen in the first year of life. In no other year did the hospital record more than 22 cases of the infection, although doctors did see cellulitis cases in children of every age. There appears to be a lull in cases, however, between age 6 and age 15, creating a U-shaped curve of events. The mean was reached at 7.6 years.
“We tend to think of abscesses as occurring in the warmer months. The results of this study indicate the incidence of parapharyngeal abscess and diseases of the pharynx is decreased during spring while peritonsillar abscesses and acute periodontitis occur more often in spring and summer.” Dr. Schweinfurth said. “Age does not appear to be related to season of first occurrence; in other words no age group is more or less likely to have severe infections related to a particular time of year.”
©2006 The Triological Society