Retropharyngeal Abscess in Emergency Medicine Follow-up

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

Further Inpatient Care

  • Once the diagnosis of retropharyngeal abscess is established, initiate intravenous antibiotics and admit the patient to the hospital.
  • If any signs of respiratory distress are present, admit the patient to the intensive care unit.
  • Careful monitoring of airway status is essential and may require intensive care unit admission, even in the absence of respiratory distress in the ED.
  • The ENT physician decides whether to incise and drain the abscess in the operating room or whether a trial of medical therapy is indicated first (eg, retropharyngeal cellulitis).
  • An 11-year chart review of 162 pediatric patients with retropharyngeal abscess at St. Louis Children's Hospital revealed that 126 of the patients required surgery initially, and, of the 36 patients treated medically initially, 17 required surgery.[3]
  • Of 24 pediatric RPAs in children treated at Starship Pediatric Hospital in Auckland, Australia, between 1999 and 2005, 10 (41.7%) required surgery, while 14 (58.3%) did not require surgery.[23]
  • Incision and drainage of retropharyngeal abscess in the ED may lead to aspiration and generally is not recommended.
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Transfer

  • Community hospitals without CT scanning or access to an ENT surgeon may need to transfer patients with suspected or known retropharyngeal abscess.
  • Patients with known or suspected retropharyngeal abscess may need to be intubated before transport, depending on their clinical status.
  • Intravenous antibiotics may be given prior to transfer but should not delay the transfer.
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Deterrence/Prevention

  • Good oral hygiene
  • Antibiotic therapy of bacterial oral and pharyngeal infections
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Complications

Complications of retropharyngeal abscess may include the following:

  • Airway obstruction
  • Mediastinitis
  • Pleural involvement
  • Atlantooccipital dislocation
  • Epidural abscess
  • Sepsis
  • Acute 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)
  • Septic thrombosis of jugular vein or hemorrhage secondary to erosion into carotid artery[26]
  • Compression of carotid artery and internal jugular vein[26]
  • Facial nerve palsy
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Prognosis

  • Prognosis generally is good if retropharyngeal abscess 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.
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Patient Education

  • Patients should be brought to the ED immediately if they develop the inability to swallow or have difficulty breathing in conjunction with a sore throat.
  • For excellent patient education resources, visit eMedicine's Infections Center. Also, see eMedicine's patient education articles Abscess and Antibiotics.
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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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