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Pediatric Retropharyngeal Abscess Clinical Presentation

  • Author: Jason L Acevedo, MD; Chief Editor: Ravindhra G Elluru, MD, PhD  more...
 
Updated: Jul 11, 2016
 

History

Patients with a retropharyngeal abscess present with constitutional complaints, such as fever, chills, malaise, decreased appetite, and irritability.

In addition, they may complain of a sore throat, difficulty in swallowing (dysphagia), pain on swallowing (odynophagia), jaw stiffness (trismus), or neck stiffness (torticollis). Small children with torticollis tend to hold their neck in a nonneutral position and do not turn their head from side to side.

Patients may also complain of a muffled voice, the sensation of a lump in the throat, or pain in the back and shoulders upon swallowing.

Difficulty in breathing may be an ominous portent of airway obstruction.

The patient history is not always straightforward. Symptoms (with decreasing incidence) can include fever, sore throat, dysphagia, trismus, decreased appetite, voice change, odynophagia, neck pain, irritability, and difficulty breathing. A review by Grisaru-Soen et al showed fever (70%) and neck pain (62%) to be the most common symptoms.[8]

The course of pharyngeal abscess can be insidious. In some cases, an upper respiratory illness can precede symptoms by weeks. Many patients do not recall (or parents or caregivers are not aware of) incidences of penetrating trauma. Accordingly, it is vital to maintain a high index of suspicion, especially in patients with upper respiratory illnesses that appear not to resolve in a normal course or to respond to conventional therapy.

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Physical Examination

Most patients with a retropharyngeal abscess are febrile. Some may even appear toxic and irritable. Tender cervical lymphadenopathy, usually unilateral, is the most common physical finding in these patients. Patients may have decreased or painful range of motion of their necks or jaws. Some patients may present with a muffled "hot potato" voice (dysphonia).

Upon inspection of the oral cavity, the physician may be able to appreciate a bulge in the posterior pharyngeal wall. The retropharyngeal bulge is typically not in the midline, because of the presence of the raphe that divides the retropharyngeal space.

Patients in respiratory distress or those who present with stridor or drooling have potential airway compromise and should be managed expeditiously. The patient should also be carefully evaluated for extension of the infection to the carotid sheath, the mediastinum, or both.

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Complications

Complications of retropharyngeal abscess arise from mass effect, rupture, or spread. A study of 138 patients over a 10-year period demonstrated mediastinitis to be the most common complication (nine patients); it also demonstrated that younger patients, and those with S aureus infections, were at higher risk for complications.[9]

The mass of the abscess in the retropharyngeal space can compress the airway, which lies immediately anterior to it. Because this is the most immediately life-threatening complication of retropharyngeal abscess, it must be addressed first, as follows:

  • Secure the airways of patients in respiratory distress and in patients with stridor or drooling
  • Attempt airway stabilization by repositioning the neck and head
  • If repositioning the neck and head is not successful, provide definitive airway control, which can be accomplished by means of endotracheal intubation (under direct visualization), fiberoptic intubation, needle cricothyroidostomy, cricothyroidotomy, or surgical tracheotomy

Abscess rupture can lead to asphyxiation or aspiration pneumonia. The abscess can rupture spontaneously or can be ruptured iatrogenically during vigorous physical examination or attempted intubation. Chest radiography is indicated to assess for pneumonia. Abscess rupture requires aggressive airway management, including suctioning and broad-spectrum antimicrobial therapy.

Infection can spread either laterally or posteriorly to adjacent structures in the neck, or it can progress inferiorly to the mediastinum. Lateral spread can involve the carotid sheath, where it can cause vascular complications. One case study detailed a pseudoaneurysm of the internal carotid secondary to a retropharyngeal abscess.[10]

Posterior spread can affect the cervical spine. Osteomyelitis necessitates long-term antibiotic therapy. Erosion of the ligaments can cause subluxation and subsequent spinal cord injuries. Destruction of the transverse ligament of the atlas has been known to cause atlanto-occipital dislocation.

Inferior spread of infection can cause several life-threatening complications. Chest radiography is indicated in the initial workup. Inflammation in the mediastinum can cause mediastinitis, purulent pericarditis, pericardial tamponade, bronchial erosion, and mediastinal abscess. Spread to the adjacent pleura can cause pleuritis, pyopneumothorax, or empyema. In addition to antibiotics, drainage of pus via pericardiocentesis, pericardial window, chest tube thoracostomy, or open thoracotomy may be necessary.

The infection also can evolve into overwhelming sepsis or necrotizing fasciitis in the neck or mediastinum.

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Contributor Information and Disclosures
Author

Jason L Acevedo, MD Otoloaryngologist-Head and Neck Surgeon

Jason L Acevedo, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Rahul K Shah, MD, FACS, FAAP Associate Professor of Otolaryngology and Pediatrics, Associate Surgeon-in-Chief, Medical Director, Peri-operative Services, Children's National Medical Center, George Washington University School of Medicine and Health Sciences; Attending Physician, Department of Otolaryngology, Children's National Medical Center

Rahul K Shah, MD, FACS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American College of Medical Quality, American Association for Physician Leadership, American College of Surgeons, Triological Society, Massachusetts Medical Society, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

John E McClay, MD Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical Center

John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Ravindhra G Elluru, MD, PhD Professor, Wright State University, Boonshoft School of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Dayton Children's Hospital Medical Center

Ravindhra G Elluru, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, Association for Research in Otolaryngology, Society for Ear, Nose and Throat Advances in Children, Triological Society, American Society for Cell Biology

Disclosure: Nothing to disclose.

Acknowledgements

Todd J Berger, MD Assistant Professor, Department of Emergency Medicine, Emory University

Todd J Berger is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Orval Brown, MD Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas

Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Nothing to disclose.

Hosseinali Shahidi, MD, MPH Assistant Professor, Departments of Emergency Medicine and Pediatrics, State University of New York and Health Science Center at Brooklyn

Disclosure: Nothing to disclose.

References
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Schematic of anatomy of deep spaces of neck, as illustrated in lateral and cross-sectional views. Fascial planes (see color key) surround potential spaces. Anteriorly, retropharyngeal space is bounded by buccal pharyngeal fascia, which invests pharynx, trachea, esophagus, and thyroid; posteriorly, by alar fascia; and laterally, by carotid sheaths and parapharyngeal spaces. Retropharyngeal space extends from base of skull to mediastinum at level of tracheal bifurcation. Note danger space located between alar fascia and prevertebral fascia.
Plain film soft tissue views of lateral neck. Top radiograph reveals widening of soft tissues, with anterior displacement of airway. Careful examination of this film reveals gas in soft tissue. Bottom radiograph is much more subtle. Soft tissue is widened at level of C2.
Contrast axial CT scan demonstrates left-side retropharyngeal abscess.
 
 
 
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