Retropharyngeal abscess

Background

• Polymicrobial abscess in space between posterior pharyngeal wall and prevertebral fascia
• Adults: Due to direct extension of purulent debris from adjacent site (e.g. Ludwig angina)
  • More likely to extend into the mediastinum
• Children: Due to suppurative changes within a lymph node (primary infection elsewhere in head or neck)
• Trauma: Direct inoculation (e.g. child falling with stick in mouth)

Clinical Features

• Sore throat (76%)
• Fever (65%)
• Torticollis (37%)
• Dysphagia (35%)
• Late symptoms:
  • Stridor, respiratory distres, chest pain (mediastinitis)
  • Involvement of carotid neurovascular sheath

Differential Diagnosis

Acute Sore Throat

Bacterial infections

• Streptococcal pharyngitis (Strep Throat)
• Neisseria gonorrhoeae
• Diphtheria (C. diptheriae)
• Bacterial Tracheitis

Viral infections

• Infectious mononucleosis (EBV)
  • Patients with peritonsillar abscess have a 20% incidence of mononucleosis
• Laryngitis
• Acute Bronchitis
• Rhinovirus
• Coronavirus
• Adenovirus
• Herpesvirus
• Influenza virus
• Coxsackie virus
  • Herpangina
  • Hand-foot-and-mouth disease
• HIV (Acute Retroviral Syndrome)

Noninfectious

• Stevens-Johnson Syndrome
• Pemphigus
• Angioedema

Other

• Deep neck space infection
  • Retropharyngeal abscess
  • Ludwig's angina
  • Parapharyngeal space infection
• Peritonsillar Abscess (PTA)
• Epiglottitis
• Kawasaki disease
• Penetrating injury
• Caustic ingestion
• Lemierre's syndrome
• Peritonsillar cellulitis
• Lymphoma
• Internal carotid artery aneurysm
• Oral Thrush
• Parotitis
• Post-tonsillectomy hemorrhage
• Vincent's angina
• Acute necrotizing ulcerative gingivitis

Pediatric stridor

<6 Months Old

• Laryngotracheomalacia
  • Accounts for 60%
  • Usually exacerbated by viral URI
  • Diagnosed with flexible fiberoptic laryngoscopy
• Vocal cord paralysis
  • Stridor associated with feeding problems, hoarse voice, weak and/or changing cry
  • May have cyanosis or apnea if bilateral (less common)
• Subglottic stenosis
  • Congenital vs secondary to prolonged intubation in premies
• Airway hemangioma
  • Usually regresses by age 5
  • Associated with skin hemangiomas in beard distribution
• Vascular ring/sling

>6 Months Old

• Croup
  • viral laryngotracheobronchitis
  • 6 mo - 3 yr, peaks at 2 yrs
  • Most severe on 3rd-4th day of illness
  • Steeple sign not reliable- diagnose clinically
• Epiglottitis
  • H flu type B
    • Have higher suspicion in unvaccinated children
  • Rapid onset sore throat, fever, drooling
  • Difficult airway- call anesthesia/ ENT early
• Bacterial tracheitis
  • Rare but causes life-threatening obstruction
  • Symptoms of croup + toxic-appearing = bacterial tracheitis
• Foreign body (sudden onset)
  • Marked variation in quality or pattern of stridor
• Retropharyngeal abscess
  • Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension

Diagnostic Evaluation

• CT neck w/ IV contrast
  • Gold standard

• XR Soft tissue
  • The prevertebral space should be less than 7mm at C2, 14mm at C6 in children regardless of the age
  • The prevertebral space should be less than 22mm at C6 in adults
  • If the prevertebral space should be less than one-half the width of the corresponding vertebral body
  • If equivocal XR, order CT

Management

1. Emergent ENT consult
   • Most patients require I&D
   • Indications for drainage - trismus, rim enhancement on CT
2. Secure airway

Antibiotics

• Clindamycin 600-900mg IV OR
• Cefoxitin 2gm IV OR
• Ampicillin/Sulbactam 3g IV

Disposition

• Admit

See Also

• PTA
• Ludwig's Angina
• Pharyngitis