SIGNS AND SYMPTOMS 
May differ between adults and children
History
- Most common:
- Additional presenting symptoms:
- Stridor, dyspnea
- Muffled voice
- Trismus
Pediatric Considerations
Young children may present with only:
Physical Exam
- Adults:
- Posterior pharyngeal edema
- Nuchal rigidity
- Cervical adenopathy
- Fever (67%)
- Drooling
- Stridor
- Dysphonia (cri du canard)
- Tracheal "rock" sign: Tenderness on moving the larynx and trachea side to side
- Children and infants:
ESSENTIAL WORKUP
Rapid assessment of airway and respiratory status:
- Normal exam does not rule out diagnosis
- No lab tests make the diagnosis
- When suspicious, obtain lateral neck x-ray or CT of neck with IV contrast
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC (WBC > 12,000 in 91% of children):
- Blood cultures (both aerobic and anaerobic)
- Throat cultures
Imaging
- Portable films appropriate if concern for airway compromise
- Lateral neck radiographs:
- Film taken in inspiration with neck slightly extended
- May not get good exposure of soft tissue if cannot adequately extend neck due to pain or difficulty cooperating in young age
- Increased suspicion if:
- Retropharyngeal space anterior to C2 > 7 mm or 2× the diameter of the vertebral body (sensitivity 90%)
- Space anterior to C6 > 14 mm in preschool children or 22 mm in adults
- Loss of normal cervical lordosis
- Chest radiograph:
- Indicated if abscess identified to assess for inferior spread of infection and/or aspiration of ruptured abscess contents
- Mediastinal widening is suggestive of mediastinitis and possible rupture
- US of neck:
- Low sensitivity
- Not recommended
- CT of neck with IV contrast:
- Now preferred imagining modality
- Obtain when x-rays nondiagnostic or to determine exact size and location of abscess noted on x-ray
- Abscess appears as hypodense lesion with peripheral ring enhancement in retropharyngeal space
- Sensitivity: 64–100%
- Specificity: 45–88%
- Can aid in operative planning, revealing extent of invasion into retro/parapharyngeal spaces
- Unclear if it reliably can distinguish abscess from cellulitis and lymphadenitis
- Due to radiation exposure and need for sedation, CT should only be obtained in young children if x-rays are nondiagnostic
- MRI:
- More sensitive than CT
- Also useful for imaging vascular lesions such as jugular thrombophlebitis
Diagnostic Procedures/Surgery
- Surgical drainage/needle aspiration should be performed in OR:
- Presence of pus is gold standard for making diagnosis
- Abscess should be completely evacuated
- Pus should be sent for Gram stain and culture
- No role for nasopharyngolaryngoscopy
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
- Keep child in position of comfort:
- Forcing child to sit up or flex neck may occlude airway
- Pulse oximetry, cardiac monitor
- Supplemental oxygen
- Adequate hydration
- Suction, endotracheal tube, tracheostomy equipment ready for potential emergent intubation
- Airway control will be required for:
- Airway compromise
- Prior to long transport
INITIAL STABILIZATION/THERAPY
- Assess and control airway
- Provide supplemental oxygen
- IV access:
- Avoid if signs of airway compromise
ED TREATMENT/PROCEDURES
- Early endotracheal intubation or tracheostomy for patients with respiratory distress or impending obstruction:
- Caution must be used with induction, as sedation medications may lead to relaxation of airway muscles causing complete obstruction
- Rescue airway equipment such as a laryngeal mask airway available, as pharyngeal swelling may make intubation difficult
- Cricothyrotomy may be required if upper airway is obstructed
- Surgical consultation (ear/nose/throat if available)
- Early administration of IV antibiotics
MEDICATION
Empiric IV antibiotic therapy to cover group A streptococci, S. aureus (including MRSA), and respiratory anaerobes:
- Antibiotic tailored to local preferences and susceptibilities
- Coverage is narrowed when culture results and sensitivities return
- Use of corticosteroids is controversial and recommended only after consultation with ear/nose/throat
- Immunocompromised, diabetics, IV drug users, institutionalized patients, and young children (< 1 yr) at high risk for MRSA
First Line
Several antibiotic regimens are available:
Second Line
If patients do not respond or there is concern for MRSA:
- Vancomycin: 15–20 mg/kg (peds: 40–60 mg/kg/24 h IV q6–8h) IV q12h
- Linezolid: 600 mg (peds: 0–11 yr: 30 mg/kg/24 h q8h; > 12 yr: Adult dose) IV/PO q12h
[Outline]
DISPOSITION
Admission Criteria
- All patients with retropharyngeal abscess should be admitted to the hospital for IV antibiotics and possible surgical drainage
- Criteria for surgical drainage:
- Airway compromise or other life-threatening complications
- Large (> 2 cm hypodense area on CT)
- Failure to respond to parenteral antibiotic therapy
- ICU admission for patients with:
- Airway compromise
- Sepsis
- Altered mental status
- Hemodynamic instability
- Infants and toxic-appearing children
- Major comorbidities
Discharge Criteria
Patients with retropharyngeal abscesses should not be discharged
Issues for Referral
Transfer should be considered if facility does not have the ability to drain infection:
- Airway should be stabilized prior to transfer
ICD9
478.24 Retropharyngeal abscess
ICD10
J39.0 Retropharyngeal and parapharyngeal abscess
[Outline]
- Chow AW. Deep neck space infections. UpToDate February 17, 2012. Available at http://www.uptodate.com/contents/deep-neck-space-infections.
- Marx JA, Hockberger RS, Walls RM, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2010.
- Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg. 2008;138:300–306.
- Reynolds SC, Chow AW. Severe soft tissue infections of the head and neck: A primer for critical care physicians. Lung. 2009;187:271–279.
- Wald ER. Retropharyngeal infections in children. UpToDate August 17, 2012. Available at http://www.uptodate.com/contents/retro pharyngeal-infections-in-children.
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