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Retropharyngeal Abscess: Differential Diagnoses & Workup
Updated: Sep 16, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Airway obstruction (In a study in Germany, 20 of 234 patients with deep space infections of the neck had airway compromise requiring tracheostomy.5 )
Sepsis
Pneumonia
Mediastinitis
Epidural abscess
A case report of a 4-year-old boy with compression of his internal carotid artery and internal jugular vein by a retropharyngeal abscess was documented.13
Workup
Laboratory Studies
- Complete blood count
- The mean white blood cell (WBC) count in one study was 17,000, with a range of 3100-45,900.
- WBC counts in 18% of the patients were less than 8000; thus, a normal WBC count does not rule out the diagnosis of retropharyngeal abscess.
- In a study in Germany, the mean WBC (±standard deviation was 14,700 [±10,500]), with a range from 200-114,000.
- Blood cultures are indicated before administration of intravenous antibiotics, but culture results may be negative in as many as 82% of retropharyngeal abscess cases.
- A culture of pus, aspirated at the time of surgical drainage of the retropharyngeal abscess, can grow one or more organisms 91% of the time.
- C-reactive protein
- In one study of adults and children with deep cervical space infections, patients with C-reactive protein level greater than 100 had longer hospital stays.
- In a recent German study, mean (±standard deviation) C-reactive protein level was 15.7 (±12.9), with a range from 0.0-74.
Imaging Studies
- Lateral neck radiography
- Widening of the retropharyngeal soft tissues was observed in 88% of patients with retropharyngeal abscess in a series that defined soft tissue swelling as more than 7 mm at C2 and more than 14 mm at C6. Most authors define retropharyngeal soft tissue swelling as more than 7 mm at C2 and more than 22 mm at C6; thus, lateral neck radiographs may be considerably less sensitive for detecting retropharyngeal abscess than this study indicates.
- Generally, the anteroposterior diameter of the prevertebral soft tissue space in children should not exceed that of the contiguous vertebral bodies.
- In addition to showing widening of the prevertebral space, the lateral neck radiograph rarely may show a gas-fluid level, gas in the tissues, or a foreign body.
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.
- CT scan of the neck
- A CT scan of the neck with intravenous contrast is very useful in the diagnosis and management of retropharyngeal abscess. Retropharyngeal abscess appears as a hypodense lesion in the retropharyngeal space with peripheral ring enhancement. Other findings on CT scan include soft-tissue swelling, obliterated fat planes, and mass effect.
- Obtain a CT scan of the neck with intravenous contrast when the findings on the lateral neck radiograph are equivocal or if the clinical suspicion for retropharyngeal abscess is high in patients with negative findings on lateral neck radiograph. Lateral neck radiographic findings may be misleading, especially in young children.
- A CT scan of the neck with intravenous contrast also may be useful if the radiographic findings are positive because the CT scan can differentiate between retropharyngeal abscess and cellulitis. The CT scan also shows the extent of the retropharyngeal abscess and its relation to the great vessels, which is very helpful to the surgeon.
- CT scan of the neck can also differentiate between retropharyngeal abscess and retropharyngeal lymphadenopathy in children, which may help the ear, nose, and throat (ENT) surgeon decide whether to treat with intravenous antibiotics alone or intravenous antibiotics plus surgical drainage.
- A chest radiograph is indicated to look for aspiration pneumonia and mediastinitis.
- An MRI with gadolinium enhancement may demonstrate a retropharyngeal abscess, but this modality has not been used widely.
- Ultrasonography may demonstrate the presence of a retropharyngeal abscess, but its use has not yet been clarified.
Procedures
- Nasopharyngolaryngoscopy
- A review of the literature did not reveal a role for nasopharyngolaryngoscopy use in the diagnosis of retropharyngeal abscess.
- Safety of this procedure in the setting of retropharyngeal abscess is unclear.
- Nasopharyngolaryngoscopy has been performed preoperatively in 2 adults; no reports of its use in children exist.
- Endotracheal intubation
- Securing the airway may be required if the patient with retropharyngeal abscess is exhibiting signs of impending upper airway obstruction. Endotracheal intubation may be attempted, but it may be difficult because of distortion of the upper airway.
- Prophylactic intubation for a patient with retropharyngeal abscess but without respiratory distress generally is not indicated unless an interhospital transfer is planned.
- If a patient with signs of upper airway obstruction cannot be intubated, a surgical or needle cricothyrotomy may be required.
- A tracheostomy may be required as definitive airway management in patients with retropharyngeal abscess and respiratory distress.
More on Retropharyngeal Abscess |
| Overview: Retropharyngeal Abscess |
 Differential Diagnoses & Workup: Retropharyngeal Abscess |
| Treatment & Medication: Retropharyngeal Abscess |
| Follow-up: Retropharyngeal Abscess |
| Multimedia: Retropharyngeal Abscess |
| References |
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Further Reading
Keywords
RPA, retropharyngeal space infection, mediastinitis, Staphylococcus aureus, Bacteroides, Veillonella, Haemophilus parainfluenzae, internal jugular vein thrombosis, carotid artery erosion, pericarditis, epidural abscess, deep cervical space infections, sepsis, airway compromise, upper respiratory infection
