Epidemiology

Upper respiratory complaints are the most common reason that patients seek medical care. Pharyngitis is diagnosed in more than 10 million patients per year. Millions of dollars are spent not only on medications and medical visits but also to arrange child care and sick leave for patients unable to go to work or school. Even though most causes of throat pain are benign and self-limited, a number of causes of sore throat may be severe and life-threatening.

The oropharynx plays a vital role in the health of every patient. Not only is it the needed entry point for food and nutrition, but oxygen and carbon dioxide must also move through the oropharynx every minute to maintain metabolic homeostasis. Any disease process that interferes with the function of the oropharynx has the potential to cause significant morbidity and perhaps mortality.

Pathophysiology

The structure of the oropharynx also provides multiple types of complications from pharyngeal emergencies. The most obvious potential complication from diseases of the airway is airway compromise. Restrictive spaces such as the hypopharynx and larynx (with the narrow vocal cords and superior epiglottis) provide ample opportunity for even mild inflammation or edema to significantly alter normal airflow through this region. In addition, the proximate location of the great vessels of the carotid artery and internal jugular veins provide fertile ground for infections or complications from airway procedures such as drainage of peritonsillar abscesses. The fascial planes in the oropharynx reach toward vital structures, which when infected may have disastrous results. The deep fascial planes track posteriorly toward the vertebral column, inferiorly into the mediastinum, and superiorly near the cavernous sinus, thus providing opportunities for cervical vertebral osteomyelitis, mediastinitis, or cranial nerve problems.

Anatomy

The pharyngeal anatomy resembles an inverted cone, with the narrowest part at the point where it attaches to the esophagus at the level of the cricoid cartilage and the widest part attaching to the base of the skull. It is a muscular and fibrous tube located immediately behind the nasal cavity and mouth and has many functions. The pharynx connects anteriorly and superiorly with the nasal cavity to allow movement of air into the lungs though a continuously open passage. At its midpoint, the pharynx connects with the oral cavity for passage of nutrition and hydration into the esophagus. Inferiorly, it connect with the esophagus posteriorly and the larynx inferiorly and allows the complex selection of food and air to travel to different organ systems. The pharynx has abundant immunologic tissue to help fight infection—the palatine tonsils, adenoids, and lingual tonsils—which may predispose the host to dangerous circumstances (e.g., airway compromise) if the inflammatory response is too dramatic.

Pathophysiology

Viruses cause most cases of pharyngitis. Even the most common cause of bacterial pharyngitis in children, group A β-hemolytic Streptococcus (GAβHS), is responsible for only 30% of cases of pharyngitis. In adults, Streptococcus species account for 23% of cases, with Mycoplasma (9%) and Chlamydia (8%) species also being significant.¹ Recently, Fusobacterium necrophorum, known to be a factor in Lemierre syndrome, has been show to be a causal agent in as many as 10% of cases of pharyngitis in young adults.²

Presenting Signs and Symptoms

Differential Diagnosis and Medical Decision Making

Differential Diagnosis

In addition to the infectious causes of pharyngitis mentioned in this chapter, a number of other infectious and noninfectious causes must be considered in the differential diagnosis of patients with pharyngitis. Among dangerous infections, deep space infections such as retropharyngeal abscesses, peritonsillar abscesses, and epiglottitis must be considered. Noninfectious but potentially serious diseases in the differential diagnosis include drug or allergic reactions, foreign body or caustic ingestion, angioedema, and chemical or thermal burns.

Treatment

Fortunately, most cases of pharyngitis are acute and self-limited. Supportive care with analgesics and antipyretics and perhaps topical anesthetics (lozenges or sprays) helps in alleviating the symptoms. However, even most infectious causes of pharyngitis rarely cause serious complications.

Among viral causes, few allow specific treatment. HSV infection may be treated with acyclovir, famciclovir, or valacyclovir, all of which produce similar earlier resolution of symptoms but do not eradicate the etiologic agent. Infectious mononucleosis has no effective antiviral agent, but some important aspects of disposition remain important. Patients suspected of having infectious mononucleosis should be advised against contact sports for 6 to 8 weeks because of concern for potential serious splenic injury. Patients with infectious mononucleosis in whom tonsillar edema and hypertrophy severely limit adequate oral hydration secondary to dysphagia may receive corticosteroids (dexamethasone, 6 to 10 mg intramuscularly) to aid in relief of symptoms.

Of all bacterial causes, GAβHS is the most common and most often studied. Regardless of the diagnostic strategy used, antimicrobial therapy directed at streptococcal species will probably be very effective. There are two main reasons to treat GAβHS pharyngitis—to improve symptoms and decrease complications. Patients who receive antibiotics during the first 2 to 3 days of symptoms are likely to improve 1 to 2 days faster than those not taking antibiotics. In terms of complications, the most feared complication of GAβHS infection is acute rheumatic fever. Antibiotic treatment within the first 9 days of infection decreases the rate of rheumatic fever after GAβHS infection. However, the incidence of acute rheumatic fever has fallen drastically in the last few decades such that the number needed to treat to prevent one case of rheumatic fever has risen from 63 to now more than 4000. This is due to the amount of antibiotics prescribed for GAβHS infection over the years, as well as the presence of less virulent strains of bacteria and improved living conditions. Antibiotic use also limits transmission to others and the amount of suppurative complications, including peritonsillar abscesses, retropharyngeal and other deep space infections, otitis, and mastoiditis. Use of antibiotics has no effect on the incidence of poststreptococcal glomerulonephritis.

Penicillin remains an effective choice for GAβHS pharyngitis. Benzathine penicillin, 1.2 million units, or a 10-day course of penicillin VK, 500 mg orally twice per day, both effectively treat pharyngitis and reduce symptoms. The intramuscular route may be more effective in treating streptococcal pharyngitis secondary to compliance issues but is associated with more severe allergic reactions. Alternative regimens include macrolide antibiotics (e.g., erythromycin, azithromycin) and clindamycin. Oral cephalosporins have been shown to result in slightly improved cure rates when compared with penicillins and may be taken over a shorter course (5 days).

Mycoplasmal pharyngitis may be treated with a course of macrolide antibiotics or tetracycline or doxycycline. C. pneumoniae pharyngitis is treated for 10 days with doxycycline, trimethoprim-sulfamethoxazole, or a macrolide. C. trachomatis pharyngitis may require repeated courses or prolonged use of antibiotics. F. necrophorum is susceptible to penicillin or clindamycin.

Corticosteroids, in conjunction with antibiotics, decrease the duration of symptoms in patients with pharyngitis without increasing complications. Steroids are particularly useful in patients with profound tonsillar hypertrophy and edema or in patients with severe dysphagia and mild dehydration. By reducing the inflammatory response, steroids allow patients to swallow without significantly reducing the pain sooner.

Disposition

Patients with pharyngitis usually have full resolution of their symptoms without difficulty. However, life-threatening complications do occur. Infectious mononucleosis may lead to airway obstruction, epiglottitis, deep space infections, and distant or systemic disorders such as splenic injury, thrombocytopenia, or hemolytic anemia. Complications of GAβHS pharyngitis include deep space infections, toxic shock syndrome, peritonsillar abscesses and autoimmune-related glomerulonephritis, rheumatic fever, and erythema nodosum. Patients in whom airway compromise is at all a concern should be admitted to the hospital for observation and personnel with advanced airway skills alerted for the potential need for a surgical airway.

Epidemiology and Pathophysiology

Peritonsillar cellulitis and peritonsillar abscess exemplify the continuum of peritonsillar infections best characterized as peritonsillitis. Peritonsillar infections represent the most common deep infection of the head and neck region. These infections occur more frequently in teenagers and young adults, but they can develop at any age. The infection begins most commonly when tonsillitis spreads beyond the boundary of the tonsillar capsule and invades the potential space between the lateral aspect of the tonsillar capsule and the superior constrictor muscle of the pharynx. The local spread of infection begins as cellulitis but progresses to abscess formation if left untreated. Predisposing factors include chronic tonsillitis, dental infections, smoking, and infectious mononucleosis. Peritonsillitis can occur in patients who have previously undergone complete tonsillectomy.

Presenting Signs and Symptoms

Differential Diagnosis

The differential diagnosis of peritonsillitis includes infectious mononucleosis, cervical adenitis, tubercular granuloma, internal carotid artery aneurysms, and neoplasms. Obviously, infectious causes will be manifested in a more rapid manner than chronic granulomas, masses, or aneurysms. Pulsatile masses or findings that do not suggest an acute infectious cause must be evaluated with other imaging techniques to elucidate the cause of the symptoms.

Diagnostic Testing

Plain radiographs do not aid in the diagnosis or treatment of uncomplicated cases of peritonsillitis. Although it is often difficult to distinguish peritonsillar cellulitis from peritonsillar abscess,⁹ a number of modalities can aid in diagnosis. For patients who cannot lie down or who are unable to cooperate with needle aspiration, intraoral ultrasound is a useful test.¹⁰ Computed tomography (CT) is helpful in delineating the extent and scope of the abscess, but it may be difficult for the patient to lie supine during the study.

Treatment

Pending airway obstruction requires emergency aspiration of a peritonsillar abscess. For less urgent conditions the classic recommendation was incision and drainage. Needle aspiration, with or without ultrasound guidance, provides a diagnosis, induces less pain, and is easier to perform than traditional incision and drainage. Approximately 10% of needle-aspirated abscesses require repeated aspiration.⁹

Patients should receive antibiotics (penicillin or clindamycin) and steroids for relief of the pain and swelling, regardless of whether the abscess is drained. One strategy if the peritonsillitis is thought to be cellulitis or if the aspiration reveals no purulence is to start antibiotic and steroid treatment and assess the patient in 24 hours to see whether the symptoms are improving or another aspiration is required.

Disposition

Most patients with peritonsillitis can be treated safely and discharged home with antibiotics, steroids, and close follow-up in 24 to 48 hours. For patients with severe dehydration or severe trismus requiring intravenous hydration, a brief inpatient stay may be required. Any patient with tissue edema and potential airway compromise must be admitted to the hospital for observation and potential aggressive airway management.

Epidemiology and Pathophysiology

Inflammation and edema of the epiglottis may result in rapid and life-threatening airway obstruction if not identified and treated effectively. In addition, the tissues immediately adjacent to the epiglottis (arytenoids, false vocal cords, and pharyngeal wall) may also become edematous and result in a similar infection known as supraglottitis. The signs and symptoms of the two diseases may be remarkably similar, although their populations may be somewhat different. Until introduction of the Haemophilus influenzae type B (Hib) vaccine in the mid-1980s, epiglottitis was a disease of children. The annual incidence decreased dramatically to a very low 0.3 to 0.6 per 100,000 children.¹¹ Adult epiglottitis appears to be on the rise. One study showed a 31% rise in the incidence of adult epiglottitis over an 18-year period.¹² Incidence rates for adults cluster near 3 per 100,000, with a case fatality rate reported to be as high as 7%. The lower overall bacteremia rates in adults than in children suggest that adults may have more viral causes, as well as other noninfectious causes. Noninfectious causes include trauma, ingestion of caustic substances, or thermal injuries from illicit drug inhalation. Of organisms recovered in blood cultures, Hib still predominates, but Streptococcus and Staphylococcus species may be isolated as well.

Presenting Signs and Symptoms

Differential Diagnosis

The differential diagnosis for epiglottitis includes other pharyngeal diseases, from the straightforward such as pharyngitis and peritonsillar abscess to the life-threatening such as retropharyngeal abscess and Ludwig angina. If the symptoms are consistent with the physical findings, the diagnosis of pharyngitis or peritonsillar abscess may be appropriate. However, if the symptoms are out of proportion to the findings on examination, the more dangerous diseases must be excluded. Other life-threatening conditions include angioedema, aspiration of a foreign body, laryngospasm, and ingestion of a caustic substance. One rare disease that is occasionally confused with epiglottitis is adult botulism. The blockade of cholinergic nerve transmission characteristically produces an inflamed and painful pharynx, and the muscular paralysis may produce a muffled voice, which may be confused with epiglottitis.

Medical Decision Making

Patients with any sign of respiratory distress (drooling, aphonia, or stridor) should be moved to a critical care room and plans made for obtaining a surgical airway if needed. Any attempt at direct laryngoscopy to visualize the epiglottis should occur only if the personnel and equipment are available to secure a surgical airway (cricothyrotomy or tracheostomy).

A lateral radiograph of patients with suspected epiglottitis has high sensitivity approaching 90% when compared with direct laryngoscopy. Findings on a lateral radiograph may include an edematous and thickened epiglottis (thumb shaped) (Fig. 29.1), disappearance of the vallecula, swelling of the epiglottic folds or arytenoids, or edema of the retropharyngeal spaces. Adults with normal radiographic findings and suspected epiglottitis must undergo laryngoscopy, either direct or indirect. In no pediatric patients should an attempt be made to visualize the epiglottis in the ED. Pediatric patients should be taken to the operating room for direct laryngoscopy while surgical staff members are present to obtain a surgical airway, if needed.

Fig. 29.1 Classic radiograph of epiglottitis with the thumb sign indicating a swollen epiglottis.

Treatment

All patients with suspected epiglottitis should be treated with extreme caution because they may suddenly progress to complete airway obstruction without warning. Endotracheal intubation must be performed under direct visualization either with a laryngoscope or with a fiberoptic bronchoscope/laryngoscope. At all times, equipment and personnel for emergency cricothyrotomy must be present.

Patients should receive broad-spectrum antibiotics that include coverage against H. influenzae, as well as other common bacterial pathogens. Ampicillin-sulbactam and ceftriaxone are both acceptable first-line agents. Steroids and racemic epinephrine have not been conclusively proved to be of benefit in these patients.

Disposition

All patients suspected of having epiglottitis or supraglottitis should be admitted to the hospital. Adults without respiratory distress (drooling, stridor, or dyspnea) may be admitted without intubation and observed, but in a carefully monitored setting. The vast majority of children with suspected epiglottitis should be intubated in the operating room and then admitted to the intensive care unit (ICU) for intravenous antibiotics. Rarely, a child with epiglottis may not require intubation. However, this is done only in consultation with the pediatric anesthesiologist and intensivist after they have evaluated the patient. Children with epiglottis who are not intubated should always be admitted to an ICU setting because of their very high potential for rapid deterioration.

Epidemiology and Pathophysiology

First described in 1836, Ludwig angina is a fast-spreading, potentially lethal infection of the submandibular, sublingual, and submental spaces. These spaces effectively function as one unit, and infection can easily spread between them. True Ludwig angina involves all of the submandibular spaces; however, serious and life-threatening infections can occur with infection of only some of the spaces. Before the advent of antibiotics and surgical decompression, mortality with this disease approached 50%, but it is now commonly reported to be less than 10%.¹³

Approximately 80% of cases involve patients with odontogenic disease. Patients with infection or recent extraction of the second or third molars are particularly at risk because the roots of these teeth extend below the mylohyoid ridge. Abscesses located in this region can easily perforate the lingual plate of the mandible, thereby allowing direct spread of infection to the submandibular spaces. Other predisposing conditions include deep lacerations or trauma to the floor of the mouth, mandibular fractures, and salivary calculi.

Presenting Signs and Symptoms

Patients with Ludwig angina appear ill and anxious. Males predominate over females by a ratio of 3 : 2. The classic symptoms include tooth pain (79%), swelling of the neck or chin (71%), dysphagia (52%), neck pain (33%), respiratory symptoms (dyspnea, tachypnea, stridor) (27%), and dysarthria (18%).

Physical findings in almost all patients include bilateral submandibular swelling, fever, and an elevated or protruding tongue (Figs. 29.2 through 29.4). Trismus is found in approximately half of all patients. Complications of Ludwig angina can be disastrous, with infection spreading to the mediastinum, pericardium, or pleural cavity, as well as the lungs and great vessels.

Fig. 29.2 Submandibular swelling in a patient with Ludwig angina.

Fig. 29.3 Submandibular redness and swelling in a patient with Ludwig angina.

Fig. 29.4 Raised floor of the mouth in a patient with Ludwig angina.

Differential Diagnosis and Medical Decision Making

The differential diagnosis in a patient with suspected Ludwig angina should also include Lemierre syndrome (septic thrombophlebitis of the superior internal jugular vein), which is distinguished from Ludwig angina by the unilateral nature of the infection. Tumors in the floor of the mouth can be distinguished from Ludwig angina by their tendency to exhibit much slower growth. Mandibular abscesses are generally unilateral and produce less swelling of the floor of the mouth.

Diagnostic Testing

Because Ludwig angina is predominantly a clinical diagnosis, diagnostic testing commonly delineates the extent of infection, not whether it is present. Soft tissue lateral neck radiographs may be helpful in showing edema of the soft tissues and air in the soft tissue spaces. If the patient is able to lie supine for a short while, helical CT may be helpful in delineating progression of the abscess and allow more accurate surgical débridement (Fig. 29.5, A and B). If the safety of the patient lying supine is at all in question, the airway must be secured first. At all times the utmost caution is required in these patients, and securing the airway will probably involve the joint capabilities of anesthesia, otorhinolaryngologic, and general surgical colleagues. No airway maneuvers may be attempted until the equipment and personnel capable of obtaining a surgical airway are present at the bedside.

Fig. 29.5 A, Computed tomography (CT) scan of Ludwig angina showing infection in the submandibular spaces (arrow). B, CT scan of Ludwig angina showing infection in the submandibular spaces.

Treatment

Treatment of patients with Ludwig angina predominantly involves three issues: protection of the airway though nasal (fiberoptic), oropharyngeal, or surgical techniques; administration of antibiotics; and surgical débridement. The antibiotic selected should have broad-spectrum coverage because up to 50% of patients have polymicrobial involvement. Although Streptococcus, Staphylococcus, and Bacteroides are the organisms commonly cultured, other species have included Klebsiella, H. influenzae, Proteus, and Pseudomonas species. Once the airway is protected, 50% will resolve with only antibiotics.

Disposition

All patients with Ludwig angina should be admitted to an ICU for further monitoring and fluid resuscitation should the clinical picture deteriorate into one of bacteremia and sepsis. ICU observation is required for those with the rare milder cases who are not immediately intubated, because progression to airway compromise and obstruction may be rapid.

Pathophysiology

A particularly dangerous and intractable complication of nearby infections, Lemierre syndrome is a suppurative thrombophlebitis located within the internal jugular vein. This dangerous but fortunately rare complication of nearby infections in the pharynx or mastoid may produce septic emboli.

Lemierre syndrome is often caused by the organism F. necrophorum, a gram-negative anaerobe that produces endotoxin and is also responsible for many cases of acute and recurring pharyngitis, as well as peritonsillar abscesses.¹⁴ F. necrophorum can colonize the upper respiratory, gastrointestinal, and genitourinary tracts. Other organisms that may also cause this particular variant of septic thrombophlebitis include Bacteroides melaninogenicus, Eikenella corrodens, and non–group A streptococci.

Presenting Signs and Symptoms

The signs and symptoms of Lemierre syndrome may mimic those of other localized infections and include fever, swelling, tenderness, and pain with range of motion of the neck. It does, however, include the additional feature of obstruction of normal blood flow in the affected internal jugular vein, which may cause unilateral swelling, edema, and induration in the tissues on the affected side, regardless of whether they actually infected.

Differential Diagnosis and Medical Decision Making

When considering Lemierre syndrome, one must also consider Ludwig angina or other deep space infections in the neck and parapharyngeal tissues. Whether from odontogenic, lymphatic, or other sources, deep space infections in the neck and pharynx must be taken very seriously.

Diagnostic Testing

Lemierre syndrome is a diagnosis that when suspected requires confirmatory testing to document involvement of the internal jugular vein. Soft tissue lateral neck radiographs may be helpful in showing edema of the soft tissues and air in the soft tissue spaces, but they lack the specific information on vein involvement needed to make the diagnosis of Lemierre syndrome. The diagnosis is made most commonly via a contrast-enhanced CT scan of the neck. In addition, magnetic resonance imaging (MRI) may also delineate the extent of involvement of the jugular vein. Both these modalities will also provide information about the surrounding anatomy, including distortion of nearby tissues and localized pockets of infection that must be drained. Other tests that may aid in the diagnosis of Lemierre syndrome include duplex ultrasonography, retrograde venography, and gallium scanning. If there is any question about the safety of the patient lying supine, the airway must be secured first.

Treatment

Treatment of Lemierre syndrome must include both heparin and antibiotics. The thrombus provides a nidus of ongoing infection and, subsequently, septic emboli. The anticoagulation effectively limits progression of the thrombosis and, in turn, limits the development of further septic emboli. The initial choice of antibiotics should be broad spectrum. Prolonged high-dose broad-spectrum antimicrobial therapy is recommended because of the high risk for septic emboli and endocarditis. Close consultation with an infectious disease specialist would be helpful in such cases.

Disposition

Patients with Lemierre syndrome clearly need to be admitted to the hospital, and consultation with a vascular surgeon may be helpful if thrombectomy is being considered.

Pathophysiology

Even though retropharyngeal abscesses predominantly occur in the pediatric population, adults may also be affected. Pediatric patients possess prominent lymph nodes in the retropharyngeal area, which can become infected and progress to cellulitis and abscess formation. These nodes atrophy by 6 years of age, and the incidence of retropharyngeal abscess drops precipitously.

The cause of retropharyngeal abscesses in the nonpediatric population differs greatly from the local lymph node infections in the age group younger than 6 years. The cause of adult retropharyngeal abscesses ranges from extension of other pharyngeal infections (e.g., parotitis, peritonsillar abscess, tonsillitis, Ludwig angina, dental infections) to instrumentation and other trauma (fishbones or dental instruments) to hematologic spread of systemic infections.¹⁵

Microbiologic testing of retropharyngeal abscesses reveals a diverse array of causative bacteria. Although the preponderance of abscesses are polymicrobial (up to 86%), some species predominate. The majority of aerobic pathogens include Streptococcus and Staphylococcus species, and Bacteroides, Fusiform, and Peptostreptococcus species dominate the anaerobic isolates. Tuberculous and fungal causes must also be considered.

Presenting Signs and Symptoms

Patients will have a sore throat, as well as any number of other symptoms, including dysphagia, drooling, odynophagia, neck pain, and a muffled voice. The dysphonia frequently sounds like a duck quack (cri du canard). Patients may complain of a feeling of a lump in their throat and may prefer to lie supine or with their neck extended to keep the swelling in their posterior pharynx from compressing their upper airway. In the pediatric population, many case series have reported the mean age as being 3 years. It is uncommon for children in this age group to describe these symptoms, and the more common complaints are related to feeding, fever, and stridor.¹⁶

On physical examination only a minority of adult patients (37%) will have visible swelling of the posterior pharynx.¹⁷ Other physical findings might include cervical lymphadenopathy, torticollis, and trismus. Palpation of the neck or moving the larynx and trachea side to side (tracheal “rock” sign) may induce pain. Pain and other symptoms out of proportion to the findings on physical examination require further diagnostic testing and evaluation.

Differential Diagnosis and Medical Decision Making

Other possible diagnoses to consider in these patients include other pharyngeal infections such as pharyngitis, peritonsillar abscess, and infectious mononucleosis. Abrasions or caustic burns involving the posterior pharynx might produce similar symptoms of dysphagia and odynophagia. Other causes of retropharyngeal swelling and pain may include cervical fracture, hematoma, or other causes of tissue edema such as tendonitis. Finally, distinguishing between a true abscess and pharyngeal cellulitis may be difficult and might be accomplished only with imaging techniques.

Diagnostic Testing

Imaging of retropharyngeal abscesses involves two main types of radiologic tests, plain lateral neck radiographs and CT scans. Early studies of normal lateral radiographs suggest that the upper limit of normal for the retropharyngeal spaces is 7 mm at C2 and 22 mm at C6. Anything beyond 7 mm is considered pathologic in both children and adults. In addition, retropharyngeal abscesses will displace the larynx and esophagus anteriorly. If there is still a question about the extent of involvement or the distinction between cellulitis and abscess, CT of the neck (Fig. 29.6) or MRI (Fig. 29.7) will easily elucidate the exact anatomic extension of the abscess. Of course, patients must be stable enough to lie flat in the supine position for the time needed to complete the study. In addition, intraoral ultrasound is another modality with great potential for distinguishing between abscess and cellulitis.¹⁸

Fig. 29.6 Computed tomography scan of a retropharyngeal abscess (arrow).

Fig. 29.7 Magnetic resonance imaging of a retropharyngeal abscess (white arrow).

Note extension into the vertebral bodies (osteomyelitis) (black arrow).

Treatment and Disposition

Retropharyngeal infections require broad-spectrum intravenous antibiotics. The antibiotics must cover anaerobes, as well as gram-positive and gram-negative species. Although most retropharyngeal abscesses require surgical drainage, selected cases may occasionally be managed with intravenous antibiotics alone.¹⁹ Even if surgical drainage is deferred, admission to a monitored bed after thorough airway evaluation is required.

Complications from retropharyngeal abscesses include spread of infection inferiorly or laterally (Fig. 29.8) into the mediastinum (Fig. 29.9), pericardium, and nearby vascular structures. Osteomyelitis (see Fig. 29.7), transverse myelitis, and epidural abscesses have also been reported.

Fig. 29.8 Computed tomography scan of a retropharyngeal abscess (arrow) extending laterally and inferiorly.

Fig. 29.9 Computed tomography scan showing inferior extension of a retropharyngeal abscess into the mediastinum.