Retropharyngeal Abscess in Emergency Medicine Treatment & Management

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

Prehospital Care

  • Supplemental oxygen and attention to upper airway patency are the essential components of prehospital care in patients with suspected retropharyngeal abscess.
  • If a child exhibits respiratory distress, the sniffing position may be beneficial.
  • Occasionally, endotracheal intubation or cricothyrotomy may be required if the patient exhibits signs of upper airway obstruction.
Next

Emergency Department Care

ED management of retropharyngeal abscess includes attention to the airway, fluid resuscitation if necessary, antibiotic treatment, and preparation for an emergency operation. Frequent vital sign checks and continuous oxygen saturation monitoring are essential.

  • Airway management
    • Apply supplemental oxygen. In young children, this can be completed in a nonthreatening way by letting the parent direct blow-by oxygen at the child's face.
    • Endotracheal intubation may be required if the patient has signs of upper airway obstruction. It may be difficult because of upper airway swelling.
    • Cricothyrotomy (surgical or needle) may be required in the patient with upper airway obstruction who cannot be intubated. Tracheostomy may be required for definitive airway management.
  • Intravenous fluids are required if the patient is dehydrated because of fever and difficulty swallowing.
Previous
Next

Consultations

An emergent consultation with an ENT specialist is necessary.

  • Consult an ENT specialist as soon as the diagnosis of retropharyngeal abscess is established or as soon as the diagnosis is suspected if the patient is exhibiting signs of upper airway obstruction.
  • If an abscess is present, an ENT specialist can drain it in the operating room.
  • A prospective study in South Korea compared intravenous antibiotics plus surgical drainage with intravenous antibiotics with or without needle drainage. One case of mediastinitis occurred in the nonsurgical group. The authors concluded that, in conjunction with neck CT scanning, selected cases of parapharyngeal abscesses may be treated conservatively without early open surgical drainage.[22]
  • 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]
  • An ENT specialist also may perform a tracheostomy.
Previous
Proceed to Medication
 
 
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.

References
  1. Abdel-Haq NM, Harahsheh A, Asmar BL. Retropharyngeal abscess in children: the emerging role of group A beta hemolytic streptococcus. South Med J. Sep 2006;99(9):927-31. [Medline].

  2. Lander L, Lu S, Shah RK. Pediatric retropharyngeal abscesses: a national perspective. Int J Pediatr Otorhinolaryngol. Dec 2008;72(12):1837-43. [Medline].

  3. Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg. Mar 2008;138(3):300-6. [Medline].

  4. Wang LF, Kuo WR, Tsai SM, Huang KJ. Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases. Am J Otolaryngol. Mar-Apr 2003;24(2):111-7. [Medline].

  5. Ridder GJ, Technau-Ihling K, Sander A, Boedeker CC. Spectrum and management of deep neck space infections: an 8-year experience of 234 cases. Otolaryngol Head Neck Surg. Nov 2005;133(5):709-14. [Medline].

  6. Shah RK, Chun R, Choi SS. Mediastinitis in infants from deep neck space infections. Otolaryngol Head Neck Surg. Jun 2009;140(6):936-8. [Medline].

  7. Coticchia JM, Getnick GS, Yun RD, Arnold JE. Age-, site-, and time-specific differences in pediatric deep neck abscesses. Arch Otolaryngol Head Neck Surg. Feb 2004;130(2):201-7. [Medline].

  8. Nwaorgu OG, Onakoya PA, Fasunla JA, Ibekwe TS. Retropharyngeal abscess: a clinical experience at the University College Hospital Ibadan. Niger J Med. Oct-Dec 2005;14(4):415-8. [Medline].

  9. Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics. Jun 2003;111(6 Pt 1):1394-8. [Medline].

  10. Marques PM, Spratley JE, Leal LM, Cardoso E, Santos M. Parapharyngeal abscess in children: five year retrospective study. Braz J Otorhinolaryngol. Dec 2009;75(6):826-30. [Medline].

  11. Chang L, Chi H, Chiu NC, Huang FY, Lee KS. Deep Neck Infections in Different Age Groups of Children. J Microbiol Immunol Infect. Feb 2010;43(1):47-52. [Medline].

  12. Hirshoren N, Gross M, Weinberger JM, Eliashar R. Retropharyngeal infected hematoma: a unique complication of nasogastric tube insertion. J Trauma. Oct 2009;67(4):891. [Medline].

  13. Ridder GJ, Technau-Ihling K, Sander A, Boedeker CC. Spectrum and management of deep neck space infections: an 8-year experience of 234 cases. Otolaryngol Head Neck Surg. Nov 2005;133(5):709-14. [Medline].

  14. Brook I. Role of methicillin-resistant Staphylococcus aureus in head and neck infections. J Laryngol Otol. Dec 2009;123(12):1301-7. [Medline].

  15. Kamath MP, Bhojwani KM, Kamath SU, Mahabala C, Agarwal S. Tuberculous retropharyngeal abscess. Ear Nose Throat J. Apr 2007;86(4):236-7. [Medline].

  16. Carinci F, Polito J, Pastore A. Pharyngeal actinomycosis: a case report. Gerodontology. Jun 2007;24(2):121-3. [Medline].

  17. Fleisch AF, Nolan S, Gerber J, Coffin SE. Methicillin-resistant Staphylococcus aureus as a cause of extensive retropharyngeal abscess in two infants. Pediatr Infect Dis J. Dec 2007;26(12):1161-3. [Medline].

  18. Falup-Pecurariu O, Leibovitz E, Pascu C, Falup-Pecurariu C. Bacteremic methicillin-resistant Staphylococcus aureus deep neck abscess in a newborn--case report and review of literature. Int J Pediatr Otorhinolaryngol. Dec 2009;73(12):1824-7. [Medline].

  19. Elsherif AM, Park AH, Alder SC, Smith ME, Muntz HR, Grimmer F. Indicators of a more complicated clinical course for pediatric patients with retropharyngeal abscess. Int J Pediatr Otorhinolaryngol. Feb 2010;74(2):198-201. [Medline].

  20. Elliott M, Yong S, Beckenham T. Carotid artery occlusion in association with a retropharyngeal abscess. Int J Pediatr Otorhinolaryngol. Feb 2006;70(2):359-63. [Medline].

  21. Ukeba Y, Saita Y, Matsuzawa T, Wada T, Kanai N, Kobayashi I. Apnea in a 2-month-old girl with retropharyngeal abscess. Acta Paediatr. Feb 2009;98(2):210. [Medline].

  22. Oh JH, Kim Y, Kim CH. Parapharyngeal abscess: comprehensive management protocol. ORL J Otorhinolaryngol Relat Spec. 2007;69(1):37-42. [Medline].

  23. Courtney MJ, Mahadevan M, Miteff A. Management of paediatric retropharyngeal infections: non-surgical versus surgical. ANZ J Surg. Nov 2007;77(11):985-7. [Medline].

  24. Gilbert DN, Moellering RC Jr, Eliopoulos GM. Parapharyngeal space infection. In: The Sanford Guide to Antimicrobial Therapy. 40th ed. 2010.

  25. Wald ER. Retropharyngeal Infections in Children. UpToDate [serial online]. May 25, 2009;Accessed May 25, 2010. Available at http://www.uptodate.com.

  26. Elliott M, Yong S, Beckenham T. Carotid artery occlusion in association with a retropharyngeal abscess. Int J Pediatr Otorhinolaryngol. Feb 2006;70(2):359-63. [Medline].

  27. Agada FO, Sharma R, Makura ZG. Atypical presentation of cutaneous tuberculosis and a retropharyngeal neck abscess. Ear Nose Throat J. Jan 2006;85(1):60-2. [Medline].

  28. Bank DE, Krug SE. New approaches to upper airway disease. Emerg Med Clin North Am. May 1995;13(2):473-87. [Medline].

  29. Beasley DJ, Amedee RG. Deep neck space infections. J La State Med Soc. May 1995;147(5):181-4. [Medline].

  30. Daya H, Lo S, Papsin BC, et al. Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int J Pediatr Otorhinolaryngol. Jan 2005;69(1):81-6. [Medline].

  31. Fogeltanz KA, Pursel KJ. Retropharyngeal abscess presenting as benign neck pain. J Manipulative Physiol Ther. Feb 2006;29(2):174-8. [Medline].

  32. Gaglani MJ, Edwards MS. Clinical indicators of childhood retropharyngeal abscess. Am J Emerg Med. May 1995;13(3):333-6. [Medline].

  33. Har-El G, Aroesty JH, Shaha A, Lucente FE. Changing trends in deep neck abscess. A retrospective study of 110 patients. Oral Surg Oral Med Oral Pathol. May 1994;77(5):446-50. [Medline].

  34. Hughes J, Martin RJ, Clutterbuck EJ. Retropharyngeal infection with Staphylococcus aureus in a haemodialysis patient. Am J Nephrol. 1993;13(6):435-6. [Medline].

  35. Kelly CP, Isaacman DJ. Group B streptococcal retropharyngeal cellulitis in a young infant: a case report and review of the literature. J Emerg Med. Aug 2002;23(2):179-82. [Medline].

  36. Lazor JB, Cunningham MJ, Eavey RD, Weber AL. Comparison of computed tomography and surgical findings in deep neck infections. Otolaryngol Head Neck Surg. Dec 1994;111(6):746-50. [Medline].

  37. Philpott CM, Selvadurai D, Banerjee AR. Paediatric retropharyngeal abscess. J Laryngol Otol. Dec 2004;118(12):919-26. [Medline].

  38. Pontell J, Har-El G, Lucente FE. Retropharyngeal abscess: clinical review. Ear Nose Throat J. Oct 1995;74(10):701-4. [Medline].

  39. Pynn BR, Sands T, Pharoah MJ. Odontogenic infections: Part one. Anatomy and radiology. Oral Health. May 1995;85(5):7-10, 13-4, 17-8 passim. [Medline].

  40. Sato K, Izumi T, Toshima M, et al. Retropharyngeal abscess due to methicillin-resistant Staphylococcus aureus in a case of acute myeloid leukemia. Intern Med. Apr 2005;44(4):346-9. [Medline].

  41. Schroeder LL, Knapp JF. Recognition and emergency management of infectious causes of upper airway obstruction in children. Semin Respir Infect. Mar 1995;10(1):21-30. [Medline].

  42. Sethi DS, Stanley RE. Deep neck abscesses--changing trends. J Laryngol Otol. Feb 1994;108(2):138-43. [Medline].

  43. Shefelbine SE, Mancuso AA, Gajewski BJ, Ojiri H, Stringer S, Sedwick JD. Pediatric retropharyngeal lymphadenitis: differentiation from retropharyngeal abscess and treatment implications. Otolaryngol Head Neck Surg. Feb 2007;136(2):182-8. [Medline].

  44. Simsek S, Yigitkanli K, Kazanci A, Belen D, Bavbek M. Medically treated paravertebral Brucella abscess presenting with acute torticollis: case report. Surg Neurol. Feb 2007;67(2):207-10. [Medline].

  45. Takao M, Ido M, Hamaguchi K, Chikusa H, Namikawa S, Kusagawa M. Descending necrotizing mediastinitis secondary to a retropharyngeal abscess. Eur Respir J. Sep 1994;7(9):1716-8. [Medline].

  46. Tannebaum RD. Adult retropharyngeal abscess: a case report and review of the literature. J Emerg Med. Mar-Apr 1996;14(2):147-58. [Medline].

  47. Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, Gonzalez-Valdepena H, Bluestone CD. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg. Mar 1995;112(3):375-82. [Medline].

  48. Vural C, Gungor A, Comerci S. Accuracy of computerized tomography in deep neck infections in the pediatric population. Am J Otolaryngol. May-Jun 2003;24(3):143-8. [Medline].

  49. Watanabe M, Ohshika Y, Aoki T, Takagi K, Tanaka S, Ogata T. Empyema and mediastinitis complicating retropharyngeal abscess. Thorax. Nov 1994;49(11):1179-80. [Medline]. [Full Text].

Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.