Retropharyngeal Abscess Clinical Presentation

Updated: Jan 08, 2021
  • Author: Joseph H Kahn, MD; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
  • Print
Presentation

History

History is variable, depending on the age group. Symptoms of retropharyngeal abscess are different for adults, children, and infants.

  • Symptoms in adults

    • Sore throat

    • Fever

    • Dysphagia

    • Odynophagia

    • Neck pain

    • Dyspnea

  • Symptoms in children older than 1 year [3, 5, 33]

    • Sore throat 

    • Fever 

    • Neck pain 

    • Dysphagia

    • Odynophagia 

    • Decreased oral intake

    • Drooling

    • Dyspnea

    • Chest pain

    • Cough

  • Symptoms in infants 

    • Fever 

    • Neck swelling 

    • Poor oral intake 

    • Rhinorrhea 

    • Lethargy 

    • Cough 

Next:

Physical

Patients with retropharyngeal abscess may present with signs of airway obstruction, but often they do not. Individuals who do not exhibit signs of airway obstruction initially may progress to airway obstruction. The most common presenting signs may be different for adult and pediatric patients.

  • Physical signs in adults

    • Posterior pharyngeal edema 

    • Nuchal rigidity

    • Cervical adenopathy

    • Fever

    • Drooling

    • Stridor

    • Torticollis [2]

    • Trismus [2]

  • Physical signs in infants and children [3, 4, 5, 33]

    • Cervical adenopathy 

    • Retropharyngeal bulge - Do not palpate in children

    • Fever 

    • Stridor 

    • Torticollis 

    • Neck stiffness or limited neck movement 

    • Drooling 

    • Agitation 

    • Neck mass 

    • Lethargy 

    • Respiratory distress 

    • Trismus [4]

    • Dysphonia

    • Tonsillar displacement

    • Associated signs, including tonsillitis, peritonsillitis, pharyngitis, and otitis media

Previous
Next:

Causes

Retropharyngeal abscess develops secondary to lymphatic drainage or contiguous spread of upper respiratory or oral infections. Pharyngeal trauma from endotracheal intubation, nasogastric tube insertion, [34] endoscopy, foreign body ingestion, and foreign body removal may cause a subsequent retropharyngeal abscess. Patients who are immunocompromised or chronically ill, such as persons with diabetes, cancer, alcoholism, or AIDS, are at increased risk for retropharyngeal abscess.

The aforementioned single-center Spanish study by Sanz Sánchez and Morales Angulo reported that medical histories among patients with retropharyngeal abscess most frequently involved not only alcoholism and diabetes, as mentioned above, but also smoking and obesity. [23]

A study by Kim et al indicated that in adolescents and adults, but not in children aged 14 years or younger, tonsillectomy raises the risk of retropharyngeal and parapharyngeal abscesses, with the post-tonsillectomy adjusted hazard ratio for deep neck infection being 1.43 (1.12 in children and 1.87 in patients aged 15 years or older). [35]

A study by Qureshi et al indicated that retropharyngeal abscess is occurring at an increasing rate among adult inpatients in the United States with peritonsillar abscess. The investigators, who used data from the National (Nationwide) Inpatient Sample, found that between 2003 and 2010 the annual rate at which retropharyngeal abscess occurred concurrently with peritonsillar abscess rose from 0.5% to 1.4% among inpatients aged 18 years or older. The study also indicated that patient age affects concurrence of the two conditions, with the likelihood that retropharyngeal abscess will complicate peritonsillar abscess increasing in patients aged 40 years or older. [36]

Buckley et al reported an increasing incidence of admissions for tonsillitis and RPAs in Wales between 1999 and 2014. The investigators questioned whether there is too great a threshold for tonsillectomy. [25]

Jain et al reported that children under age 5 years with RPA often have an antecedent upper respiratory infection causing suppurative cervical lymphadenitis. [37]

The most common organisms causing retropharyngeal abscesses include aerobes and anaerobes; gram-negative organisms also may be observed. Often, mixed flora is cultured. The incidence of RPA caused by methicillin-resistant Staphylococcus aureus (MRSA) is increasing. [16]

Organisms causing retropharyngeal abscess in adults include the following [38, 25] :

  • Group A streptococcus (Streptococcus pyogenes)

  • Streptococcus viridans

  • Peptostreptococcus species (now Peptoniphilus) [11]

  • Fusobacterium species [11]

  • Staphylococcus aureus

  • Methicillin-resistant Staphylococcus aureus ( MRSA) [39]

  • Klebsiella pneumoniae

  • Bacteroides species

  • Staphylococcus epidermidis

  • Anaerobic streptococci

  • Bartonella henselae

  • Eikenella corrodens

  • Escherichia coli

  • Prevotella species

  • Pseudomonas aeruginosa [11, 7]

  • Group C or G streptococci [7]

  • Extended-spectrum beta-lactamase (ESBL)–producing Enterobacteriaceae [7]

  • Mycobacterium tuberculosis [40, 2]

  • Actinomycetes [41]

  • Cryptococcus neoformans [42]

Organisms causing retropharyngeal abscess in children include the following:

  • Group A streptococcus (Streptococcus pyogenes) [30, 4]  - The incidence is increasing (54%), according to review of cases at the Children's Hospital of Michigan. [15]

  • S aureus [30]

  • MRSA [16, 39, 43, 44]

  • Haemophilus species

  • Bacteroides species

  • Peptostreptococcus species

  • Fusobacterium species

  • Prevotella species

  • Veillonella species [4]

  • Staphylococcus coagulase negative

  • Brucella species

Previous