Retropharyngeal abscess

Published on 23/06/2015 by admin

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Last modified 22/04/2025

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14.4 Retropharyngeal abscess

1 The potential for airway compromise and other complications mandates early diagnosis and treatment.

2 Retropharyngeal abscess should be suspected in children with sore throat, neck pain, fever, dysphagia, dysphonia, neck swelling or torticollis.

3 The differential diagnosis includes meningitis and epiglottitis.

4 Antibiotics must be initiated early.

5 Patients should be managed in an institution with appropriate paediatric medical, surgical, anaesthetic and intensive-care facilities.

Introduction

Retropharyngeal abscess is an uncommon condition with the potential for significant complications including airway compromise. Retropharyngeal abscess formation occurs in the space between the fascia covering the posterior pharyngeal wall and the pre-vertebral fascia. The related parapharyngeal abscess occurs in the deep neck space lateral to the pharynx containing the carotid sheath and cranial nerves.

Retropharyngeal abscess in the paediatric population is usually secondary to upper respiratory tract infection and suppuration in retropharyngeal lymph nodes. Other causes include infection following trauma, foreign body ingestion or dental problems. While abscess formation may occur at any age, the peak incidence is in children aged less than 6 years.

The most common causative organisms are group A β-haemolytic streptococci and Staphylococcus aureus. Anaerobes, especially Bacteroides, Gram-negative and mixed infections also occur.

History

Children with retropharyngeal abscess may present with a history of recent upper respiratory tract infection, fever, neck pain, sore throat, dysphagia, poor oral intake, trauma or other infective focus of the head and neck.

Examination

Examination may reveal fever, a neck mass, lymphadenopathy, limitation of neck extension, torticollis, dysphonia or bulging of the pharyngeal wall. There may be evidence of complications, including respiratory compromise, dehydration or spread of infection.

Investigations

Computerised tomography (CT) scanning is the investigation of choice. It is essential to ensure the patient is stable and safe for this procedure, with special attention to the airway. The CT result will assist with diagnosis and the differentiation of cellulitis from abscess formation which is essential in determining the need for surgery.

Lateral soft tissue neck X-ray may reveal prevertebral swelling, gas, foreign body, air fluid level or bony erosion but is not sensitive or specific. Both magnetic resonance imaging and ultrasound have also been used. A chest X-ray may reveal evidence of aspiration or mediastinitis.

Laboratory studies typically reveal an elevation of white blood cell count and inflammatory markers. Microbiology specimens, including blood cultures and culture of pus obtained at the time of surgery, are important in guiding subsequent antibiotic therapy.

Treatment

The initial priority in treatment is to ensure an adequate and stable airway. The potential for upper airway obstruction and a difficult intubation should be planned for. Consideration should be given to performing intubation in the operating theatre with both anaesthetic and surgical assistance available.

Once resuscitation is complete, antibiotics must be commenced as soon as possible. Empiric treatment must cover the most likely causative organisms and account for possible resistance. Antibiotic combinations include a third-generation cephalosporin, flucloxacillin and metronidazole. Clindamycin, penicillin, vancomycin and ticarcillin + clavulanate are also considered in some references. Attention must also given to analgesic needs, fluid and metabolic resuscitation. Complications should be excluded and these include airway compromise, septic shock, aspiration, mediastinitis, septic emboli, osteomyelitis and involvement of vessels or cranial nerves.

Controversies and future directions

Current debate centres on the need for surgery or initial medical treatment with antibiotics and close observation.

Further reading

Brook I. Microbiology and management of peritonsillar, retropharyngeal and parapharyngeal abscess. J Oral Maxillofacial Surg. 2004;62(12):1545-1550.

Cmejrek R.C., Coticchia J.M., Arnold J.E. Presentation, diagnosis and management of deep-neck abscesses in infants. Arch Otolaryngol-Head Neck Surg. 2002;128(12):1361-1364.

Craig F.W., Schunk J.E. Retropharyngeal abscess in children: Clinical presentation, utility of imaging and current management. Paediatrics. 2003;111(6):1394-1398.

Dawes L.C., Bova R., Carter P. Retropharyngeal abscess in children. ANZ J Surg. 2002;72(6):417.

Shefelbine S.E., Mancuso A.A., Gajewski B.J., et al. Paediatric retropharyngeal lymphadenitis: differentiation from retropharyngeal abscess and treatment implications. Otolaryngol Head Neck Surg. 2007;136(2):182-188.

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Textbook of Paediatric Emergency Medicine