Retropharyngeal Abscess in Emergency Medicine Clinical Presentation

  • Author: Joseph H Kahn, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Jun 17, 2010
 

History

History is variable, depending on the age group. Symptoms of retropharyngeal abscess are different for adults, children, and infants.

  • Symptoms in adults
    • Sore throat
    • Fever
    • Dysphagia
    • Odynophagia
    • Neck pain
    • Dyspnea
  • Symptoms in children older than 1 year
    • Sore throat (84%)
    • Fever (64%)[10]
    • Neck stiffness (64%)[10]
    • Odynophagia (55%)[10]
    • Cough
  • Symptoms in infants
    • Fever (85%)
    • Neck swelling (97%)
    • Poor oral intake (55%)
    • Rhinorrhea (55%)
    • Lethargy (38%)
    • Cough (33%)
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Physical

Patients with retropharyngeal abscess may present with signs of airway obstruction, but often they do not. Individuals who do not exhibit signs of airway obstruction initially may progress to airway obstruction. The most common presenting signs may be different for adult and pediatric patients.

  • Physical signs in adults
    • Posterior pharyngeal edema (37%)
    • Nuchal rigidity
    • Cervical adenopathy
    • Fever
    • Drooling
    • Stridor
  • Physical signs in infants and children
    • Cervical adenopathy (36%)[10]
    • Retropharyngeal bulge (55%; do not palpate in children)[10]
    • Fever (64%)[10]
    • Stridor (3%)
    • Torticollis (18%)
    • Neck stiffness (64%)[10]
    • Drooling (22%)
    • Agitation (43%)
    • Neck mass (55%)[10]
    • Lethargy (42%)
    • Respiratory distress (4%)
    • Associated signs including tonsillitis, peritonsillitis, pharyngitis, and otitis media
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Causes

Retropharyngeal abscess develops secondary to lymphatic drainage or contiguous spread of upper respiratory or oral infections. Pharyngeal trauma from endotracheal intubation, nasogastric tube insertion,[12] endoscopy, foreign body ingestion, and foreign body removal may cause a subsequent retropharyngeal abscess. Patients who are immunocompromised or chronically ill, such as persons with diabetes, cancer, alcoholism, or AIDS, are at increased risk for retropharyngeal abscess.

The most common organisms causing retropharyngeal abscesses include aerobes and anaerobes; gram-negative organisms also may be observed. Often, mixed flora are cultured.

  • Organisms causing retropharyngeal abscess in adults[13]
    • Beta-hemolytic streptococci
    • Streptococcus viridans
    • S aureus
    • Methicillin-resistant Staphylococcus aureus ( MRSA)[14]
    • Klebsiella pneumoniae
    • Bacteroides species
    • Staphylococcus epidermidis
    • Anaerobic streptococci
    • Bartonella henselae
    • Eikenella corrodens
    • Escherichia coli
    • Prevotella species
    • Mycobacterium tuberculosis[15]
    • Actinomycetes[16]
  • Organisms causing retropharyngeal abscess in children
    • S aureus[7]
    • Methicillin-resistant Staphylococcus aureus (MRSA)[17, 18, 14]
    • Haemophilus species
    • Beta-hemolytic streptococcus (Streptococcus pyogenes)[7] - The incidence is increasing (54%), according to review of cases at the Children's Hospital of Michigan.[1]
    • Bacteroides species
    • Peptostreptococcus species
    • Fusobacterium species
    • Prevotella species
    • Staphylococcus coagulase negative
    • Brucella species
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Contributor Information and Disclosures
Author

Joseph H Kahn, MD  Director of Medical Student Education, Associate Professor, Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine

Joseph H Kahn, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Physicians for Social Responsibility, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael Glick, DMD  Professor and Acting Chair, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey

Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Mark W Fourre, MD  Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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A 5-year-old boy presented to the ED with 2 days of neck pain and fever but with no sore throat. The child had vomited once, and the mother reported that he was irritable. The child's temperature was 101.7° F, pulse was 118 beats per minute, respirations were 24 per minute, and blood pressure was 122/65 mm Hg. A decreased range of motion of the neck and a right anterior cervical node were observed; the child refused to swallow. Lateral neck radiographic findings show increased retropharyngeal space (white arrow). The CT scan did not demonstrate an abscess. The child was seen by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved for 2-3 days and then worsened. Repeat neck CT scan findings demonstrated a retropharyngeal abscess. Incision and drainage was performed in the operating room. Cultures of the pus grew group A beta-hemolytic streptococci and alpha-streptococci, both sensitive to clindamycin. He improved and was discharged on the tenth hospital day on oral clindamycin.
An 8-month-old infant boy presented with fever and a stiff neck. According to the mother, the baby was not moving his neck as much as usual. The mother also reported decreased oral intake. His temperature was 100° F, pulse was 104 beats per minute, respirations were 48 per minute, oxygen saturation was 98% (room air [RA]). The left tympanic membrane (TM) was inflamed and nonmobile. Left submandibular and left postauricular nodes were noted. The lateral neck radiograph shows increased retropharyngeal space. The CT scan demonstrated a small retropharyngeal abscess. The WBC count was 26,000 (24 polymorphonuclear leukocytes [P], 5 bands [B], 63 lymphocytes [L], 8 monocytes [M]). The baby was examined by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved over the next few days and was discharged on the fifth hospital day on oral clindamycin with a plan for repeat CT scans of the neck on an outpatient basis.
 
 
 
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