Pediatric Retropharyngeal Abscess Treatment & Management

Determining airway stability remains a top priority (ABCs of emergency care) in patients with retropharyngeal abscess. Allow patients to remain in a position of comfort, which is usually supine with their necks extended. Neck flexion or forcing a child to sit up can occlude the airway.

Only a physician experienced in airway management should attempt a definitive procedure. Remember that sedatives and paralytics can cause relaxation of airway muscles with subsequent complete occlusion.

After obtaining a CBC count and blood cultures, initiate empiric antibiotic therapy without delay.

Broad-spectrum coverage is indicated. Clindamycin is first-line treatment. Because of the increasing frequency of resistant bacteria, treatment may be initiated alone or in combination with cefoxitin or a beta-lactamase–resistant penicillin, such as ticarcillin/clavulanate, piperacillin/tazobactam, or ampicillin/sulbactam.

Patients with cellulitis can be treated with parenteral antibiotics alone. Closely observe these patients for development of an abscess. Some authors advocate the use of antibiotics alone for small abscesses. These patients need to be closely monitored for improvement.

McClay et al described a series of 11 pediatric patients with radiographic evidence of deep neck abscess but without severe symptomatology who were treated with intravenous antibiotics alone (no surgical intervention).^[12] 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.

The success of surgical intervention versus medical therapy in retropharyngeal abscess has been a topic of controversy and the topic of several studies. In Lander et al's national series, 43% of patients underwent surgical drainage.^[1]

Grisaru-Soen et al found no difference in hospital stay between patients undergoing surgical versus medical therapy.^[5]

In Johnston et al's series of 22 patients with retropharyngeal abscess, 9 were able to be discharged with medical therapy alone, with comparable hospital stay.^[13]

The low specificity of CT scanning has led investigators to try and define a set a of criteria to better define which patients necessitate surgical drainage. A retrospective study by Page et al summarizes the controversy and suggests several criteria, including the following:^[14]

• Retropharyngeal bulge and trismus are findings that suggest true abscess versus 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.
• As for 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 a positive CT scan findings.
• The authors also commented on the male predominance and the typical age range of patients (>5 y), but these factors cannot be reliably used for diagnosis.

Kirse and Roberson's reported scalloping of the abscess on CT imaging to have a positive predictive value of 94%; they proposed that, along with rim enhancement, this scalloping should be considered as an indicator that surgical intervention is warranted.^[11] They also reported great success with transoral drainage in pediatric patients and stated that, in this population, it should be the preferred approach. They reported that this was the safest approach in pediatric patients, if the CT scan revealed an abscess medial to the great vessels and is a confined process (within an inflammatory rind). They caution 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 by the intraoral route. Larger abscesses require incision and drainage using either an intraoral or transcervical approach or both, depending on the location of the carotid sheath in relationship 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 by an external approach.

CT scanning or ultrasonography may be used to help guide the aspiration. Suryadevara and Kellman describe a case of transoral incision and drainage with assistance from the InstaTrak image guidance system (CT-based).^[15]

The patient should remain intubated. Place the patient in an ICU postoperatively for airway monitoring.

Often times, the lesion is first aspirated and localized with needle guidance and then formal incision and drainage is 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, an open incision and drainage of the neck can be extended down to the level of T4. Alternatively, the surgeon can perform a thoracotomy.

Consultations with the appropriate specialists are mandatory and should take place in and urgent or emergent fashion.

• Surgical consultation with a specialist in otolaryngology, 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 appropriate treatment regimens.

• Prohibit patients with retropharyngeal abscess from taking anything by mouth (NPO), until the possibility of surgical intervention is determined.

• For patients with retropharyngeal abscess, advise bed rest to avoid compromise of their airways during activity. Allow patients to remain supine for optimal airway positioning.