eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Retropharyngeal Abscess

Author: Joseph H Kahn, MD, Director of Medical Student Education, Associate Professor, Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine
Contributor Information and Disclosures

Updated: Jan 23, 2008

Introduction

Background

Retropharyngeal abscess (RPA) produces the symptoms of sore throat, fever, neck stiffness, and stridor. Retropharyngeal abscess occurs much less commonly today than in the past because of the widespread use of antibiotics for suppurative upper respiratory infections. Retropharyngeal abscess, once almost exclusively a disease of children, is observed with increasing frequency in adults. Retropharyngeal abscess poses a diagnostic challenge for the emergency physician because of its infrequent occurrence and variable presentation.

Early recognition and aggressive management of retropharyngeal abscess are essential because it still carries significant morbidity and mortality.

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.

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 organisms, such as Haemophilus parainfluenzae and Bartonella henselae

The high mortality rate of retropharyngeal abscess is owing to its association with airway obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, necrotizing fasciitis, sepsis, and erosion into the carotid artery.

Frequency

United States

A review of cases of retropharyngeal abscess over an 11-year period at the Children's Hospital of Michigan revealed a 4.5 times increase in the incidence of retropharyngeal abscess when compared with the previous 12 years.1

Mortality/Morbidity

Once mediastinitis occurs, mortality approaches 50%, even with antibiotic therapy. Retropharyngeal abscess can also cause internal jugular vein thrombosis, carotid artery erosion, pericarditis, and epidural abscess. In addition to invasion of contiguous structures, retropharyngeal abscess can cause sepsis and airway compromise.

Overall mortality rate was 1% in a review of deep cervical space infections in Taiwan.2

In a recent study of 234 adults with deep space infections of the neck in Germany, the mortality rate was 2.6%. The cause of death was primarily sepsis with multiorgan failure.3

Race

  • In a 10-year review of retropharyngeal abscess cases treated at KingsCountyHospital in Brooklyn, New York, 70% of patients were African American, 25% were white, and 5% were Hispanic.
  • A recent study of pediatric patients with retropharyngeal abscess at Wayne State University in Detroit revealed 43% of cases occurred in blacks, 54% in whites, 1% in Hispanics, and 1% in biracial.4

Sex

Retropharyngeal abscess is more common in males than in females, with generally reported male preponderance of 53-55%.

  • A study of children with retropharyngeal abscess in Toronto reported 67% of cases in males.
  • A study of retropharyngeal abscess in children in Detroit found 56% of cases in males.
  • A study of adults with deep space infections of the neck in Germany revealed that 56% of patients were male and 44% were female.
  • A study of cases in Nigeria found a male-to-female ratio of 1:1.5

Age

Initially, retropharyngeal abscess was thought to be a disease limited to children, but now it is being encountered with increasing frequency in adults.

  • A review of adults with deep space infections of the neck in Germany revealed a mean age (±standard deviation) of 44.5 (±21.8) years.
  • A review of retropharyngeal abscess cases at the Hospital for Sick Children in Toronto revealed that 66% of pediatric cases occurred in children younger than 6 years.
  • A review of 30 cases of retropharyngeal abscess over an 11-year period in Nigeria found the median age to be 21 months, and 77% of patients were younger than 5 years. Eighty-three percent of retropharyngeal abscesses occurred in children, and 17% occurred in adults.5
  • A 10-year review at KingsCountyHospital in Brooklyn, New York, revealed that 30% of the cases were in pediatric patients aged 16 months to 8 years and 70% were in adults aged 21-64 years.
  • A 35-year review of cases involving children who were treated for retropharyngeal abscess at the Children's Hospital of Los Angeles revealed that 50% of patients were younger than 3 years and 71% were younger than 6 years.
  • A review or retropharyngeal abscess in children in Detroit found a mean age of 4.1 years, with a range from 2 months to 18 years.
  • A review in Sydney, Australia, found that, in 55% of pediatric cases of retropharyngeal abscess, the children were younger than 1 year, with 10% diagnosed in the neonatal period.
  • A review of RPA cases in children in Albuquerque revealed a median age of 36 months, with 75% of patients younger than 5 years and 16% of patients younger than 1 year.6

Clinical

History

History is variable, depending on the age group. Symptoms 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
    • Neck stiffness
    • Odynophagia
    • Cough
  • Symptoms in infants
    • Fever (85%)
    • Neck swelling (97%)
    • Poor oral intake (55%)
    • Rhinorrhea (55%)
    • Lethargy (38%)
    • Cough (33%)

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 (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

Causes

Retropharyngeal abscess develops secondary to lymphatic drainage or contiguous spread of upper respiratory or oral infections. Pharyngeal trauma from endotracheal intubation, endoscopy, foreign body ingestion, and 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
    • Beta-hemolytic streptococci
    • Streptococcus viridans
    • S aureus
    • MRSA
    • Klebsiella pneumoniae
    • Bacteroides species
    • Staphylococcus epidermidis
    • Anaerobic streptococci
    • Bartonella henselae
    • Eikenella corrodens
    • Escherichia coli
    • Prevotella species
    • Mycobacterium tuberculosis
  • Organisms causing retropharyngeal abscess in children
    • S aureus
    • Haemophilus species
    • Beta-hemolytic streptococcus (Streptococcus pyogenes) - The incidence is increasing (54%) according to recent review of cases at the Children's Hospital of Michigan.1
    • Bacteroides species
    • Peptostreptococcus species
    • Fusobacterium species
    • Prevotella species
    • Staphylococcus coagulase negative
    • Brucella species

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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References

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Further Reading

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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

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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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

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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