Retropharyngeal abscess : Guideline
See Also
Neck Lump Guide Line
*Prior to reading this guideline*
Any neck lump associated with any respiratory symptoms need URGENT
ENT review
Definition
Retropharyngeal abscess is a collection of pus in the deep tissues in the back of the
throat.
Background
Retropharyngeal abscess generally affects children under age 5. Retropharyngeal
abscess (RPA) occurs much less commonly today than in the past because of the
widespread use of antibiotics for suppurative upper respiratory infections. RPA, once
almost exclusively a disease of children, is observed with increasing frequency in
adults. RPA poses a diagnostic challenge because of its rare occurrence and variable
presentation.
Early recognition and aggressive management of RPA are essential because RPA still
carries significant morbidity and mortality
The retropharyngeal space can become infected in 2 ways. Either infection spreads
from a contiguous area or the space is inoculated directly secondary to penetrating
trauma.
Pathophysiology: The retropharyngeal space is posterior to the pharynx, bound by
the buccopharyngeal fascia anteriorly, the prevertebral fascia posteriorly, and the
carotid sheaths laterally. It extends superiorly to the base of the skull and inferiorly to
the mediastinum.
The high mortality rate of RPA is owing to its association with airway obstruction,
mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, and
erosion into the carotid artery.
Causes :
Infection : Typically, an upper respiratory infection (URI) causes spread to
retropharyngeal lymph nodes, which form chains in the retropharyngeal space on
either side of the superior constrictor muscle.
Sources of infection can include pharyngitis, tonsillitis, adenitis, otitis, sinusitis, and
other infections (ie, nasal, salivary, dental). Infectious sources (eg, osteomyelitis of
the spine) also can spread anteriorly from the prevertebral space.
Abscesses in this space can be caused by the following organisms:
 Aerobic organisms, such as beta-hemolytic streptococci and Staphylococcus
aureus
 Anaerobic organisms, such as species of Bacteroides and Veillonella
 Gram-negative respiratory organisms, such as Haemophilus influenzae
Trauma : Penetrating trauma is involved prominently in retropharyngeal space
infection. Accidental lacerations are not uncommon in children who run and fall down
after they have placed an object (eg, toy, stick, frozen popsicle, lollipop, toothbrush)
in their mouths. Foreign bodies (eg, fishbones) also have been implicated in
penetrating trauma to the retropharyngeal space. Iatrogenic causes of inoculation to
this space include instrumentation with laryngoscopy, endotracheal intubation,
surgery, endoscopy, feeding tube placement, and dental injections and procedures.
Assessment
1. Clinical History
History is variable, depending on the age group. Symptoms are different for
young adults, children, and infants
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Patients with retropharyngeal abscess present with constitutional complaints
such as fever, chills, malaise, decreased appetite, and irritability.
Patients may complain of sore throat, difficulty swallowing (dysphagia), pain
on swallowing (odynophagia), jaw stiffness (trismus), or neck stiffness
(torticollis), head hanging to one side.
Patients also may complain of muffled voice, the sensation of a lump in the
throat, and/or pain in the back and shoulders upon swallowing.
Difficulty breathing is an ominous complaint that signifies impending
airway obstruction. (usually a late sign)
Patient history is not always straightforward.
Symptoms in young adults
 Sore throat
 Fever
 Dysphagia
 Odynophagia
 Neck pain
 Dyspnea
Symptoms in children older than 1 year
 Sore throat (84%)
 Fever
 Neck stiffness
 Odynophagia
 Cough
Symptoms in infants
 Fever (85%)
 Neck swelling (97%)
 Poor oral intake (55%)
 Rhinorrhea (55%)
 Lethargy (38%)
 Cough (33%)
2. Physical Symptoms
 Most patients with retropharyngeal abscess are febrile.
 Some appear toxic and irritable.
 Cervical lymphadenopathy, usually unilateral, is the most common physical
finding in these patients.
 Patients may have decreased or painful range of motion of their necks or jaws.
 A neck mass or tenderness may be appreciated
 Dysphonia
 Patients in respiratory distress or those who present with stridor or
drooling have potential airway compromise.
 These patients prefer to lie supine with their necks extended,
maximizing their airway patency.
 Sitting up or flexing their necks worsens their respiratory distress.
Physical signs in young adults
 Cervical lymphadenopathy
 Nuchal rigidity
 Posterior pharyngeal oedema (37%)
 Fever
 Drooling
 Stridor
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Physical signs in infants and children
 Cervical lymphadenopathy (83%)
 Retropharyngeal bulge (43%; do not palpate in children)
 Fever (86%)
 Stridor (3%)
 Torticollis (18%)
 Neck stiffness (59%)
 Drooling (22%)
 Agitation (43%)
 Neck mass (91%)
 Lethargy (42%)
 Respiratory distress (4%)
 Associated signs including tonsillitis, peritonsillitis, pharyngitis, and otitis media
Investigations
Consider the following :
However if airway compromise get help and do investigations in a controlled
environment.
1. FBC CRP Blood Culture, Throat Swab
2. Lateral Chest X ray
3. CT Neck
Management
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Stay calm (you and the patient)
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If Retropharyngeal abscess suspected ask for senior help.
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URGENT ENT review
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Will need Neck imaging
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Do Not examine throat
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If airway compromise urgently contact ENT, Anaesthetics and Paediatric
consultants on call.
IV access and start antibiotics on the ward if no airway compromise
If Airway compromise IV access should be obtained in theatre with ENT team
avaliable
Notify PICU
Once the airway has been secured surgical drainage of the collection needs to
be considered- send pus for urgent microscopy and culture if collection
drained
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Antibiotic choice.:
IV Cefuroxime and Metronidazole
(if anaphylasis with penicllins or cephalosporin allergy discuss with the on-call
medical microbiologist)
For doses see BNF for children
Complications
1.
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4.
5.
6.
7.
8.
9.
Airway obstruction
Mediastinitis
Pleural involvement
Atlantooccipital dislocation
Epidural abscess
Sepsis
Adult respiratory distress syndrome (ARDS)
Erosion of the second and third cervical vertebrae
Cranial nerve deficits (cranial nerves IX-XII are contained in the cervical
fascia)
10. Septic thrombosis of jugular vein or hemorrhage secondary to erosion into
carotid artery.
Prognosis:
Prognosis generally is good if RPA is identified early, managed aggressively, and
complications do not occur.
The mortality rate may be as high as 40-50% in patients in whom serious
complications develop
References
www.emedicine.com/emerg/topic506.htm
http://www.emedicine.com/ped/topic2682.htm
www.nlm.nih.gov/medlineplus/ency/article/000984.htm