A 21-month-old male came to an outside emergency department with fever, difficulty swallowing, and neck stiffness. The plain radiograph of the neck showed concern for a retropharyngeal abscess and the patient was transferred by helicopter for surgical evaluation and treatment. The radiologic evaluation at the referral hospital of a neck computed tomographic examination revealed an enlarged hypodense area anterior to the cervical vertebra with ring enhancement consistent with the diagnosis of signficant retropharyngeal abscess. He was taken to the operating room where a combined team of pediatric otolaryngologists and pediatric surgeons performed a transoral and lateral neck drainage of a significant retropharyngeal abscess. The patient was intubated for airway control because of the extent of the abscess but was extubated on post-operative day 2. The cultures grew methicillin-sensitive Staphylococcal aureus and the patient received a total of 10 days IV antibiotics and an additional 1 week of oral antibiotics. He was sent home with an additional 1 week of oral antibiotics and the patient’s clinical course at 1 week after discharge found him doing well.
Figure 107 – CT examination of the neck performed with intravenous contrast shows a large retropharyngeal abscess that extends from the skull base to the mediastinum that displaces and compresses the airway and esophagus (top), which involves the carotid spaces bilaterally as well as the retropharyngeal space (middle), and encases the trachea and mediastinal vessels (bottom).
Retropharyngeal abscesses (RPA) occur in the potential space bound anterior to the prevertebral fascia, posterior to the pharyngeal constrictor muscles and their fascia and laterally by the carotid sheaths and parapharyngeal space (another potential space lying laterally to the pharynx). The retropharyngeal potential space runs superiorally from the base of the skull to the mediastinum distally. It is the most common deep neck infection. In children under 4 years of age, retropharyngeal lymph nodes are present which regress after this age. RPA is most common in young children when these lymph nodes are present, with probable suppuration of these lymph nodes and extension of the infection. RPAs in children are most commonly preceded by an upper respiratory tract infection (45%) such as tonsillitis, pharyngitis, sinusitis or cervical lymphadenitis, a foreign body ingestion (27%) or idiopathic (28%) in one study. Adults have more history of trauma or instrumentation preceding RPA. The organisms most commonly associated with RPA are mixed oral flora with gram-positive organisms such as Streptococcus viridians, Staphylococcus aureus, and Staphylococcus epidermidis being common. Gram-negative organisms include Haemophilus influenza, Bacteroides species and Fusobacterium species. Similar organisms are seen in peritonsilar abscess also.
It can be difficult to discern other common infections from RPA as many patients will show fever, decreased oral intake, neck lymphadenopathy, neck swelling and sore throat. Patients who also show neck pain with movement, torticollis, trismis, drooling, dysphonia or stridor may be easier to recognize, but other severe infections such as laryngotracheobronitis, epigottitis and meningitis may also show these symptoms.
Evaluation includes many indications of infection and inflammation such as complete blood count, erythrocyte sedimentation rate and C-reactive protein but are not specific. Radiological methods are most helpful. Plain lateral soft tissues radiographs can show anterior widening of the soft tissue space and narrowing of the airway. Plain radiographs are 80-88% sensitive and 100% specific. Ultrasound can be used but can be difficult to obtain and a negative examination does not rule out RPA. Computed tomography is considered the gold standard for diagnosis with a homogenous hypodense mass with ring enhancement.
Treatment is with intranvenous antibiotics and most often surgical drainage via a transoral route but also lateral neck and/or extension into the chest cavity may be necessary. Supportive measures such as intubation or tracheostomy may also be necessary.
Complications of RPAs include upper airway obstruction, jugular vein thrombosis, vascular rupture and hemorrhage, bacteremia, septic shock, mediastinitis, pericarditis, pleural empyema, aspiration pneumonia (due to spontaneous rupture), meningitis, and epiglottitis. Recurrence occurs in 1-5% of patients. Death can occur in up to 40-50% of patients. Higher death rates are seen in adults than children.
Questions for Further Discussion
1. What antibiotics would be appropriate for empiric treatment of a retropharyngeal abscess?
2. Describe the common location of a peritonsilar abscess?
- Specialty: Critical Care | Emergency Medicine | Otolaryngology | Radiology / Nuclear Medicine / Radiation Oncology | Surgery
- Age: Toddler
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Wang LF, Kuo WR, Tsai SM, Huang KJ. Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases. Am J Otolaryngol. 2003 Mar-Apr;24(2):111-7.
Philpott CM, Selvadurai D, Banerjee AR. Paediatric retropharyngeal abscess. J Laryngol Otol. 2004 Dec;118(12):919-26.
Al-Sabah B, Bin Salleen H, Hagr A, Choi-Rosen J, Manoukian JJ, Tewfik TL. Retropharyngeal abscess in children: 10-year study. J Otolaryngol. 2004 Dec;33(6):352-5.
Brook I. Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg. 2004 Dec;62(12):1545-50.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital