Basics
Description
A relatively rare but potentially life-threatening infection occurring in the potential space between the posterior pharyngeal wall and prevertebral fascia ‚
Epidemiology
Children <6 years of age are most at risk, with 50% of the cases occurring in those <48 months of age. ‚
Incidence
Most large children 's hospital centers report 1 " “5 cases per year. ‚
Pathophysiology
- Most infections result from pharyngitis or supraglottitis and occur because of suppuration of the retropharyngeal lymph nodes, which lie in 2 paramedial chains and drain various nasopharyngeal structures and sinuses.
- These lymph gland chains disappear in childhood; thus, retropharyngeal abscesses are most common in infancy and early childhood.
- Cellulitis of the retropharyngeal area leads to formation of a phlegmon, which matures into an abscess.
- Other sources of infection in this space, often seen in older children and adolescents, include penetrating trauma of the posterior pharynx (e.g., foreign object aspiration, dental procedures, attempts at intubation).
- Extension of infection into this space can arise from vertebral body osteomyelitis or a dental abscess.
Etiology
- Infectious: Cultures frequently reveal multiple organisms.
- The predominant organisms isolated include the following:
- Streptococcus (group A and others)
- Staphylococcus aureus
- Various anaerobic species (e.g., Bacteroides, Peptostreptococcus, Fusobacterium)
- Many of the isolates are Ž ²-lactamase producers.
Diagnosis
History
- Symptoms may be present from hours to days before correct diagnosis is established. Many patients will have been taking oral antibiotics for presumed pharyngitis/sinusitis.
- Ask about neck trauma, especially penetrating injuries, recent surgery (especially dental), and history consistent with aspiration of a foreign object.
- Physicians must maintain a high index of suspicion. The presentation of a retropharyngeal abscess can be subtle, with the most frequent initial diagnostic impression usually epiglottitis or severe pharyngitis.
- Signs and symptoms:
- Most frequent symptoms include sore throat, decreased oral intake, muffled voice, drooling, stiff or painful neck, fever, dysphagia, and stridor.
- Fever
- Stridor (seen in up to 50% of children in 1 study but only 5% in a more recent series)
- Drooling
- A tender cervical neck region/mass and restricted range of motion
- Classic diagnostic finding of a bulging posterior pharyngeal wall; may be absent or difficult to appreciate in an ill, apprehensive child
Physical Exam
- Classic presentation is the young child who develops fever, neck stiffness, torticollis, neck mass, and acute cervical lymphadenitis.
- Infants and children often appear ill, but the manifestations are subacute and may be subtle.
- Other findings may include the following:
- Muffled voice
- Drooling
- Fever
- Dysphagia
- Stridor
Diagnostic Tests & Interpretation
Lab
CBC may reveal an elevated total leukocyte level, with a significant left shift. ‚
Imaging
- Lateral neck x-ray
- Widening of retropharyngeal space and at times an air " “fluid level
- Negative plain neck film does not rule out retropharyngeal abscess.
- CT scan (contrast-enhanced) of the neck
- Superior to plain film
- Can usually differentiate abscess from local cellulitis/adenitis, although the sensitivity and specificity of this study for defining abscess vs. cellulitis are less than 70%
Differential Diagnosis
- Pharyngitis
- Peritonsillar or lateral wall abscess
- Epiglottitis/supraglottitis
- Penetrating foreign body
- Cervical osteomyelitis
Treatment
Medication
- Start empiric broad-spectrum antibiotics, active against Staphylococcus aureus, Streptococcus pyogenes, other non " “group A streptococci, and anaerobic organisms.
- Ampicillin-sulbactam or clindamycin are good initial choices. Vancomycin may be added for suspected methicillin-resistant S. aureus infections in a child with severe infection.
- Antibiotics may be tailored based on microbiologic and susceptibility data.
Additional Treatment
General Measures
- Urgent consultation with an otolaryngology surgical team is warranted for airway management and possible surgical drainage; a team experienced in pediatric airway management is critical.
- Recent data suggest that up to 50% of patients can be successfully managed without surgical intervention.
- Patients with a well-defined abscess on admission CT are most likely to require surgical intervention.
- Patients treated with antibiotics alone must be followed closely for signs of worsening clinical status.
Issues for Referral
After diagnosis is confirmed, urgent consultation with experienced surgical staff who have expertise in management of a pediatric airway is mandatory. ‚
Inpatient Considerations
Initial Stabilization
Emergency therapy requires maintaining patent airway; be wary of sudden spontaneous drainage of the abscess, with catastrophic aspiration. ‚
Ongoing Care
Prognosis
Excellent with appropriate antibiotics, expectant care, and surgery, if needed, at optimal time ‚
Complications
- Spontaneous rupture with aspiration of infected material, with subsequent asphyxia or overwhelming pulmonary infection
- Hemorrhage from extension into local arteries and/or venous thrombosis from involvement of major neck vessels
- Extension of the infection inferiorly can occur, leading to mediastinitis, a subdiaphragmatic or psoas abscess.
Additional Reading
- Chang ‚ L, Chi ‚ H, Chiu ‚ NC, et al. Deep neck infections in different age group of children. J Microbiol Immunol Infect. 2010;43(1):47 " “52. ‚ [View Abstract]
- Daya ‚ H, Lo ‚ S, Papsin ‚ BC, et al. Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int J Pediatr Otolaryngol. 2005;69(1):81 " “86. ‚ [View Abstract]
- Elsherif ‚ AM, Park ‚ AH, Alder ‚ SC, et al. Indicators of a more complicated clinical course for pediatric patients with retropharyngeal abscess. Int J Pediatr Otorhinolaryngol. 2010;74(2):198 " “201. ‚ [View Abstract]
- Grisaru-Soen ‚ G, Komisar ‚ O, Aizenstein ‚ O, et al. Retropharyngeal and parapharyngeal abscess in children " ”epidemiology, clinical features and treatment. Int J Pediatr Otorhinolaryngol. 2010;74(9):1016 " “1020. ‚ [View Abstract]
- Loftis ‚ L. Acute infectious upper airway obstructions in children. Semin Pediatr Infect Dis. 2006;17(1):5 " “10. ‚ [View Abstract]
- Page ‚ NC, Bauer ‚ EM, Lieu ‚ JEC. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg. 2008;138(3):300 " “306. ‚ [View Abstract]
Codes
ICD09
- 478.24 Retropharyngeal abscess
ICD10
- J39.0 Retropharyngeal and parapharyngeal abscess
SNOMED
- 18099001 retropharyngeal abscess (disorder)
FAQ
- Q: What is the age group most at risk of having a retropharyngeal abscess?
- A: They are most common in preschool children; the paramedical chains of lymph nodes in the retropharyngeal area regress during childhood and adolescents. Thus, prior to their regression, these nodes filter lymph from the nasopharynx and paranasal sinuses and are responsible for retropharyngeal abscesses.