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
• Coxsackievirus
  • 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

<6mo

• Laryngotracheomalacia
• Vocal cord paralysis (weak cry)
• Subglottic stenosis (previous intubation)
• Airway hemangioma (usually regresses by age 5)
• Vascular ring/sling

>6mo

• Croup
• Epiglottitis
• Bacterial tracheitis
• Foreign body (sudden onset)
• Retropharyngeal abscess (muffled voice, fever)

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

1. Emergent ENT consult
   • Most patients require I&D
   • Indications for drainage - trismus, rim enhancement on CT
2. Secure airway - care must be taken to minimize contact with abscess as rupture is significant risk
   1. Tracheostomy or fiberoptic intubation may be necessary
   2. CT or MRI may help prepare for method of definitive airway

Antibiotics

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

Disposition

• Admit

See Also

• PTA
• Ludwig's Angina
• Pharyngitis

References

Authors

Jordan Swartz, Kevin Lu, Peter Morris, Ross Donaldson, Sharon Cu, Michael Holtz, Daniel Ostermayer, Neil Young