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 [1]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Noninfectious
Other
- Deep neck 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
- H flu type B
- 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
Evaluation
- CT neck with 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
- Emergent ENT consult
- Most patients require I&D
- Indications for drainage - trismus, rim enhancement on CT
- Secure airway - care must be taken to minimize contact with abscess as rupture is significant risk
- Tracheostomy or fiberoptic intubation may be necessary
- CT or MRI may help prepare for method of definitive airway[2]
Antibiotics
- Clindamycin 600-900mg IV OR
- Cefoxitin 2gm IV OR
- Ampicillin/Sulbactam 3g IV
Disposition
- Admit