Pediatric Retropharyngeal Abscess Follow-up

• Patients with retropharyngeal abscess should be admitted to a monitored setting or directly to the operating room.
• Most patients are able to be monitored in the wards, but patients who are unstable, who are at the extremes of age, or who have comorbidities may need to be monitored in the ICU.

• At the time of discharge, consider transitioning to an oral equivalent of the antibiotic; patients may need intravenous access (peripherally inserted central catheter) for prolonged antibiotic courses that last as long as 4-6 weeks.

• Administer parenteral antibiotics until the infection has resolved.

• The patient should be transferred if facility does not have the capability or personnel required to adequately drain the infection. This should take place only after the airway has been secured or deemed stable enough for transport.

• Regardless of antibiotic therapy, monitor patients diagnosed with upper respiratory symptoms. If a patient's symptoms do not resolve or if symptoms worsen in an appropriate amount of time, suspect infection of the deep spaces of the neck.

Complications of retropharyngeal abscess occur from mass effect, rupture, or spread. A recent study of 138 patients over a ten year period demonstrated mediastintis (nine patients) to be the most common complication. It also demonstrated that younger patients, and those with S aureus infections, were at higher risk for complications.^[16]

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, address this complication first. 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 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. Perform chest radiography 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.

Infection can spread laterally to the carotid sheath, where it can cause vascular complications. Infection can also spread posteriorly, affecting the cervical spine. Osteomyelitis requires long-term antibiotics. 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 atlantooccipital dislocation.

One case study detailed a psudoaneuysm of the internal carotid secondary to a retropharyngeal abscess.^[17]

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.

• In uncomplicated cases of retropharyngeal abscess in a relatively healthy patient, the prognosis for complete recovery without sequelae is excellent.

• Advise a follow-up appointment for parents and/or caregivers of children diagnosed with upper respiratory infections (URIs) that do not follow appropriate course of resolution. Advise these parents and/or caregivers to return immediately if the patient develops clinical manifestations of deep space infection, such as difficulty swallowing, swelling in the back of throat or neck, muffled voice, jaw or neck stiffness, or worsening of symptoms (or if symptoms do not resolve after a reasonable course of time). Advise parents to remain especially alert for signs of airway compromise, such as shortness of breath, drooling, or noisy breathing.
• For excellent patient education resources, visit eMedicine's Infections Center. Also, see eMedicine's patient education articles Abscess and Antibiotics.