Deep Neck Infections by ert634

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                         Deep Neck Infections




                          F . .                F           F
   . ., . . (                           F
                                        ), . . (                 F        F                 F          F)
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                                                        F                                       F
                         F                                  F               . . 2550
                                                                 2




                                                             F

1.   Fasciae of the head and neck                        1
2.   Potential spaces of the neck                        4
3.   Etiology and pathogenesis of deep neck infection   8
4.   Clinical manifestation                             10
5.   General work up                                    10
6.   Ludwig s angina                                    11
7.   Parapharyngeal space infection                     15
8.   Retropharyngeal space infection                    17
9.   References
                                                                                        3



               F       F             F         deep neck infections
                                                                 F                          F
           F               F    F       F          F        F             F   F     F
       F                     deep neck infections     F               F                         F
                   F
                       F      deep neck infections F               F Mediastinitis ,
airway obstruction, carotid artery hemorrhage      septicemia           F
source         infection, signs and symptoms , microbiologic features
laboratory       radiologic workups                      F
             F             F deep neck infections                 F F      fascial
planes          potential space                                 F
drainage F F             F

Fasciae of the head and neck
               F    2 F     1. Cervical spine       musculature             spine
musculature           F      support                  cervical portion     spinal cord
  F F       F F spine 2. Visceral segment            viscera, vasculature, nerves
lymphatics F cervical fasciae          F      visceral structures       F    2 F
superficial      deep layer

Superficial cervical fascia
        Superficial cervical fascia     sheet fibrous connective tissue      F
 F                  adherent        deep fascia
        Superficial cervical fascia       platysma muscle    platysma muscle
    cervical branch fascial nerve F marginal mandibular branch facial nerve
     F F F superficial cervical fascia, Potential space     F superficial      deep
cervical fascia                FF           platysma muscle     F   F
                                                                                        4

The deep cervical fascia
        Deep cervical fascia (        1       2)                                   spread
     cervical infections               F          3 F
        1. superficial or investing layer of the deep cervical fascia
        2. middle layer or vesceral fascia
        3. deep layer or prevertebral fascia
         various fascia           F         F         potential space          F
infections neck space F                  F




                                       1 Cross section of the neck

Superficial layer of the deep cervical fascia
              F              skull       chest              mother of the cervical fasciae
       F deep cervical fascia            develop         fascia
                                                                                                   5

                            superficial layer of the deep cervical fascia      ligamentum nuchae,
spine             cervical vertebrae            external occipital protuberance, mastoid process
        zygoma
             F       F                 mandible       hyoid bone
               F F                     scapula, clavicle     manubrium                sternum
           Superficial layer of the deep cervical fascia                1        F          2
   F             trapezius           F       sternocleidomastoid                           F sternum
                1-3 .             suprasternal space of Burns fascia                   hyoid bone
     mandible             F submandibular space             submental space F anteromedial
      F           anterior belly of the digastric
           Superficial layer            fascia                  capsule        parotid gland
         F parotidomasseteric fascia                                  parotid gland          masseter
muscle parotidomasseteric fascia                             superiorly            inferior border of
zygoma                     fascia             superiorly      temporalis muscle fascia
           lateral orbital margin            temporal line of skull F The deeper layer
pterygoid muscle                mandible           deep parotid gland        F           2 spaces
parotid            masticator spaces.

Middle or Visceral fascia of the deep cervical fascia
        Fascia           viscera           F pharynx , esophagus, larynx, trachea
thyroid gland                  strap muscles fascia         F space            F
                                  mouth, pharynx, esophagus, larynx      trachea
        The visceral layer of deep cervical fascia       F    3 F          F        strap
muscle, F          viscera      carotid sheath
         F cervical visceral fascia form capsule              thyroid gland       F
pharynx, esophagus, larynx         trachea F          base of skull, superior constrictor
muscle        pharynx , pharyngeal aponeurosis, mandible             pterygomandibular
raphae
        The buccopharyngeal fascia          F         fascia          constrictor muscle
     buccinator muscle extending base of skull                    cricoid cartilage
                                                                                       6

          F carotid sheath connective tissue F               carotid artery, vagus nerve,
intenal jugular vein    cervical sympathetic chain              base of skull
clavicle, carotid sheath                                    F chest       mediastinum




                                    2 Midsagittal section

Deep cervical fascia or prevertebral fascia
       The prevertebral fascia (         2) F F F cervical vertebral bodies
paraspinous muscle (musculus longus colli , musculus longus capitis, scalene muscle)
 F lateral      tip of transverse processes of cervical vertebrae
                                                                                       7

Potential Spaces of the Neck
                  Potential space                 F
     F          potential space

The lateral pharyngeal or parapharyngeal space
        Parapharyngeal space (          1,3)                F pharyngomaxillary space
         F connective tissue F space F medial F pterygoid muscle, mandible
    carotid sheath F            base of skull, F F                        hyoid F F
posterolateral       carotid sheath , Posteromedial          retropharyngeal space, F
medial buccopharyngeal fascia                constrictor muscle F         tonsillar fossa
 F F anterior        inferior      F spaces             floor of mouth




                                     3 Oblique cross section

The submandibular space
       Submandibular space (          4) F       2 space      mylohyoid muscle       F
 F mylohyoid muscle         F submaxillary space          F F F       F    submental
space               anterior belly of digastric muscle , mandible    hyoid bone
                                                                                         8

           F space F            F mylohyoid muscle sublingual space
          submandibular space F              oral mucosa , tongue , mandible          F
             hyoid       F F         space
          most common                                                    injury F floor of
month ,                   sublingual     submandibular gland ,                      root of
mandibular teeth
                                submandibular space               F          F submaxillary
      sublingual space F F              F mylohyoid        geniohyoid muscle              F
mylohyoid cleft
               Wharton s duct, lingual nerve, hypoglossal nerve , branch of facial artery
       multiple lymphatics F mylohyoid cleft F                                    F F
midline           sublingual       submaxillary F                   Ludwig s angina
cellulitis                     molar              sublingual space F
2 F                F tongue                upward      posteriorly       F severe airway
obstruction           F                        posterior      F F carotid sheath
retropharyngeal space F




                                        4 Coronal view
                                                                                        9

The masticator space
       The masticator space (          4)                  fascia superficial layer of
the deep cervical fascia             mandible    muscle of mastication        2 F
  F anterior           F masseter muscle, medial        lateral pterygoid muscle, ramus
   F Posterior          F F body of mandible         tendinous insertion temporalis
muscle                     masticator space             Zygoma, mandible , pterygoid
muscle       base of skull     F        superomedially        F temporal space         F
    F   F Zygomatic arch           F      F               masticator space
               3

The retropharyngeal space
        Retropharyngeal space (            2      3) F F deep layer of the deep
cervical fascia        buccopharyngeal fascia           constrictor muscles      pharynx
      F              esophagus       F F
               space         F F F alar layer
        alar layer F           deep layer of the deep cervical fascia            base of
skull                     Thoracic vertebra 2 F fascia                F       sheath
esophagus F           F F F deep layer of the deep cervical fascia F F        F alar layer
                   F base of skull              diaphragm             prevertebra space
              F danger space                        space               F              F F
mediastinum F F
        Retropharyngeal space                         parapharyngeal space , masticator
space        parotid space            retropharyngeal lymph node
                           F     space                    endoscopy F

Parotid space
        Parotid space (       3) F F superficial           deep capsule        porotid
gland                          fascia superfical layer of the deep cervical fascia
         F superficial capsule F F                            F   parotid gland F
deep capsule             F           parapharyngeal space                  F medial
capsule       F lateral capsule F      parapharyngeal space                    parotid
                                                                                                       10

space                             F parapharyngeal space      F F retropharyngeal space
carotid sheath                     mediastinum        complication            F    F
                            (1)
suppurative parotiditis

Etiology and pathogenosis of deep neek infections
                       deep neck infections                F spaces F spaces ,                 F
   antibiotic deep neck infections                                       pharynx     tonsil
70% F                                       F antibiotic F         F
                              deep neck infections                   F 50% F                source of
infection F (2)                                         deep neck infections F
          1.                                                                                          F F
sublingual            submaxillary spaces             F         Ludwig s angina ,                      F F
masticator space                  F                      parapharyngeal space , infratemporal
fossa           pterygopalatine fossa F F                       carotid sheath      retropharyngeal
space                F mediastinitis                F                      Mixed microbiologic flora
     alpha          beta-streptococci, Staphylococcus, Peptostreptococcus, Fusobacterium
nucleatum , Bacleroides melanogenicus, B. oralis, Veillonella, Actinomyces ,
Spirochaeta
          2.                        tonsillar      peritonsillar       F       F        F    antibiotic
   F                                     deep neck infections Peritonsillar abscess
cellulitis                                              streptococcal                     F
retrograde thrombophlebitis                parapharyngeal space F                    Carotid sheath
              F              Mediastinum F                     F posterior          parapharyngeal
space fascia                            retropharyngeal F                        F
retropharyngeal space F F
          3. Trauma                  aerodigestive tract F                  blunt, penetrating
iatrogenic              F F      deep neck infections                                 F           F
            F                    retropharyngeal space             parapharyngeal space             F
                                                                                                       11

           4. Retropharyngeal lymph nodes                   drain              nose paranasal sinuses,
pharynx , middle ear , eustachian tube , muscle                        bone F               lymph nodes
      F                                                                F
retropharyngeal abscess F F                          F F         F       compromised immune system
              F F           Streptococcus pyogenes, Staphylococcus oralis                        anaerobic
bacteria                   retropharyngeal space                   alar layer F F prevertebral space
             mediastinum F
           5. Prevetebral space                              cervical vertebral body infection
necrosis                       Pott s disease          tuberculosis
           6. Sialadenitis                    Staphylococcus                Streptococcus
submandibular gland                              F submandibular space                              F
parapharyngeal space F                         parotitis                    F F masticator space
parapharyngeal space                          fascia                      posteroinferior        deep lobe
        parotid gland
           7. Temporal bone                                         F parapharyngeal space
Bezold s abscess                               mastoid air cell F                 tip              mastoid
    F                   F parapharyngeal space                  F F F
           8.                   congenital cyst          fistulas              F deep neck infections
  F                        F F fascial compartment F                 foregut anomalies, bronchogenic
cysts, thyroid cysts , laryngoceles , thyroglossal duct cysts,                            branchial arch
anomalies              source deep neck infections F
                                                                                             (3)
           9.                  report deep neck infections
                     supraclavicular                                                  carotid sheath
         mediastinum F                    F         Staphylococcus aureus                 beta-hemolytic
streptococci
               F             F       injury F carotid artery                  innominate artery F
pseudoaneurysm formation F
                                                                                                    12

Clinical manifestations
           Clinical presentation       deep neck infections                  F space
         F        F      specific deep neck infections F                 F         F      pain , fever,
limitation mandibular             neck motion
           Pain                     F      primary source            infection              F
                                                          F F          F        F
abscess retropharyngeal space                          F         F                      F     F F
    F
           Fever         deep neck infections              F       F            spiking temperatures
        F F septicemia F                            thrombophlebitis internal jugular vein
                F      mediastinum
           Trismus and limitation neck motion                  deep neck infections
                    F       F                                   pitting edema
deep neck infections           F F fluctuance
                          F        F progressive dysphagia                 odynophagia , change in
voice         dyspnea
           Change in voice                                     retropharyngeal space
parapharyngeal space            F        Hot potato voice
           Dysnea                           airway                            Ludwig s angina F
pharyngeal swelling                   parapharyngeal space                  retropharyngeal space
abscess, dyspnea                                  F                  F F F            F mediastinal
extension             F chest pain, severe dyspnea           radiographic evidence                F
mediastinum F

General work up
                                F       F               F                    work up F
deep neck infections F initial laboratory examination              F complete blood count
with differential , erythrocyte sedimentation rate , serum electrolyte level, calcium level ,
coagulation parameters          blood cultures F          sepsis         cultures with gram
strain             F                F radiographic examination F film lateral neck
          F          airway                      floor of mouth (Ludwig s angina)
                                                                                   13

retropharyngeal abscess          F air        F           F F                   F
retropharyngeal space          F                retropharyngeal space         F
         Non invasive techniques F CT scan F                       localize       F
     infection F                     spread infection F                     F
              cellulitis    abscess F       F           F (4) F arteriography
               F       deep neck infections
pseudoaneurysm injury F innominate artery carotid artery

Specific deep neck infections
Ludwig s Angina
               .1836 Wilhelm Friedrich von Ludwig F           F 5          soft tissue
infection F                   F submandibular space        floor of month F
               acute airway obstruction F                              submandibular
space F Ludwig s angina




                     5 Mylohyoid line as view medially

Anatomy
       Ludwing s angina (         4     5)                 submandibular space
submandibular space             F 2 spaces submandibular space            submaxillary
space           2 spaces                F       mylohyoid muscle F            F
mylohyoid cleft                F submandibular gland , Wharton s duct , lingual nerve,
hypoglossal nerve lymphatics , arteries    vein
                                                                                        14

         Submandibular space            F superficial layer of the deep cervical fascia
                hyoid mandible                  F        F        midline submaxillary
     sublingual space
                        F     Ludwig s angina                                  submaxillary
space F               F sublingual space          anterior teeth     first molar       F
  F mylohyoid line                            F        sublingual space F second
third molar               F F F mylohyoid ridge                          lingual surface
   F F submaxillary space F

Definition
         Pseudo-Ludwig s angina                      sublingual space , submandibular
lymph nodes, submandibular gland submental space F Ludwig s angina
         1. Spreding cellulitis     F      F      abscess
         2. Involvement submaxillary         sublingual spaces            bilateral
         3. Spred        fascial planes F        lymphatics
         4. Involvement of muscle       fascia F F F submandibular gland            lymph
            nodes
         5.               submaxillary space F              F sublingual space

Etiology
         Ludwig s angina most common             young adults
                         second        third molar             submaxillary space F F
mylohyoid ridge            cellulitis
                                                75-80%       F            F
     injury floor of mouth F          stab wound , gunshot wound       F
             F                   molar                           F     Ludwig s angina

Microbiologic features
                         F     F                              bacterial cultures
    F oral flora                    Mixed flora     aerobes      anaerobes        most
common reported aerobes            alpha-hemolytic streptococci       F Staphylococcus
                                                                                                 15

  F anaerobes F Peptostreptococcus, Peptococcus, Fusobacterium nucleatum,
Bacteroides melanogenicus, B.oralis , Veillonella,  Spirochaeta Mixed flora F
     synergistic effect       F   endotoxins F collagenase, hyaluronidase
proteases        F     tissue necrosis, local thrombophlebitis, putrid odor gas
formation

Clinical features
           F        Ludwig s angina                      F           F                     F
                                   unilateral F               bilateral F
external perimandibular region                 floor of mouth , Soft tissue        floor of mouth
       F                 F                  posterior      superior
             F                  neck rigidity, trismus, odynophagia           drooling ,
                 o     o                           o
      F 100 -120 F F F                         104 F F                                 F
airway             Dyspnea             stridor                      F F                       airway
obstruction
                            F        F               F                   F endotracheal intubation
          F airway obstruction F
               F           tracheostomy                    F      F                  F            F
                    F onset                 respiratory obstruction        F      12-24 .

Physical examination
      F              -Fever
                     -Trachycardia
                     -Variable degree respiratory obstruction
                     -Dysphagia
                     -Drooling
                     -Submandibular and submental region tense, swollen
                      tender
                     -Floor of mouth tense    indurated      mucosa
Fluctuance     F F                  superior  marked trismus
                                                                                                                  16

         Indirect laryngoscope                        F              F      F fiberopticscope       base
of tongue            epiglottis                   F       posterior F     supraglottis     endolarynx



Laboratory and radiologic examination
                    Ludwig s angina          F clinical parameter F laboratory
radiologic studies            F F             F          white blood cell count
                     15,000 20,000           mark shift to the left
        X-ray studies       soft tissue              gas                      posterior
  F airway            F                 F                                       panoramic
tomography        F      origin of infection                               F

Treatment
                             F        Stage                     F                   F                  periapical
abscess           mild cellulitis            massive sepsis           airway obstruction early stages
     Ludwig s angina                   unilateral                 F                      F intravenous antibiotic
and supportive                                      F                            F F F                            F
         F                     dysphagia                 bilateral, drooling                                airway
compromise                         F control airway F               F F      F
              F                                  control airway                   drainage
           airway               F nasotracheal intubation F                             F acute obstruction
       tracheostomy                            F               tracheostomy                    F                    F
  F                       F                                                    F           F            F F
airway                 F          cricothyroidotomy
                F        drainage                     decompression               suprahyoid region
horizontal incision                    3-4 finger breadths F F mandibular region
incision          F F                F F submandibular region 2 F                          mylohyoid muscle
            midline              drainage medial              lateral             Gross purulence               F
                   woody induration, watery edema                                     F
                     antibiotic                  High-dose penicillin (12-16 million units/day)
drug of choice              F chloramphenicol            clindamycin                         F    F penicillin F
                                                                                                17

antibiotic    gram negative   penicillin-resistant staphylococci           F
    F immunocompromised host
                  F       70%            controlled F conservative medical
management F    F F 81%       F                 F      F (5)

Complications
                            Ludwig s angina             acute airway obstruction
tracheostomy                       airway obstruction                      F
          carotid sheath         retropharyngeal space                   F mediastinum
     F     mediastinitis                chest x-ray film          mediastinum F        ,
pericardial air , pulmonary infiltrates      extrapleural fluid
                    Ludwig s angina         F F pus
   F              F
                 CT scan          neck with contrast media                   F
pockets                            F drainage
         F mortality rate                 F
       F                 10%         F (5,6)

Parapharyngeal spaces infections
             F        parapharyngeal spaces (             3)
                    F       petrous portion               temporal                          F F F
           F          hyoid Carotid sheath F                    F posterior        inferior       F
                                    inferior F F             mediastinum F
        Parapharyngeal space              F      anterior         Posterior compartments
styloid process, Posterior compartment                         F internal carotid artery, internal
jugular vein, cranial nerves 9, 10            12 ,       cervical sympathetic trunk. Parotid ,
masticator, submandibular              retropharyngeal spaces             F        parapharyngeal
spaces                                          parapharyngeal spaces          F F
                  F       F        peritonsillar infection             F      F polymicrobial
               oropharyngeal flora          F Immunocompromised host
   F            F                             F
                                                                                                                                            18

                              F                F                      fever, trismus                  perimandibular edema
                   parotid            submandibular region                                           marked pain              limitation of
neck motion                              Trismus
              Intraoral examination                          F                               lateral pharyngeal wall
   F             F posterior tonsillar pillar F tonsil                                                        anterior        medial,
                                cranial nerves 9,10                             12 , Horner s syndrome                              F
                   cervical sympathetic chain                                                             F F             parapharyngeal
abscess                                               rare                                     F               hematoma                   skull
base F F                                                     fissure of Santorini                           F                                F
       F            ligation of carotid artery
                F parapharyngeal spaces infections                                                  uncommon                       CT scan
                                                                                      (7)
                                           F                    F             F
                                   F         F      parapharyngeal spaces infections F                                          F antibiotic
     F high-dose penicillin                              F                                                 antibiotic                      F
         aminoglycoside                          F         F                               F
                     F                                                                                                  10-15% F
          F                F           F                                  F      F            F F F                          hemorrhage,
subcutaneous emphysema, neurological deficit, skin necrosis                                                                 F cellulitis,
dyspnea, severe sepsis                                                   internal jugular vein thrombosis                          abscess
formation                    CT scan               MRI                               F F F                          F                 F
            F              24-48 . F                              F                F                   F antibiotic F
                         F       F                                  F
                       F                 F intraoral                      external               intraoral approaches                   F
peritonsillar abscesses                                F F F parapharyngeal space abscesses                                                    F
         inadequate exposure F                                 severe bleeding
              External approach parapharyngeal space                                                                  F         transverse
submandibular incision                                  2 ½ fingerbreadths F F mandibular margin
anterior limits                      submandibular gland                                  angle of mandibular                       incision
  F superficial layer of the deep cervical fascia                                                   submandibular gland F free
            inferior            posterior F F parapharyngeal space                                             dissect         F tail
submandibular gland                                 F                  F             sternocleidomastoid, F F F medial F
                                                                                                  19

mandible               medial F F           internal pterygoid         approach
base of skull F
                    . . 1929 , Mosher F F                  T-shaped incision         submandibular
fossa approach F F parapharynx                       carotid sheath       F           T      F F F
   F             sternocleidomastoid           F            submandibular transverse incision
      F                     F F F carotid sheath        visceral space F F
              F Complication               parapharyngeal space infections                    Airway
compromise                             pharynx
          Internal jugular vein thrombosis                    septic emboli with pulmonary emboli,
pneumonia, emphysema, bacterial endocarditis                        uncontrolled septicemia
        F               ligation of internal jugular vein
          Mediastinitis                  F                       carotid sheath                  high
mortality rate
               F the most frequent fatal complication             parapharyngeal space infections
     carotid artery hemorrhage                         necrosis      artery wall        F abscess
cavity
          Bleeding most common                   oropharyngeal location            involves internal
carotid artery               oropharyngeal bleeding                            tranoral drainage
  F peritonsillar abscess
            F        F                  bleeding F F                        carotid sheath
common carotid artery                controlled bleeding

Retropharyngeal space infection
       Retropharyngeal space abscess (                    1-3)       F
abscessed lymph nodes          draining                       ,
      F F           trauma F                        ,       F endotracheal tube
endoscopic                   F            tracheostomy F F (8)
       Clinical presentation retropharyngeal abscess F                   F      F F
                           F       F irritability , poor appetite      fever F
                   neck rigidity         tenderness               F             posterior
                                                                                                                                20

pharyngeal swelling                            F F F                              F        muffled cry, drooling
respiratory compromise
                   F F                                  fever, sorethroat, odynophagia, neck tenderness
             Dyspnea             F          F                     abscesses                           F F                  lateral
       F midline                       midline                              F alar fascia             prevertebral fascia
                   Pott s abscess nontuberculous prevertebral abscesses                                                   midline
             Radiographic examination                         F              lateral x-ray film                  neck           most
important study                  soft tissue                      retropharyngeal space                       F 7 .
         F F            Soft tissue                   retrotracheal space                    F 14 .                       22 .
        F F F x-ray F F                                  fluoroscopy             cycle                                F
                                       F F loss of lordosis                      curvature                   , CT scan,
                F F F                            F F                                  F Cellulitis               abscess , film
lateral neck F specific F                                       F air sign (9)
                                F antibiotic                       fluid replacement                           F        F
oropharyngeal flora                                    high-dose penicillin                    drug of choice                   F
                    abscess F                     F F                 F                intraoral          external             F F
respiratory obstruction                       F drainage transoral                               posterior pharyngeal wall
under general anaesthesia (10)                                   F F                        (Rose position)
aspiration F F F                    airway obstruction                                                 inferior              F
external drainage                               anterior cervical approach                                         F F F
sternocleidomastoid                  F                      hyoid cricoid cartilage
                         incision F superficial layer of the deep cervical fascia F retract
           lateral F carotid sheath F retract                                  posterior F F                            medial F
carotid sheath               lateral F trachea                            drainage                F        F        F F drain F
  F         F F                             mediastinum F                                     thoracic surgery
                 F                                  tracheostomy                    F               F
     F endotracheal tube                F                               F rupture abscess F
rupture             abscess                            F lung abscess                     pneumonia                     aspiration
    F Retropharyngeal space infections                                                   posterior F alar fascia F F
danger space                              F            mediastinum F
                                                   ----------------------------------
                                                                                     21

                                      References

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    Gluckman JL, Meyerhoff WL, eds. Otolaryngology. 3 rd ed. Philadelphia; W.B.
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2. Ballenger JJ. Diseases of the Oropharynx. In : Ballenger JJ, Snow JB, eds.
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3. Schondorf J,Jungehulsing M, Brochhagen HG, et al. Infection of deep soft tissues of
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4. Johnson JT. Deep Neck Infection. In : Gates GA, ed. Current Therapy in
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5. Kurien M, Mathew J, Job A, et al. Ludwig s angina. Clin Otolaryngol 1997 Jun; 22(3):
    263-5
6. De Bast Y, Appoloni O, Firket C, et al. Ludwig s angina. Rev Med Brux 2000 Jun; 21
    (3) : 137-41
7. Sichel JY, Gomori JM, Saah D, et al. Parapharyngeal abscess in children: the role of
    CT for diagnosis and treatment. Int J Pediatr Otorhinolaryngol 1996 May: 35 (3) :
    213-22
8. Stein S, David AS. Retropharyngeal abscess : an unusual complication of tracheal
    intubation. Eur J Anaesthesiol 1999 Feb; 16 (2) : 133-6
9. Boucher C, Dorion D, Fisch C. Retropharyngeal abscesses: a clinical and radiologic
    correlation. J Otolaryngol 1999 Jun; 28 (3) : 134-7
10. Ameh EA. Acute retropharyngeal abscess in children. Ann Trop Paediatr 1999 Mar;
    19 (1) : 109-12

								
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