The first priority in treating a patient with a suspected retropharyngeal abscess is to determine the stability of airway patency. If the patient has symptoms or signs of airway compromise, this issue becomes the top priority, and modalities to stabilize the airway should be sought on an emergency basis.
After a complete blood count (CBC) and blood cultures are obtained, empiric antibiotic therapy is initiated. Broad-spectrum coverage is typically indicated. Clindamycin is a good choice for initial treatment. However, because of the increasing frequency of resistant bacteria, treatment may be initiated with this agent alone or in combination with cefoxitin or a beta-lactamase–resistant penicillin (eg, ticarcillin-clavulanate, piperacillin-tazobactam, or ampicillin-sulbactam).
Patients with cellulitis can be treated with parenteral antibiotics alone. However these patients should be observed closely for development of an abscess.
McClay et al described a series of 11 pediatric patients with radiographic evidence of deep neck abscess but without severe symptoms who were treated with intravenous (IV) antibiotics alone (no surgical intervention).  Ten of the 11 patients responded, and no surgical therapy was necessary. All abscesses had a retropharyngeal component, if they were not completely retropharyngeal. Clindamycin with or without cefuroxime was the primary medical therapy.
Wong et al presented a retrospective case-control study that included 54 children with abscesses.  Thirteen required operative drainage, and in 10 of the 13, previous medical management had failed. The authors advocated a trial of empiric antibiotics for stable children, especially those with small abscesses.
The success of surgical intervention versus medical therapy in retropharyngeal abscess has been a topic of controversy and the subject of several studies. In a national series, Lander et al found that 43% of patients underwent surgical drainage.  Grisaru-Soen et al found no difference between surgical therapy and medical therapy with respect to hospital stay.  Johnston et al found that nine of 22 patients with retropharyngeal abscess could be discharged with medical therapy alone, with a hospital stay comparable to that of surgical therapy. 
The low specificity of computed tomography (CT) led investigators to try to define a set of criteria for better determination of which patients require surgical drainage. A retrospective study by Page et al summarized the controversy and suggested several criteria, including the following  :
Retropharyngeal bulge and trismus are findings that suggest true abscess as opposed to phlegmon (cellulitis)
The presence of a rash was negatively associated with abscess and should alert the clinician to consider other etiologies, such as Kawasaki disease or scarlet fever
With respect to radiologic criteria, the authors found the cross-sectional area to be the most reliable predictor of abscess; however, this measure still had only a 68% chance of finding pus at the time of surgery in patients with positive CT findings
The authors also commented on the male predominance and the typical age range of patients (>5 years), but these factors cannot be reliably used for diagnosis
Kirse and Roberson reported that scalloping of the abscess on CT had a positive predictive value of 94%; accordingly, they proposed that this scalloping, along with rim enhancement, should be considered as an indicator that surgical intervention is warranted. 
Kirse and Roberson also reported great success with transoral drainage in pediatric patients and stated that it should be the preferred approach in this population.  They found it to be the safest approach in pediatric patients if the CT scan revealed that the abscess was medial to the great vessels and was a confined process (within an inflammatory rind). They cautioned that adult illness is different and may warrant a more aggressive approach (transcervical).
Needle aspiration of an abscess can be performed both to assist in diagnosis and to treat an abscess. This should only be performed by a qualified surgeon in the operating suite. Definitive airway management should be immediately available.
A small retropharyngeal abscess can be aspirated with an 18-gauge needle via the intraoral route. Larger abscesses require incision and drainage via an intraoral approach, a transcervical approach, or both, depending on the location of the carotid sheath in relation to the abscess.
Completely evacuate pus from the abscess. Obtain a specimen for Gram stain, culture, and sensitivity. Abscesses in the parapharyngeal space isolated lateral to the carotid sheath can be aspirated via an external approach.
CT or ultrasonography may be used to help guide the aspiration. Suryadevara and Kellman described a case of transoral incision and drainage with assistance from the InstaTrak image guidance system (CT-based). 
The patient should remain intubated and may be placed in an intensive care unit (ICU) postoperatively for airway monitoring.
Often, the lesion is first aspirated and localized with needle guidance, and then formal incision and drainage are performed.
Abscesses with extensive spread or those involving multiple deep spaces must be incised and drained via an external approach and transoral approach as necessary.
Make an incision along the anterior border of the sternocleidomastoid. Retract the carotid sheath and open and evacuate the deep spaces. Send a specimen of the abscess wall, along with some pus, to pathology for culture and sensitivity.
If mediastinal involvement is present, open incision and drainage of the neck can be extended down to the level of T4. Alternatively, the surgeon can perform a thoracotomy.
If a facility does not have the capability or personnel required to drain the infection adequately, the patient should be transferred. Transfer should take place only after the airway has been secured or deemed stable enough for transport.
Diet and Activity
Prohibit patients with retropharyngeal abscess from taking anything by mouth (nil per os [NPO]) until the possibility of surgical intervention is determined.
For patients with a retropharyngeal abscess, advise bed rest to avoid compromise of the airways during activity. Allow patients to remain supine for optimal airway positioning.
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.
Consultations with the following appropriate specialists are mandatory and should take place on an urgent or emergency basis:
Surgical consultation with a specialist in otolaryngologic, oromaxillofacial, or pediatric surgery should be pursued
Inform a pediatric anesthesiologist about the patient as well
Radiology consultation may be necessary to order or interpret imaging studies
Often, assistance from infectious disease specialists helps with determining appropriate treatment regimens
Patients with a retropharyngeal abscess should be admitted to a monitored setting or directly to the operating room. Most patients can be monitored in the wards, but patients who are unstable, who are at the extremes of age, or who have comorbidities may have to be monitored in the ICU.
At the time of discharge, consider transitioning to an oral equivalent of the antibiotic; patients may need IV access (eg, a peripherally inserted central catheter [PICC]) for prolonged antibiotic courses that last as long as 4-6 weeks.
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