info@auctorespublishing.com
+1-(302)-520-2644
+1-(302)-520-2644

Changing Epidemiology Microbiology and Management Techniques of Retropharyngeal Abscess in Developing Economy in India

  1. Home
  2. Journals
  3. Journal of Clinical Otorhinolaryngology
  4. Archives
Submit Guidelines

Research Article | DOI: https://doi.org/10.31579/2692-9562/052

Changing Epidemiology Microbiology and Management Techniques of Retropharyngeal Abscess in Developing Economy in India

  • Keshav Gupta 1
  • Mohit Srivastava 2*
  • Pratik Kumar 3

1 Gupta1st Assistant Professor ENT GS Medical College & Hospital Hapur India.
2 Srivastava2nd Consultant ENT, Kingdom of Saudi Arabia (Corresponding author)
32nd Post Graduate Resident ENT PGIMS Rohtak India

*Corresponding Author: Mohit Srivastava, Srivastava2nd Consultant ENT, Kingdom of Saudi Arabia

Citation: Keshav Gupta, Mohit Srivastava, Pratik Kumar (2022). Changing Epidemiology Microbiology and Management Techniques of Retropharyngeal Abscess in Developing Economy in India; Journal of Clinical Otorhinolaryngology 4(3); DOI: 10.31579/2692-9562/052

Copyright: © 2022 Mohit Srivastava. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 27 April 2022 | Accepted: 22 May 2022 | Published: 25 June 2022

Keywords: retropharyngeal abscess; presentation; diagnosis; management; antibiotic; drainage; practice; current scenario

Abstract

Aim: Retropharyngeal abscess are potentially fatal infections of deep neck spaces with high morbidity and mortality. We study the current clinical scenario of this fatal infection in the modern world.

Background: Retropharyngeal abscess are considered predominantly as pediatric infections of deep neck spaces. Their prompt diagnosis and management has always presented a challenge to healthcare expert

Study design: This is a retrospective multi-centric study conducted for 3 years at two tertiary care units and comprising 16 cases (2 pediatric and 14 adults). It focuses on each aspect of retropharyngeal abscess in today's world ranging from epidemiology to management to outcome.

Conclusion: We have noted an increase in regional incidence of retropharyngeal abscess in adult females. However, infection is more severe in children. Most of the cases in adults are a result of odontogenic infections. Also, there is an increase in no of cases due to Pseudomonas species. Increase in the number of multidrug resistant strains is seen. Case of tubercular retropharyngeal abscess is still seen and requires anti-tuberculosis therapy of long duration for complete resolution. Complete surgical drainage of abscess under General Anesthesia reduces duration of Hospital stay.

Interference

Modern healthcare facilities with prompt diagnosis and complete surgical drainage under triple antibiotic cover should be promptly available to a child with stridor. Adults need to have better dental hygiene and anti-microbial testing with judicious use of antibiotics. Tuberculosis should always be ruled out in high incidence countries.

Introduction and Review of Literature

Noisy breathing or stridor is a matter of concern in pediatric patients [1]. In adults it presents as neck swelling and swallowing difficulty [2]. Retropharyngeal abscess is a common cause of pediatric stridor, commonly seen in children below five years of age[3]. Etiology might be infective, Traumatic, metabolic, neoplastic or iatrogenic[4]. Infective causes include bacteriological, tubercular, viral and fungal Etiology. Respiratory obstruction is rapidly progressive in children and hence retropharyngeal abscess is invariably fatal until not diagnosed or not drained [5]. Diagnosis may be delayed despite the fact that a retropharyngeal abscess may be diagnosed simply by oral cavity examination and a plain x ray neck lateral view [6]. When suspected, contrast enhanced computerized tomography should be done to delineate it's complete extent and so that complete drainage may be ensured. CT contributes greatly to the diagnosis, but it has limitations in differentiating abscess from cellulitis of the retropharyngeal space. 

The plain radiograph in lateral view is very specific when it shows air in the retropharyngeal space [6]. However, steps for radiological and microbiological diagnosis should not delay any step of medical and surgical management as there is a risk of airway obstruction and death. Posterior pharyngeal wall bulge is seen on oral cavity examination [2]. Patients are started on Amoxycillin + Clavulinic acid 30mg/Kg body weight per dose maximum 1.2 gram per dose intravenous thrice daily or Injection Piperacillin + Tazobactum 75 mg/Kg body weight per dose maximum 3.375 gram per dose administered 6 hourly if Pseudomonas is suspected, Amikacin 10mg/Kg body weight maximum 500 mg per dose twice daily, Metronidazole 10mg/Kg body weight maximum 500 mg per dose thrice daily [8]. Plain x ray neck lateral view shows retropharyngeal opacity obstructing airway/food passage/both [6]. Immediate contrast enhanced computerized tomography is done to see extent of abscess in patients where repeat drainage is difficult.

The ideal time to make the drainage is in dispute. Some suggest local antibiotic injection at the same time as surgical drainage. Some studies suggest drainage of retropharyngeal abscess in selected cases only. Intra-oral or external drainage will be done depending on extent of involvement [7]. Procedure should done in General Anesthesia in pediatric patients and uncooperative patients [9]. In other patients, drainage without Anesthesia in sitting position is preferred [10]. Few patients may require external drainage as well [11]. Pus culture sensitivity and AFB should be sent in all patients [12]. Average hospital stay is less than 20 days where intraoral drainage alone is sufficient [13]. But cases with external drainage take more time in healing of surgical wound and duration of stay increases to 1-3 weeks [8]. Rapid recovery is seen in most cases following complete incision and drainage of abscess [14].

Aim

  1. To study etiology of retropharyngeal abscess
  2. To study the effect of time taken to diagnose on the outcome of disease
  3. To study the effect of prompt surgical drainage on outcome
  4. To compare between outcome of complete drainage under General Anesthesia with outcome of drainage under Local Anesthesia
  5. To compare the outcome of Intra-oral drainage with external drainage.

Study design

This is a multicentric retrospective study conducted at two tertiary care centres at India- PGIMS Rohtak and G S Medical College & Hospital Hapur including data of admitted patients in the Department of ENT over last 3 years (1st April 2019- 31st March 2022)

Inclusion criteria

Patients of all ages, patients of either sex who satisfied all of following criteria were included in the study.

  1. Were admitted at our Institute during 1st April 2019- 31st March 2022
  2. Had Retropharyngeal bulge on oral examination
  3. Had Retropharyngeal opacity on imaging

Exclusion criteria

  1. Patients with known malignancy at present
  2. Patients with history of malignancy
  3. Patients with history of radiotherapy
  4. Patients with benign tumors of oral cavity or oropharynx
  5. Patients with arteriovenous malformations.
Table 1.1: Clinical details of 16 cases of Retropharyngeal abscess presenting to our Tertiary Care Centre during last 3 years.

Abbreviations - S. No. - Serial Number,M- Male, F- Female, GA- General Anesthesia, LA- Local Anesthesia, Amx- Amoxycillin Clavulinic Acid, Amk- Amikacin, Mtz- Metronidazole, Piptaz- Piperacillin Tazobactum, all administered intravenously.

Material and Methods

We collected data for patients admitted with retropharyngeal abscess at PGIMS Rohtak and G S Medical College & Hospital Hapur from 1st April 2019- 31st March 2022. The data was tabulated in accordance with some significant clinical points and interference drawn regarding diagnosis, treatment approach, morbidity and outcome. Microsoft Windows SPSS 24 package was used to draw following interference.

  1. We calculated the prevalence of various etiological factors in the population under study.
  2. We recorded the duration of Hospital stay and outcome results. This was compared to the day of illness on which the patient got admitted, and hence significance of early diagnosis was calculated.
  3. We compared duration of Hospital stay and outcome results with the day on which abscess was drained after onset of symptoms, and hence significance of early drainage was calculated.
  4. We compared between results of drainage in General Anesthesia and drainage in Local Anesthesia
  5. We compared between results of intra-oral drainage and external drainage
Figure 1.1: 08 months female child presented in biphasic stridor, breathing difficulty and inability to swallow. Contrast enhanced computerised tomography neck shows huge retropharyngeal, para-pharyngeal and para-tonsillar opacity with air fluid levels suggestive of retropharyngeal abscess
Figure 1.2:  Patient was planned for emergency retropharyngeal abscess drainage in General Anesthesia. But had to be put on ventilator before transferring to operation theater
Figure 1.3: Pre and post-operative x-ray neck lateral view of same patient. Patient was extubated in imediate post-oerative period and discharged on day 2 post-operative in fair condition.
Figure 1.4: 29 years old female presented with fever, difficulty in swallowing and difficulty in breathing. On oral examination, huge retropharyngeal bulge could be seen suggestive of retropharyngeal abscess. Intra-oral drainage was done in General Anesthesia and patient was discharged in fair condition on fourth post-operative day.
Figure 1.5: 34 years old male presented with fever and difficulty in swallowing. A small retro-pharyngeal abscess of odontogenic origin was seen on oral examination. Abscess was punctured and aspirated in Local Anesthesia. Dental treatment given and discharged on 6th post-operative day in fair condition.
Figure 1.6: 56 years male presented with external neck swelling and difficulty in swallowing. On examination, retropharyngeal bulge with external neck swelling was seen. Initially intra-oral puncture and aspiration was done in Local Anesthesia. 2 days later, on softening, external neck swelling was drained by an external incision 1 inch above and behind right angle of mandible to avoid injury to right marginal mandibular nerve. Patient recovered in 2 weeks and was discharged in fair condition.
Figure 1.7: Retropharyngeal abscess in same patient
Figure1.8: Retropharyngeal abscess with sub mental and bilateral submandibular extension
Figure 1.9: Plain radiogram neck lateral view showing retropharyngeal opacity

Observations and Result

We collected data for 16 patients over 3 years (2 children and 14 adults). First case was an eight months sick child with severe biphasic stridor and massive retropharyngeal opacity (Figure 1.1-Figure 1.3). She was intubated early during presentation and immediate surgical drainage was planned. She underwent a fast recovery and was discharged on second post-operative day. Figure 1.4-1.9 shows other clinical pictures. All the data was tabulated (Table 1.1) and results were drawn.

Majority of patients admitted with retropharyngeal abscess were adults. We saw a female predominant picture (Male: Female ratio 7:9). The cause for infection was antecedent nasopharyngeal infection in pediatric patients. Amongst adult patients (total 14, 11 had odontogenic causes, 5 had diabetes mellitus and one patient had injury by fish bone which he coughed out by himself by frequently gagging with his fingers 5 days back but developed retropharyngeal abscess. In all patients, diagnosis could be made on presentation. In patients with breathing difficulty and inability to swallow, abscess was drained on urgent basis. 6 patients required drainage on urgent basis including both pediatric patients. In three of them surgical drainage was done in GA while in other three patients puncture with 16 Gauze needle and aspiration in LA was done. In other patients also, it was ensured to aspirate pus sample soon on presentation and send it for microbiological culture-sensitivity. Empirically triple antibiotics were started soon after obtaining pus sample. Antibiotics may be changed later as per culture-sensitivity report in poorly responsive cases. 

However, no such need was felt in any of our patients. All the patients improved symptomatically with drainage and antimicrobial cover. Improvement was more rapid in patients where complete excision was done in General Anesthesia (within a day) compared to patients where puncture and aspiration in Local Anesthesia was done (1-3 days). Patients with external skin incision were admitted longer (8-21 days) as complete healing took more time compared to patients with intra-oral incision only (3-11 days). Duration of hospital stay was less in patients where surgical drainage in GA was done (3-18 days) compared to those where puncture and aspiration in LA was done (8-21 days). However, the admission day on which drainage was done had no effect on duration of hospital stay. 

Discussion

Retropharyngeal abscess are seen due to infection of deep neck spaces. These deep neck space infections can result in immediate life-threatening emergency, with potential for airway compromise and other catastrophic complications [15]. The retropharyngeal space is posterior to the pharynx, limited by the bucco-pharyngeal fascia anteriorly, the prevertebral fascia posteriorly, and the carotid sheaths laterally. It extends superiorly to the base of the skull and inferiorly to the mediastinum [16]. Bacteriological causes are seen in most of cases and include beta-hemolytic Streptococci and Staphylococcus aureus, anaerobic organisms (species of Bacteroides and Veillonella), or Gram-negative organisms (Haemophilus parainfluenzae and Bartonella henselae) [17]. In our patients, we isolated only two species Staphylococcus Aureus and Pseudomonas Areugenosa. 

Retropharyngeal abscess has high mortality as it is capable of complications like airway obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, necrotizing fasciitis, sepsis, and erosion into the carotid artery[18]. While in children, abscess are because of nasopharyngeal infections, in adults abscesses are usually secondary to dental infections, diabetes and trauma [19]. While retropharyngeal abscesses are considered more common in pediatric patients, we came across more adult patients. The possible explanation is that most of pediatric patients were seen by Pediatrician and ENT consultation was sought for critically ill patients only. Retropharyngeal abscess is more common in males than in females, with generally reported male preponderance of 53–55% [9]. However, we noted a female preponderance (Male:Female ratio 7:9). Adults present with neck swelling, difficulty is swallowing and fever. The most common physical presentation is posterior pharyngeal oedema (37%), nuchal rigidity, cervical adenopathy, drooling, and stridor [19]. Carrying out radiological and microbiological examinations should not delay care [20]. Prompt diagnosis with appropriate choice of antibiotics and surgical facilities wherever required have substantially reduced mortality and morbidity in present era [21].

Conclusion

While children develop retropharyngeal abscess as a result of antecedent nasopharyngeal infections, most of the cases in adults are a result of odontogenic infections followed by Diabetes and trauma. Microbiologically, there is an increase in no of cases due to Pseudomonas species. Increase in the number of multidrug resistant strains is seen. Empirically triple antibiotics should be started after sending pus culture sample and before availability of reports. Antibiotics should be changed as soon as culture sensitivity report is available in poorly responsive cases [22]. Cases of tubercular retropharyngeal abscess are still seen and requires anti-tuberculosis therapy of long duration for complete resolution. Complete surgical drainage of abscess under General Anesthesia reduces duration of Hospital stay.

References

  1. Sasidaran K, Bansal A, Singhi S. (2011). Acute upper airway obstruction. Indian J Pediatr. 78(10):1256-1261.
    View at Publisher | View at Google Scholar
  2. Bochner RE, Gangar M, Belamarich PF. (2017). A Clinical Approach to Tonsillitis, Tonsillar Hypertrophy, and Peritonsillar and Retropharyngeal Abscesses. Pediatr Rev. 38(2):81-92.
    View at Publisher | View at Google Scholar
  3. Jain H, Knorr TL, Sinha V. (2022). Retropharyngeal Abscess.
    View at Publisher | View at Google Scholar
  4. Adoviča A, Veidere L, Ronis M, Sumeraga G. (2017). Deep neck infections: review of 263 cases. Otolaryngol Pol.71(5):37-42.
    View at Publisher | View at Google Scholar
  5. Joshua J, Scholten E, Schaerer D, Mafee MF,Alexander TH, Crotty Alexander LE. (2018). Otolaryngology in Critical Care. Ann Am Thorac Soc.15(6):643-654.
    View at Publisher | View at Google Scholar
  6. Boucher C, Dorion D, Fisch C. (1999). Retropharyngeal abscesses: a clinical and radiologic correlation. J Otolaryngol. 28(3):134-137.
    View at Publisher | View at Google Scholar
  7. Glasier CM, Stark JE, Jacobs RF, Mancias P, Leithiser RE Jr, Seibert RW, Seibert JJ. (1992). CT and ultrasound imaging of retropharyngeal abscesses in children. AJNR Am J Neuroradiol.13(4):1191-1195.
    View at Publisher | View at Google Scholar
  8. Vashist A, Wadhera R, Gulia JS, Gupta K, Hooda S. Necrotizing Fasciitis. (2019). Case Series of Four Cases. Innovative Journal of Medical and Health Science.9(3):347-350.
    View at Publisher | View at Google Scholar
  9. A. Harkani, R. Hassani, T. Ziad, L. (2011). Aderdour, H. Nouri, Y. Rochdi, A. Raji,
    View at Publisher | View at Google Scholar
  10. Gupta G, McDowell RH. (2022). Peritonsillar Abscess.
    View at Publisher | View at Google Scholar
  11. Retropharyngeal Abscess, Lateral Pharyngeal (Parapharyngeal) Abscess, and Peritonsillar Cellulitis/Abscess. Robert M. Kliegman MD, in Nelson Textbook of Pediatrics,:p411-15.
    View at Publisher | View at Google Scholar
  12. Lorrot M, Haas H, Hentgen V, Van Den Abbeele T, Bonacorsi S, Doit C, Cohen R, Grimprel E2020. (2020). [Antibiotherapy of severe ENT infections in children: peripharyngeal abscesses]. Arch Pediatr. Nov;20 Suppl 3:e1-4.
    View at Publisher | View at Google Scholar
  13. Daya H., Papsin B.C., Zachariasova A. (2005). Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int. J. Pediatr. Otorhinolaryngol.69:81–86.
    View at Publisher | View at Google Scholar
  14. Garg A, Wadhera R, Gulati SP, Kishore D, Singh J. (2009) Giant retropharyngeal abscess secondary to tubercular spondylitis. Indian J Tuberc.56:225–228.
    View at Publisher | View at Google Scholar
  15. Acevedo JL, Shah RK. (2009). Retropharyngeal Abscess. eMedicine Specialties, Pediatrics: Surgery, Otolaryngology.
    View at Publisher | View at Google Scholar
  16. Lafitte F, Martin-Duverneuil N, Brunet E, et al. (1997). Rhinopharynx et espaces profonds de la face : anatomie et applications a la pathologie. Journal of Neuroradiology.24(2):98–107.
    View at Publisher | View at Google Scholar
  17. Sato K, Izumi T, Toshima M, et al. (2005). Retropharyngeal abscess due to methicillin-resistant Staphylococcus aureus in a case of acute myeloid leukemia. Internal Medicine.44(4):346–349.
    View at Publisher | View at Google Scholar
  18. Herzon FS, Martin AD. (2006). Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Current Infectious Disease Reports.8(3):196–202.
    View at Publisher | View at Google Scholar
  19. Singh I, Meher R, Agarwal S, Raj A. (2003). Carotid artery erosion in a 4-year child. International Journal of Pediatric Otorhinolaryngology.67(9):995–998.
    View at Publisher | View at Google Scholar
  20. Pollard BA, El-Beheiry H. (1999) Pott’s disease with unstable cervical spine, retropharyngeal cold abscess and progressive airway obstruction. Canadian Journal of Anaesthesia. 46(8):772–775.
    View at Publisher | View at Google Scholar
  21. Chatrath P, Black M, Blaney S. (2001) Subclinical presentation of massive retropharyngeal abscess. Journal of the Royal Society of Medicine.94(1):36–37.
    View at Publisher | View at Google Scholar
  22. Gupta K et al. (2021) Changing microbiological picture and sensitivity in otolaryngology in developing world. International Journal of Otorhinolaryngology and Head and Neck Surgery. 7(3): 459-62.
    View at Publisher | View at Google Scholar

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

img

Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

img

Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

img

Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

img

Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

img

Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

img

Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

img

Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

img

Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

img

Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

img

Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

img

Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

img

Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

img

Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

img

Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

img

Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

img

Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

img

Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

img

Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

img

Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

img

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

img

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

img

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

img

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

img

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

img

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

img

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

img

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

img

Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

img

Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

img

Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

img

Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

img

Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

img

Dr Maria Dolores Gomez Barriga