Pediatric deep neck space infections (DNSIs)-peritonsillar, retropharyngeal, and parapharyngeal abscesses and Ludwig's angina-are uncommon but potentially life-threatening due to rapid progression to airway obstruction, sepsis, and mediastinal extension. This narrative review summarizes evidence for emergency clinicians. A literature search of PubMed/Scopus (2000-2025) identified studies on pediatric DNSI epidemiology, imaging, microbiology, and management. DNSIs peak at ages 2-5 years because of prominent retropharyngeal lymph nodes. Nonspecific symptoms (fever, irritability, neck stiffness) often delay diagnosis in young children, while older children present with trismus, dysphagia, and "hot potato" voice. Airway compromise is the highest priority and must be assessed before imaging. Contrast-enhanced CT remains the gold standard for stable patients, but point-of-care ultrasound has high accuracy for peritonsillar abscesses. Microbiology is polymicrobial; methicillin-resistant Staphylococcus aureus is increasingly reported. Empiric broad-spectrum intravenous antibiotics (e.g., ampicillin-sulbactam) should be initiated early, with vancomycin added if MRSA risk factors are present. Surgical drainage is indicated for abscesses >2-2.5 cm, airway compromise, or failure of medical therapy. Multidisciplinary collaboration reduces complications. Early recognition, an airway-first approach, selective imaging, and timely antibiotics improve outcomes. Standardized emergency department (ED) protocols and risk stratification tools are needed to prevent life-threatening complications in this vulnerable group.

Transoral ultrasound is a valuable tool for PTA diagnostics, especially when the diagnosis is uncertain due to ambiguous findings.

Peritonsillar abscess (PTA) is a common deep infection of the head and neck that can present with significant clinical symptoms. Patients typically present with fever, malaise, sore throat, otalgia, dysphagia, and the characteristic muffled "hot-potato" voice. Although PTA is generally managed effectively with antibiotics, analgesics, and abscess drainage, spontaneous rupture is uncommon and may falsely suggest clinical resolution, posing a diagnostic and management challenge. We present the case of a 25-year-old woman who presented with a five-day history of sore throat, fever, odynophagia, dysphagia, hot-potato voice, and foul taste in the mouth. Examination revealed right peritonsillar swelling with a mucosal opening consistent with spontaneous rupture of the abscess. The rupture was presumed to have occurred prior to presentation and was further supported by the patient's history of a sudden onset of a foul taste around the third day of symptoms, followed by partial symptomatic relief. Laboratory investigations demonstrated significant inflammation, with a C-reactive protein (CRP) level of 190 mg/L and neutrophilic leukocytosis. The patient was admitted for intravenous antibiotics, dexamethasone, and observation; however, she requested discharge against medical advice one day after admission due to reported symptomatic improvement and travel plans. Spontaneous rupture of a peritonsillar abscess is a rare event that may lead to transient symptom relief and a misleading impression of recovery due to possible incomplete drainage. This case highlights the importance of careful clinical evaluation and continued management despite apparent improvement, as persistent infection and complications may still occur.

Antibiotics save lives, but their long-term side effects are often underestimated. To prevent side effects and maintain the effectiveness of antibiotics, uncomplicated infections should be treated as narrowly as possible, while life-threatening infections should be treated as broadly as necessary. Acute upper respiratory tract infections should only be treated with antibiotics if there is a clear bacterial cause and the infection is severe. Penicillin V is the first-line treatment for tonsillopharyngitis, amoxicillin for acute otitis media (AOM) and acute rhinosinusitis (ARS), and a group 1 cephalosporin for furuncles and skin phlegmons. For severe infections with possible involvement of anaerobic bacteria (abscesses of the mouth and throat, oto- and sinogenic complications), aminopenicillin-beta-lactamase combination therapy is the first choice. Fluoroquinolones, cephalosporins (except group 1), clindamycin, and carbapenems should only be used in well-founded exceptional cases.

Shewanella species are motile, oxidase-positive, non-fermenting Gram-negative bacilli widely distributed in marine and aquatic environments. Although primarily environmental organisms, Shewanella spp. are rare human pathogens, most often associated with skin and soft tissue infections. Involvement of the head and neck region is exceptional. We report the case of a 28-year-old immunocompetent male with no history of seawater exposure who presented with a one-week history of odynophagia, fever, trismus, and dysphagia. Clinical examination revealed a unilateral peritonsillar abscess. Needle aspiration yielded hemopurulent material. Direct microscopy showed numerous neutrophils and Gram-negative bacilli. Culture on standard media grew monomorphic, non-lactose-fermenting colonies. Identification by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) (Bruker Daltonics, Bremen, Germany) confirmed Shewanella putrefaciens with a high-confidence score. Antimicrobial susceptibility testing demonstrated resistance to penicillins, β-lactam/β-lactamase inhibitor combinations, and cephalosporins, with preserved susceptibility to fluoroquinolones, aminoglycosides, and carbapenems. Empiric therapy with amoxicillin-clavulanate was ineffective, whereas targeted treatment with levofloxacin resulted in complete clinical recovery. This case highlights S. putrefaciens as an uncommon but clinically relevant cause of refractory peritonsillar abscess and underscores the importance of accurate microbiological identification, particularly in patients not responding to standard empiric therapy.

The term standard of care is a legal concept in health care representing the duty a practitioner owes to each patient, and this duty is the same for telehealth encounters, whether video based or audio only, as it is for in-person encounters. This article presents an anonymized case analysis of a fatal peritonsillar abscess misdiagnosed during an audio-only telehealth encounter, highlighting the telehealth regulatory variations across states and emphasizing professional liability considerations for nurse practitioners (NPs) delivering remote care. Through the PEP and AUDIO telehealth frameworks, NPs can implement the telehealth modality that is most clinically appropriate and best safeguards diagnostic accuracy and patient safety for each patient encounter. Understanding evolving regulatory landscapes and maintaining proper documentation allow NPs to leverage telehealth advantages while fulfilling their professional duty and preventing potentially fatal diagnostic and management errors.

The persistence of resistant pathogens in otorhinolaryngology is associated with substantial disease burden and limited effectiveness of the available antimicrobials. We aimed to provide an updated overview of nationwide antimicrobial susceptibility surveillance for major pathogens causing otorhinolaryngological infections in Japan. The 12th joint four-society survey was conducted between 2021 and 2023 in 37 institutions nationwide. Bacterial isolates from patients with acute otitis media, acute exacerbation of chronic otitis media, acute tonsillitis, and peritonsillar abscess were analyzed. Among 537 patients, 378 target bacterial isolates for antimicrobial susceptibility testing were recovered, including Haemophilus influenzae (59 isolates), Streptococcus pneumoniae (23 isolates), and anaerobes (124 isolates). The proportion of penicillin-susceptible S. pneumoniae (at a benzylpenicillin [PCG] minimum inhibitory concentration [MIC] of ≤0.06 μg/mL) was 56.5%, and penicillin-resistant S. pneumoniae (at a PCG MIC of ≥2 μg/mL) isolates were not detected. Capsular serotyping revealed that almost all S. pneumoniae isolates were non-pneumococcal conjugate vaccine 13 (PCV13) serotypes, with 10A and 35B being the most frequent; only one isolate belonged to a PCV13 serotype (19A). Notably, all 35B isolates were classified as penicillin-intermediate S. pneumoniae (PCG MIC, 0.12-1 μg/mL) and harbored pbp1a, pbp2b, and pbp2x mutations. H. influenzae showed a modest recovery of ampicillin-susceptible strains. Anaerobes from peritonsillar abscesses remained highly susceptible to β-lactam/β-lactamase inhibitor combinations and metronidazole. The 12th nationwide surveillance revealed improved antimicrobial susceptibility in major otorhinolaryngological pathogens; however, non-PCV13 serotypes such as 35B warrant continuous monitoring in the post-PCV20 era.

Extrasinusal mucoceles are exceptionally rare cystic lesions that arise outside the paranasal sinuses and may pose diagnostic challenges, particularly when incidentally detected in atypical locations. Their imaging appearance can overlap with other cystic skull-base and intracranial lesions. We report the case of a 45-year-old woman with an asymptomatic extrasinusal mucocele incidentally discovered on CT performed during follow-up of a peritonsillar abscess. Imaging revealed a well-defined expansile cystic lesion in the spheno-temporo-orbital region, causing cortical thinning without surrounding intracranial edema or diffusion restriction. MRI demonstrated homogeneous fluid signal intensity, thin peripheral enhancement, and absence of solid components. Based on these radiological findings, an imaging-based diagnosis of a probable extrasinusal mucocele was favored. As the patient declined surgical intervention, a conservative approach with regular clinical follow-up every 3 months and annual MRI surveillance was adopted. At the most recent follow-up, the lesion remained radiologically stable without interval growth or new symptoms. This case underscores the importance of considering extrasinusal mucocele in the differential diagnosis of skull-base cystic lesions.

Spontaneous tonsillar hemorrhage (STH) is a rare but potentially life-threatening complication most commonly associated with tonsillitis and, less frequently, peritonsillar abscess. Prompt recognition and management are critical due to the risk of airway compromise and vascular injury. We report the case of a 30-year-old female who developed massive oropharyngeal hemorrhage following spontaneous drainage of a peritonsillar abscess, requiring emergent airway protection and surgical intervention. The patient underwent Quinsy tonsillectomy, which revealed an extensive defect created by the hematoma communicating with the parapharyngeal and submandibular spaces, placing major cervical vessels at risk. Given the size and depth of the defect, reconstruction was performed using a pedicled buccal fat pad flap to provide vascularized coverage of exposed deep neck spaces. Computed tomography angiography demonstrated close proximity of the peritonsillar space to the facial artery without evidence of pseudoaneurysm or active extravasation. The patient had an uneventful recovery with complete mucosalization of the reconstructed oropharyngeal defect. This case highlights that spontaneous tonsillar hemorrhage following peritonsillar abscess drainage may result in extensive deep neck space involvement requiring not only definitive tonsillectomy but also reconstructive intervention. The successful use of a buccal fat pad flap in this non-oncologic infectious setting expands reconstructive options for complex oropharyngeal defects and underscores its utility in preventing secondary hemorrhage and vascular complications.