CASE 10048 Published on 02.05.2012

Percutaneous drainage of complicated neck and mediastinal abscesses in children


Paediatric radiology

Case Type

Clinical Cases


Kenney JF, Shiels II WE, Koranyi KI

Nationwide Children's Hospital,
The Children’s Radiological Institute,
Department of Radiology;
700 Children’s Drive 43205 Columbus;

6 months, female

Area of Interest Arteries / Aorta, Mediastinum, Head and neck, Cardiac, Ear / Nose / Throat ; Imaging Technique CT, Fluoroscopy, Ultrasound
Clinical History
A 6-month-old febrile infant presented with MRSA pneumonia, multiple neck and anterior mediastinal abscesses, and Lemierre’s syndrome.
Imaging Findings
A six-month-old African American female patient was admitted to the emergency department and subsequently to the paediatric intensive care unit for respiratory distress and swelling of the left side of the neck. She was diagnosed with respiratory syncytial virus bronchiolitis two days prior to admission. The day of admission she had fever and difficulty moving her neck. On examination she was febrile, irritable, and the neck was swollen and tender. She was tachypneic and had subcostal retractions. A pericardial friction rub was heard on auscultation. A neck CT examination showed multiple neck abscesses, in the retropharyngeal space and left lateral neck, with an anterior mediastinal phlegmon. Left internal jugular vein thrombosis was present (Fig. 1). Chest radiograph demonstrated patchy airspace disease and round pneumonia in the right upper lobe.
Neck abscesses can be complicated and multifocal and may spread quickly via the deep cervical fascia to other areas, to include the skull base, chest, and mediastinum. Additionally, Lemierre’s syndrome, septic thrombophlebitis of the internal jugular vein, is a rare but serious complication of neck abscesses or mouth infections. While many abscesses have been previously treated surgically, surgical drainage is difficult due to the presence of prominent nerves and blood vessels in the neck and mediastinum. [1] Even though this modality has been utilised extensively when treating neck abscesses in adults, [1] we believe this is the first time this procedure has been used to drain neck and mediastinal abscesses in children. In experienced hands, the procedure is safe, precise, and effective in treating abscesses and its complications.

Real-time, high-resolution ultrasound guidance provides millimetre accuracy and control, allowing interventional radiologists the ability to avoid critical structures in the neck and chest. The un-ossified sternum of infants and children provides excellent retrosternal visualisation and guidance for safe drainage of both the pericardial and anterior mediastinal abscesses, a unique procedure that cannot be performed on older patients with complete sternal ossification. Successful percutaneous drainage of anterior neck, retropharyngeal, and mediastinal abscesses avoids extensive neck and intrathoracic surgical procedures. As a result of the precise percutaneous abscess drainage coupled with appropriate antibiotics to treat methicillin-resistant Staphylococcus aureus and Lemierre’s syndrome, the patient made a full recovery with no additional complications. Follow-up CT scans showed no recurrent abscesses or complications. As a result of successful management of this first patient (described above), a second patient with neck abscesses (anterior neck and parapharyngeal spaces) and anterior mediastinal abscess was managed with similar ultrasound guided percutaneous drainage of both neck abscesses and anterior mediastinal abscess using the retrosternal approach (Fig. 4 and 5). Even though Lemierre’s syndrome is traditionally caused by Fusobacterium necrophorum, methicillin-resistant Staphylococcus aureus is becoming an increasingly common cause of Lemierre’s syndrome. [2]

In experienced hands, percutaneous drainage of complicated neck and mediastinal abscesses are safe procedures, avoiding extensive surgical intervention, and now provides paediatric specialists effective options for care of children with complicated neck and chest infections.
Differential Diagnosis List
MRSA pneumonia, multiple neck and anterior mediastinal abscesses, Lemierre’s syndrome
MRSA pneumonia
Complicated neck abscesses
Complicated mediastinal abscesses
Lemierre\'s syndrome
Final Diagnosis
MRSA pneumonia, multiple neck and anterior mediastinal abscesses, Lemierre’s syndrome
Case information
DOI: 10.1594/EURORAD/CASE.10048
ISSN: 1563-4086