Retropharyngeal Abscess 

Updated: Jan 08, 2021
Author: Joseph H Kahn, MD; Chief Editor: Gil Z Shlamovitz, MD, FACEP 

Overview

Practice Essentials

Retropharyngeal abscess (RPA) produces the symptoms of sore throat, fever, neck stiffness, and stridor. RPA occurs less commonly today than in the past because of the widespread use of antibiotics for suppurative upper respiratory infections. The incidence of RPA in the United States is rising, however. Once almost exclusively a disease of children, RPA is observed with increasing frequency in adults. It poses a diagnostic challenge for the emergency physician because of its infrequent occurrence and variable presentation.[1]  Emergency department (ED) management of retropharyngeal abscess includes attention to the airway, fluid resuscitation if necessary, antibiotic treatment, and preparation for an emergency operation, if indicated.

Early recognition and aggressive management of RPA are essential because it still carries significant morbidity and mortality.

Signs of retropharyngeal abscess

Physical signs of RPA in adults include the following:

  • Posterior pharyngeal edema
  • Nuchal rigidity
  • Cervical adenopathy
  • Fever
  • Drooling
  • Stridor
  • Torticollis [2]
  • Trismus [2]

Physical signs of RPA in infants and children include the following:

  • Cervical adenopathy [3]
  • Retropharyngeal bulge - Do not palpate in children [3]
  • Fever [3]
  • Stridor
  • Torticollis
  • Neck stiffness [3]
  • Drooling
  • Agitation
  • Neck mass [3]
  • Lethargy
  • Respiratory distress
  • Trismus [4]
  • Change in vocal quality [4]
  • Tonsillar displacement
  • Associated signs, including tonsillitis, peritonsillitis, pharyngitis, and otitis media

Workup in retropharyngeal abscess

Laboratory studies include the following:

  • Complete blood count (CBC)
  • Blood cultures - Indicated before administration of intravenous antibiotics, but culture results may be negative in as many as 82% of RPA cases
  • A culture of pus - Aspirated at the time of surgical drainage of the RPA, it can grow one or more organisms 91% of the time
  • C-reactive protein
  • Erythrocyte sedimentation rate [5]
  • COVID-19 testing - In adult or pediatric patients who present with a sore throat [6]

Imaging studies include the following:

  • Lateral neck radiography
  • Computed tomography (CT) scanning of the neck - Obtain a CT scan of the neck with intravenous contrast when the findings on the lateral neck radiograph are equivocal or if the clinical suspicion for RPA is high in patients with negative findings on lateral neck radiograph
  • Chest radiography - A chest radiograph is indicated to look for aspiration pneumonia and mediastinitis
  • Magnetic resonance imaging (MRI) with gadolinium enhancement - This modality can reveal the existence and size of a retropharyngeal abscess, although the imaging study takes long than does CT scanning [7]

Management of retropharyngeal abscess

ED management of RPA includes attention to the airway, fluid resuscitation if necessary, antibiotic treatment, and preparation for an emergency operation, if indicated. Frequent vital sign checks and continuous oxygen saturation monitoring are essential.

Securing the airway may be required if the patient with RPA is exhibiting signs of impending upper airway obstruction. Endotracheal intubation may be attempted, but it may be difficult because of distortion of the upper airway. The preferred approach is intubation in the operating room (OR), with the surgeon and anesthesiologist present.[8]

If a patient with signs of upper airway obstruction cannot be intubated, a surgical or needle cricothyrotomy may be required, but distortion due to edema and inflammation may make surgical airway management difficult.[9]

A tracheostomy may be required as definitive airway management in patients with retropharyngeal abscess and respiratory distress, but this may also be technically challenging due to edema and inflammation.[9]

Intravenous fluids are required if the patient is dehydrated because of fever and difficulty swallowing.

Pathophysiology

The retropharyngeal space is posterior to the pharynx, bound by the buccopharyngeal fascia anteriorly, the prevertebral fascia posteriorly, and the carotid sheaths laterally. It extends superiorly to the base of the skull and inferiorly to the mediastinum.

Abscesses in this space are often polymicrobial; they can be caused by the following organisms:

  • Aerobic organisms, such as group A streptococci and Staphylococcus aureus, including methicillin-resistant S aureus (MRSA)[10]

  • Anaerobic organisms, such as species of Bacteroides, Veillonella, Prevotella, Peptostreptococcus, Fusobacterium, and Porphyromonas[10]

  • Gram-negative organisms, such as Pseudomonas (in high-risk groups), Haemophilus influenzae, H parainfluenzae, and others[11, 12]

The high mortality rate of retropharyngeal abscess is owing to its association with airway obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, necrotizing fasciitis, sepsis, and erosion into the carotid artery.

Epidemiology

Frequency

United States

The incidence of pediatric RPA in the United States more than doubled in the first decade of the 21st century, according to a study of pediatric deep neck space infections. Deriving their statistics from the Kids’ Inpatient Database (KID), Novis et al found that between 2000 and 2009, the incidence of RPA increased from 0.1 cases per 10,000 to 0.22 cases per 10,000. They also found no significant change in the incidence of either peritonsillar or parapharyngeal abscess in those years.[13]

A study by Woods et al, also using the KID, reported the incidence of RPA to have risen, among children under age 20 years, from 2.98 per 100,000 population in 2003 to 4.10 per 100,000 population in 2012.[14]

A review of cases of RPA over an 11-year period at the Children's Hospital of Michigan revealed a 4.5-times increase in the incidence of RPA when compared with the previous 12 years.[15] A later review at the same hospital revealed that the incidence increased 2.8-fold between 2004 and 2010, compared with the incidence from 1993-2003.[16]

Similarly, an 11-year chart review of 162 pediatric patients with RPA at St. Louis Children's Hospital revealed that the number of RPA cases in children increased significantly from 1995 to 2006.[17]

A study by Angajala et al determined that of 119 pediatric patients in the greater Los Angeles community with a neck abscess treated with incision and drainage, 10.1% had an RPA. Patients with neck abscesses requiring incision and drainage tended to reside in lower income neighborhoods.[18]

International

A review of deep neck infections (DNI) in children over a 12-year period at a medical center in Taiwan revealed 50 children with DNI. Nine children had DNI in the retropharyngeal space, 17 in the parapharyngeal space, 21 in the peritonsillar region, and 3 were mixed.[19]

Another study from Taiwan, by Huang et al, found that out of 52 children with DNI, the retropharyngeal space was the third most common site of infection (7 patients), after the parapharyngeal space (22 patients) and the submandibular space (12 patients).[20]

A review of RPAs and parapharyngeal abscesses (PPAs) in children presenting to 2 pediatric tertiary care medical centers in Israel over an 11-year period revealed 39 children with RPA or PPA. The incidence increased during the course of the study.[21]

A retrospective analysis of children diagnosed with RPA and PPA over a 9-year period in a tertiary care medical center in Spain revealed 17 children with RPA, 11 with PPA, and 3 with both.[22]

Another Spanish study, a retrospective, single-center report by Sanz Sánchez and Morales Angulo, found the incidence of RPA over an approximately 25-year period to be 0.2 cases per 100,000 inhabitants per year.[23]

A study by Yap et al found that in Wales, hospital admissions for RPA, as well as for tonsillitis, PPA, and peritonsillar abscess, rose between 1999 and 2014.[24]

A retrospective review at a single center in Scotland revealed that the number of deep neck space abscesses grew between 2006 and 2015 from 1 to 15, respectively.[25]

Mortality/Morbidity

Once mediastinitis occurs, mortality approaches 25%, even with antibiotic therapy. Retropharyngeal abscess can also cause internal jugular vein thrombosis, carotid artery erosion, pericarditis, and epidural abscess. In addition to invasion of contiguous structures, retropharyngeal abscess can cause sepsis and airway compromise.[7]

Overall mortality rate was 1% in a review of deep cervical space infections in Taiwan.[26]

In a study of 234 adults with deep space infections of the neck in Germany, the mortality rate was 2.6%. The cause of death was primarily sepsis with multiorgan failure.[27]

In the United States, in 2003, a review of the Kids' Inpatient Database (KID) revealed 1321 pediatric admissions with RPA, with no fatalities.[28]

A case series from Children's National Medical Center in Washington DC presents 4 children of ages ranging from 8 months to 18 months with RPA who developed mediastinitis. All 4 were treated aggressively with antibiotics and surgical drainage of RPA, and 3 patients required thoracoscopic debridement. All 4 children survived without sequelae.[29]

Race

In a 10-year review of retropharyngeal abscess cases treated at Kings County Hospital in Brooklyn, New York, 70% of patients were Black, 25% were White, and 5% were Hispanic.

A study of pediatric patients with retropharyngeal abscess at Wayne State University in Detroit revealed 43% of cases occurred in Blacks, 54% in Whites, 1% in Hispanics, and 1% in biracial.[30]

In the United States, in 2003, a review of the Kids' Inpatient Database (KID) revealed 1321 pediatric admissions with retropharyngeal abscess, of which 37.4% were White, 11.7% were Black, 11.1% were Hispanic, 2% were Asian, and 3.8% were other races, with the race not being recorded in the rest of the patients.[28]

Sex

Retropharyngeal abscess is more common in males than in females, with generally reported male preponderance of 53-55%.

  • Children's Hospital of Michigan reports 54% of cases of RPA in males in a 2012 study.[16]

  • A study of children with retropharyngeal abscess in Toronto reported 67% of cases in males.

  • A study of retropharyngeal abscess in children in Detroit found 56% of cases in males.[30]

  • A study of adults with deep space infections of the neck in Germany revealed that 56% of patients were male and 44% were female.[27]

  • A study of cases in Nigeria found a male-to-female ratio of 1:1.[31]

  • In the United States, in 2003, a review of the Kids' Inpatient Database (KID) revealed 1321 pediatric admissions with retropharyngeal abscess, of which 63% were male.[28]

Age

Initially, retropharyngeal abscess was thought to be a disease limited to children, but now it is being encountered with increasing frequency in adults.

  • In children, retropharyngeal abscesses develop most frequently between the ages of 2 and 4 years.[4]

  • This was supported by a review by Bochner, which found the incidence to be greatest in children younger than age 5 years and, by gender, in boys.[5]

  • A review of adults with deep space infections of the neck in Germany revealed a mean age (±standard deviation) of 44.5 (±21.8) years.

  • A review of retropharyngeal abscess cases at the Hospital for Sick Children in Toronto revealed that 66% of pediatric cases occurred in children younger than 6 years.

  • A review of 30 cases of retropharyngeal abscess over an 11-year period in Nigeria found the median age to be 21 months, and 77% of patients were younger than 5 years. Eighty-three percent of retropharyngeal abscesses occurred in children, and 17% occurred in adults.[31]

  • A 10-year review at Kings County Hospital in Brooklyn, New York, revealed that 30% of the cases were in pediatric patients aged 16 months to 8 years and 70% were in adults aged 21-64 years.

  • A 35-year review of cases involving children who were treated for retropharyngeal abscess at the Children's Hospital of Los Angeles revealed that 50% of patients were younger than 3 years and 71% were younger than 6 years.

  • A review or retropharyngeal abscess in children in Detroit found a mean age of 4.1 years, with a range from 2 months to 18 years.

  • A review in Sydney, Australia, found that, in 55% of pediatric cases of retropharyngeal abscess, the children were younger than 1 year, with 10% diagnosed in the neonatal period.

  • A review of RPA cases in children in Albuquerque revealed a median age of 36 months, with 75% of patients younger than 5 years and 16% of patients younger than 1 year.[32]

  • In the United States, in 2003, a review of the Kids' Inpatient Database (KID) revealed 1321 pediatric admissions with retropharyngeal abscess, with an average age of 5.1 years (SD, 4.4).[28]

  • An 11-year chart review of 162 pediatric patients with retropharyngeal abscess at St. Louis Children's Hospital revealed an average age of 4.9 years (range, 6 d to 17 y).[17]

  • A 5-year review of 11 children with parapharyngeal abscess in Portugal revealed an average age of 3.3 years (range, 0-12 y).[3]

  • A 12-year retrospective review of 50 pediatric patients with deep neck infections in Taipei revealed that all of the retropharyngeal abscesses occurred in children younger than 10 years.[19]

 

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 

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

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

 

DDx

Diagnostic Considerations

Differentials include the following:

  • Airway obstruction

  • Calcific retropharyngeal tendinitis[45]

  • Apnea[46]

  • Sepsis

  • Pneumonia

  • Mediastinitis

  • Epidural abscess

  • Epiglottitis[4]

  • Croup[4]

  • Bacterial tracheitis[4]

  • Peritonsillar abscess[4]

  • Uvulitis[4]

  • Foreign body ingestion[47]

  • Angioedema[47]

  • Lymphoma[47]

  • Diphtheria[4]

In a study in Germany, 20 of 234 patients with deep space infections of the neck had airway compromise requiring tracheostomy.[27] In a study in Salt Lake City, 7 of 130 pediatric patients with RPA presented with airway obstruction requiring Pediatric Intensive Care Unit admission and/or intubation.[48]

A case report of a 4-year-old boy with compression of his internal carotid artery and internal jugular vein by a retropharyngeal abscess was documented.[49]

Differential Diagnoses

 

Workup

Laboratory Studies

See the list below:

  • Complete blood count

    • The mean white blood cell (WBC) count in one study was 17,000, with a range of 3100-45,900.

    • WBC counts in 18% of the patients were less than 8000; thus, a normal WBC count does not rule out the diagnosis of retropharyngeal abscess.

    • In a study in Germany, the mean WBC (±standard deviation was 14,700 [±10,500]), with a range from 200-114,000.

  • Blood cultures are indicated before administration of intravenous antibiotics, but culture results may be negative in as many as 82% of retropharyngeal abscess cases.

  • A culture of pus, aspirated at the time of surgical drainage of the retropharyngeal abscess, can grow one or more organisms 91% of the time.

  • C-reactive protein

    • In one study of adults and children with deep cervical space infections, patients with C-reactive protein level greater than 100 had longer hospital stays.

    • In a German study, mean (±standard deviation) C-reactive protein level was 15.7 (±12.9), with a range from 0.0-74.

    • A study in Taiwan reveals that deep neck infection patients with C-reactive protein values greater than 100 tend to develop complications and have prolonged hospitalizations.[50]

  • Erythrocyte sedimentation rate[5]

  • COVID-19 testing - In adult or pediatric patients who present with a sore throat[6]

Imaging Studies

See the list below:

  • Lateral neck radiography

    • Widening of the retropharyngeal soft tissues was observed in 88% of patients with retropharyngeal abscess in a series that defined soft tissue swelling as more than 7 mm at C2 and more than 14 mm at C6. There is some variability in the literature as to what dimensions define retropharyngeal widening on soft tissue lateral neck radiographs. Some authors define retropharyngeal soft tissue swelling as more than 7 mm at C2 and more than 14 mm at C6 in children and more than 22 mm at C6 in adults. Others define retropharyngeal widening as greater than 5-7 mm at C2 and more than 14mm at C6 in children and greater than 20 mm at C6 in adults. Thus, lateral neck radiographs may be considerably less sensitive for detecting retropharyngeal abscess than the above-mentioned study indicates.[1, 4, 5, 6, 7, 51, 52, 53, 54]

    • Klein found the prevertebral space to widen in children if it measures more than 7 mm at C2 or greater than 14 mm at C6.[51]

    • Generally, the anteroposterior diameter of the prevertebral soft tissue space in children should not exceed half that of the contiguous vertebral bodies from C1-4 or the full thickness of contiguous vertebral bodies from C5-7.[6]

    • In addition to showing widening of the prevertebral space, the lateral neck radiograph rarely may show a gas-fluid level, gas in the tissues, or a foreign body.

    • A hospital in Ireland reports a case series of 3 children with RPA who had negative lateral soft tissue neck x-ray films. Diagnosis was made using CT scan in all 3 cases.[55]

      A 5-year-old boy presented to the ED with 2 days o A 5-year-old boy presented to the ED with 2 days of neck pain and fever but with no sore throat. The child had vomited once, and the mother reported that he was irritable. The child's temperature was 101.7° F, pulse was 118 beats per minute, respirations were 24 per minute, and blood pressure was 122/65 mm Hg. A decreased range of motion of the neck and a right anterior cervical node were observed; the child refused to swallow. Lateral neck radiographic findings show increased retropharyngeal space (white arrow). The CT scan did not demonstrate an abscess. The child was seen by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved for 2-3 days and then worsened. Repeat neck CT scan findings demonstrated a retropharyngeal abscess. Incision and drainage was performed in the operating room. Cultures of the pus grew group A beta-hemolytic streptococci and alpha-streptococci, both sensitive to clindamycin. He improved and was discharged on the tenth hospital day on oral clindamycin.
      An 8-month-old infant boy presented with fever and An 8-month-old infant boy presented with fever and a stiff neck. According to the mother, the baby was not moving his neck as much as usual. The mother also reported decreased oral intake. His temperature was 100° F, pulse was 104 beats per minute, respirations were 48 per minute, oxygen saturation was 98% (room air [RA]). The left tympanic membrane (TM) was inflamed and nonmobile. Left submandibular and left postauricular nodes were noted. The lateral neck radiograph shows increased retropharyngeal space. The CT scan demonstrated a small retropharyngeal abscess. The WBC count was 26,000 (24 polymorphonuclear leukocytes [P], 5 bands [B], 63 lymphocytes [L], 8 monocytes [M]). The baby was examined by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved over the next few days and was discharged on the fifth hospital day on oral clindamycin with a plan for repeat CT scans of the neck on an outpatient basis.
  • CT scan of the neck

    • A CT scan of the neck with intravenous contrast is very useful in the diagnosis and management of retropharyngeal abscess. Retropharyngeal abscess appears as a hypodense lesion in the retropharyngeal space with peripheral ring enhancement. Other findings on CT scan include soft-tissue swelling, obliterated fat planes, and mass effect.

    • Obtain a CT scan of the neck with intravenous contrast when the findings on the lateral neck radiograph are equivocal or if the clinical suspicion for retropharyngeal abscess is high in patients with negative findings on lateral neck radiograph. Lateral neck radiographic findings may be misleading, especially in young children.

    • A CT scan of the neck with intravenous contrast also may be useful if the radiographic findings are positive because the CT scan can differentiate between retropharyngeal abscess and cellulitis. The CT scan also shows the extent of the retropharyngeal abscess and its relation to the great vessels, which is very helpful to the surgeon.

    • CT scan of the neck can also differentiate between retropharyngeal abscess and retropharyngeal lymphadenopathy in children, which may help the ear, nose, and throat (ENT) surgeon decide whether to treat with intravenous antibiotics alone or intravenous antibiotics plus surgical drainage.

    • Li and Kiemeney reported that the size of the abscess can be determined through CT scanning of neck; surgical intervention is generally required when abscesses exceed 2.2 cm in size.[12]

    • Wilkie et al reported that abscess size greater than 2.5 cm significantly predicts whether surgical intervention is required.[56]

  • A chest radiograph is indicated to look for aspiration pneumonia and mediastinitis.

  • An MRI with gadolinium enhancement can demonstrate the presence and size of a retropharyngeal abscess, but this modality takes longer to obtain than does CT scanning.[7]

  • Ultrasonography may demonstrate the presence of a retropharyngeal abscess, but its use has not yet been clarified.[12, 57]

Procedures

See the list below:

  • Nasopharyngolaryngoscopy

    • A review of the literature did not reveal a role for nasopharyngolaryngoscopy use in the diagnosis of retropharyngeal abscess.

    • Safety of this procedure in the setting of retropharyngeal abscess is unclear.

    • Nasopharyngolaryngoscopy has been performed preoperatively in two adults, but no reports of its use in children have been found.

  • Endotracheal intubation

    • Securing the airway may be required if the patient with retropharyngeal abscess is exhibiting signs of impending upper airway obstruction. Endotracheal intubation may be attempted, but it may be difficult because of distortion of the upper airway.[8]

    • Prophylactic intubation for a patient with retropharyngeal abscess but without respiratory distress generally is not indicated unless an interhospital transfer is planned.

  • A literature review did not reveal the role of surgical or needle cricothyrotomy in RPA, but If a patient with signs of upper airway obstruction cannot be intubated, a surgical or needle cricothyrotomy may be required; the procedure may be difficult to perform, however, due to tissue edema and distortion.

  • A tracheostomy may be required as definitive airway management in patients with retropharyngeal abscess and respiratory distress, but the procedure may be difficult to perform due to tissue edema and distortion.[9]

  • Airway management in the operating room is preferred, with surgeon and anesthesiologist present, if clinical condition and time allow it.[8]

 

Treatment

Approach Considerations

A prospective study in South Korea compared intravenous antibiotics plus surgical drainage with intravenous antibiotics with or without needle drainage. One case of mediastinitis occurred in the nonsurgical group. The authors concluded that, in conjunction with neck CT scanning, selected cases of parapharyngeal abscesses may be treated conservatively without early open surgical drainage.[58]

An 11-year chart review of 162 pediatric patients with retropharyngeal abscess at St. Louis Children's Hospital revealed that 126 of the patients required surgery initially, and, of the 36 patients treated medically initially, 17 required surgery.[17]

Of 24 pediatric RPAs in children treated at Starship Pediatric Hospital in Auckland, Australia, between 1999 and 2005, 10 (41.7%) required surgery, while 14 (58.3%) did not require surgery.[59]

According to a systematic review, medical treatment of pediatric deep neck abscesses may be a safe alternative to surgical drainage of these lesions, but the investigators cautioned that further studies will be needed before a more solid conclusion can be drawn.[60]

A retrospective study by Kosko and Casey suggested that in pediatric patients with a retropharyngeal or parapharyngeal abscess, intravenous antibiotic therapy alone is more likely to fail, and surgery more likely to be required, when the abscess is larger than 2 cm in diameter.[61]

Li and Kiemeney reported an association between abscess size greater than 2.2 cm and the need for surgical intervention.[12]

Vinckenbosch et al reported that surgery is indicated if the abscess size is greater than 2 cm or if there are complications or worsening of symptoms during medical treatment.[33]

Wilkie et al reported that selected pediatric deep neck space infections can be managed medically but that that abscess size greater than 2.5 cm significantly predicts whether surgical intervention is required.[56]

Prehospital Care

See the list below:

  • Supplemental oxygen and attention to upper airway patency are the essential components of prehospital care in patients with suspected retropharyngeal abscess.

  • If a child exhibits respiratory distress, the sniffing position may be beneficial.

  • Occasionally, endotracheal intubation or cricothyrotomy may be required if the patient exhibits signs of upper airway obstruction.

Emergency Department Care

ED management of retropharyngeal abscess includes attention to the airway, fluid resuscitation if necessary, antibiotic treatment, and preparation for an emergency operation, if indicated. Frequent vital sign checks and continuous oxygen saturation monitoring are essential.

  • Airway management

    • Apply supplemental oxygen. In young children, this can be completed in a nonthreatening way by letting the parent direct blow-by oxygen at the child's face.

    • Endotracheal intubation may be required if the patient has signs of upper airway obstruction. It may be difficult because of upper airway swelling.

    • Cricothyrotomy (surgical or needle) may be required in the patient with upper airway obstruction who cannot be intubated, but the procedure may be difficult to perform due to tissue edema and distortion.

    • Tracheostomy may be required for definitive airway management, but the procedure may be difficult to perform due to tissue edema and distortion.[9]

    • Airway management in the operating room is preferred, with surgeon and anesthesiologist present, if clinical condition and time allow it.[8]

  • Intravenous fluids are required if the patient is dehydrated because of fever and difficulty swallowing.

  • Antibiotic treatment (see the Medication section)

Consultations

An emergent consultation with an ENT specialist is necessary. This specialist should be consulted as soon as the diagnosis of retropharyngeal abscess is suspected, especially if the patient is exhibiting signs of upper airway obstruction.

If an abscess is present, an ENT specialist can drain it in the operating room. An ENT specialist may also perform a tracheostomy.

 

Medication

Medication Summary

The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications. Intravenous broad-spectrum antibiotic coverage is indicated in the treatment of retropharyngeal abscess.

 

Antibiotics

Class Summary

 

Gram-positive organisms (including beta-lactamase – producing microbes), gram-negative organisms, and anaerobes must be covered. The Sanford Guide to Antimicrobial Therapy recommends adding empiric vancomycin to the regimen if the patient is in a high-risk group.[11]

In a review of retropharyngeal infections in children, Wald recommended adding vancomycin or linezolid to the regimen in patients who do not respond to clindamycin and in those who present with severe disease, in order to cover MRSA.[4]

 

Empiric Therapy (does not address possible infection with S aureus or P aeruginosa)[11] :

Ceftriaxone + metronidazole

Levofloxacin + clindamycin

Ampicillin-sulbactam

 

Directed/Specific Therapy[11] :

     Positive culture or high risk for S aureus:

            add vancomycin

     Positive culture of high risk for P aeruginosa:

            Piperacillin-tazobactam

            Cefepime + metronidazole

Cephalosporins, 3rd Generation

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity; has lower efficacy against gram-positive organisms but higher efficacy against resistant organisms; highly stable in presence of beta-lactamases (penicillinase and cephalosporinase) of gram-negative and gram-positive bacteria; bactericidal activity results from inhibiting cell-wall synthesis by binding to 1 or more penicillin-binding proteins; exerts antimicrobial effect by interfering with synthesis of peptidoglycan (major structural component of bacterial cell wall); bacteria eventually lyse because activity of cell-wall autolytic enzymes continues while cell-wall assembly is arrested.

Nitroimidazoles

Metronidazole (Flagyl, Flagyl ER, Flagyl IV RTU)

Inhibits nucleic acid synthesis by disrupting DNA and causing strand breakage; amebicidal, bactericidal, trichomonacidal

Fluoroquinolones

Levofloxacin (Levaquin, Levofloxacin Systemic)

L-stereoisomer of parent compound ofloxacin; D-isomer form is inactive

Inhibits DNA gyrase activity, which in turn promotes breakage of DNA strands

Good monotherapy with extended coverage against Pseudomonas spp, as well as excellent activity against pneumococcus

Antibiotics, Lincosamide

Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal)

Suppresses protein synthesis by binding to 50S ribosomal subunits; bacteriostatic or bactericidal depending on drug concentration, organism and infection site

Penicillins, Amino

Ampicillin/sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin; interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms; alternative to amoxicillin when unable to take medication orally; covers skin, enteric flora, and anaerobes; not ideal for nosocomial pathogens.

Glycopeptides

Vancomycin (Firvanq, Vancocin)

Inhibits cell-wall biosynthesis; blocks glycopeptide polymerization by binding tightly to D-alanyl-D-alanine portion of cell wall precursor

Penicillins, Extended-Spectrum

Piperacillin/tazobactam (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor; inhibits biosynthesis of cell wall mucopeptide synthesis by binding to 1 or more of the penicillin-binding proteins and is effective during active-multiplication stage

Cephalosporins, Other

Cefepime (Maxipime)

Fourth-generation cephalosporin; has gram-negative coverage comparable to ceftazidime but better gram-positive coverage (comparable to ceftriaxone); is zwitterion and rapidly penetrates gram-negative cells; is best beta-lactam for IM administration; has poor capacity to cross blood-brain barrier and thus is not used for treatment of meningitis

 

Follow-up

Further Inpatient Care

See the list below:

  • Once the diagnosis of retropharyngeal abscess is suspected, consult an ENT, initiate fluid resuscitation (if indicated), initiate intravenous antibiotics, and carefully monitor the airway.

  • If any signs of respiratory distress are present, the patient may require airway management in the OR, with surgeon and anesthesiologist present.

  • Careful monitoring of airway status is essential and may require intensive care unit admission, even in the absence of respiratory distress in the ED.

  • The ENT physician decides whether to incise and drain the abscess in the operating room or whether a trial of medical therapy is indicated first.

  • Incision and drainage of retropharyngeal abscess in the ED may lead to aspiration and generally is not recommended.

  • An 11-year chart review of 162 pediatric patients with retropharyngeal abscess at St. Louis Children's Hospital revealed that 126 of the patients required surgery initially, and, of the 36 patients treated medically initially, 17 required surgery.[17]

  • Of 24 pediatric RPAs in children treated at Starship Pediatric Hospital in Auckland, Australia, between 1999 and 2005, 10 (41.7%) required surgery, while 14 (58.3%) did not require surgery.[59]

Transfer

See the list below:

  • Community hospitals without CT scanning or access to an ENT surgeon may need to transfer patients with suspected or known retropharyngeal abscess.

  • Patients with known or suspected retropharyngeal abscess may need to be intubated before transport, depending on their clinical status.

  • Intravenous antibiotics may be given prior to transfer but should not delay the transfer.

Deterrence/Prevention

See the list below:

  • Good oral hygiene

  • Antibiotic therapy of bacterial oral and pharyngeal infections

Complications

Complications of retropharyngeal abscess may include the following[62, 63, 64, 65, 4, 7] :

  • Airway obstruction
  • Acute necrotizing mediastinitis - 25% mortality in adults
  • Aspiration pneumonia
  • Sepsis
  • Pleural involvement
  • Atlanto-occipital dislocation
  • Erosion of the second and third cervical vertebrae
  • Cranial nerve deficits - Cranial nerves IX-XII are contained in the cervical fascia
  • Carotid sheath involvement
  • Carotid artery rupture
  • Suppurative jugular thrombophlebitis
  • Compression of carotid artery and internal jugular vein
  • Facial nerve palsy
  • Esophageal perforation
  • Purulent meningoencephalitis
  • Septic embolization

Prognosis

See the list below:

  • Prognosis generally is good if retropharyngeal abscess is identified early, managed aggressively, and complications do not occur.

  • The mortality rate may be as high as 40-50% in patients in whom serious complications develop.

Patient Education

Patients should be brought to the ED immediately if they develop the inability to swallow or have difficulty breathing in conjunction with a sore throat.

For patient education information, see Medscape Drugs & Diseases' Infections Center, as well as Skin Abscess and Antibiotics.

 

Questions & Answers

Overview

What is a retropharyngeal abscess (RPA)?

What is the pathophysiology of a retropharyngeal abscess (RPA)?

What is the prevalence of retropharyngeal abscess (RPA) in the US?

What is the global prevalence of retropharyngeal abscess (RPA)?

What is the mortality and morbidity associated with retropharyngeal abscess (RPA)?

What are the racial predilections of retropharyngeal abscess (RPA)?

What are the sexual predilections of retropharyngeal abscess (RPA)?

Which age groups have the highest prevalence of retropharyngeal abscess (RPA)?

Presentation

What are the signs and symptoms of a retropharyngeal abscess (RPA) in children?

What are the signs and symptoms of a retropharyngeal abscess (RPA) in infants?

What are the signs and symptoms of a retropharyngeal abscess (RPA) in adults?

Which physical findings are characteristic of a retropharyngeal abscess (RPA) in infants and children?

Which physical findings are characteristic of a retropharyngeal abscess (RPA) in adults?

What causes a retropharyngeal abscess (RPA)?

Which organisms cause retropharyngeal abscess (RPA) in adults?

Which organisms cause retropharyngeal abscess (RPA) in children?

DDX

Which conditions are included in the differential diagnoses of retropharyngeal abscess (RPA)?

What are the differential diagnoses for Retropharyngeal Abscess?

Workup

What is the role of lab tests in the workup of retropharyngeal abscess (RPA)?

What is the role of imaging studies in the workup of retropharyngeal abscess (RPA)?

What procedures are used in airway management of a retropharyngeal abscess (RPA)?

What is the role of nasopharyngolaryngoscopy in the workup of retropharyngeal abscess (RPA)?

Treatment

What is included in prehospital care of a retropharyngeal abscess (RPA)?

How is a retropharyngeal abscess (RPA) treated?

Which specialist consultations are beneficial to patients with a retropharyngeal abscess (RPA)?

What is the efficacy of nonsurgical treatment of retropharyngeal abscess (RPA)?

Medications

What is the role of medications in the treatment of a retropharyngeal abscess (RPA)?

Which medications in the drug class Antibiotics are used in the treatment of Retropharyngeal Abscess?

Which medications in the drug class Cephalosporins, Other are used in the treatment of Retropharyngeal Abscess?

Which medications in the drug class Penicillins, Extended-Spectrum are used in the treatment of Retropharyngeal Abscess?

Which medications in the drug class Glycopeptides are used in the treatment of Retropharyngeal Abscess?

Which medications in the drug class Penicillins, Amino are used in the treatment of Retropharyngeal Abscess?

Which medications in the drug class Antibiotics, Lincosamide are used in the treatment of Retropharyngeal Abscess?

Which medications in the drug class Fluoroquinolones are used in the treatment of Retropharyngeal Abscess?

Which medications in the drug class Nitroimidazoles are used in the treatment of Retropharyngeal Abscess?

Which medications in the drug class Cephalosporins, 3rd Generation are used in the treatment of Retropharyngeal Abscess?

Follow-up

What is the role of surgery in the treatment of a retropharyngeal abscess (RPA)?

When is patient transfer indicated for the treatment of retropharyngeal abscess (RPA)?

How is a retropharyngeal abscess (RPA) prevented?

What are the possible complications of a retropharyngeal abscess (RPA)?

What is the prognosis of retropharyngeal abscess (RPA)?

What is included in patient education about retropharyngeal abscess (RPA)?