Pediatric Retropharyngeal Abscess Treatment & Management

The first priority in treating a patient with a suspected retropharyngeal abscess (RPA) is to determine airway stability. If the patient has symptoms or signs of airway compromise, this particular concern becomes the top priority, and modalities to stabilize the airway should be sought on an urgent basis.

Surgical vs medical management

The success of surgical intervention as compared with medical therapy in RPA has been a topic of controversy and the core subject of several studies. In a national series, Lander et al found that 43% of patients underwent surgical drainage. ^[4]  Grisaru-Soen et al found no difference between surgical intervention and medical therapy with respect to hospital stay. ^[9]  Johnston et al found that nine of 22 patients with RPA could be discharged after medical therapy alone, with a hospital stay comparable to that of surgical therapy. ^[21]

The low specificity of computed tomography (CT) led investigators to try for a better way of defining a unique set of criteria that could more effectively determine which patients require surgical drainage. A retrospective study by Page et al summarized the controversy and suggested several criteria, including the following ^[22] :

• Retropharyngeal bulge and trismus were findings that suggested true abscess formation as opposed to phlegmon
• The presence of rash was negatively associated with abscess formation and should alert the clinician to consider other etiologies, such as  Kawasaki disease or scarlet fever
• With respect to radiographic criteria, the authors found cross-sectional area to be the most reliable predictor of abscess formation; however, this parameter had only a 68% chance of finding purulence intraoperatively in patients with positive CT findings
• The authors also commented on male predominance and the typical age range of patients (>5 years) with RPA, but these factors cannot be reliably used for diagnosis

Although patients receiving surgical care still require antibiotic therapy, medical management alone may be attempted in some situations. Small abscesses (< 2 cm) that do not show signs of infectious complications or severe symptoms are generally treated with a medical trial of intravenous (IV) antibiotics for 24-72 hours and are followed closely by pediatric otolaryngologists for adequate clinical progression. 

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 IV antibiotics alone (no surgical intervention). ^[23]  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 in this series.

Wong et al presented a retrospective case-control study that included 54 children with abscesses. ^[24]  Of the 54 subjects, 13 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.

Khudan et al explored conservative management for uncomplicated abscesses up to 4.5 cm in size and found that most can be managed effectively with conservative therapy and without undue morbidity or requirement for surgery. ^[11]

As noted, if the patient has symptoms or signs of airway compromise, stabilization on an emergency basis is mandatory.

After appropriate blood tests (complete blood count [CBC] with differential, inflammatory markers, and blood cultures) are ordered, empiric antibiotic therapy is initiated. Broad-spectrum coverage is typically indicated in the initial management of RPA.

Although penicillin G and metronidazole were once considered the mainstays of therapy, the increasing presence of beta-lactamase–producing bacteria forced practice away from this combination. Treatment may be initiated with a beta-lactamase–resistant combination penicillin (eg, ticarcillin-clavulanate, piperacillin-tazobactam, or ampicillin-sulbactam). In some cases, when concern about methicillin-resistant S aureus (MRSA) is present, treatment is likely to involve clindamycin or vancomycin.

The microbiology of RPA commonly includes multiple pathogens, most frequently gram-negative rods and anaerobes. Sole medical management is also typically employed in a monitored hospital setting for up to 72 hours to determine its adequacy; surgical intervention is often indicated if the clinical picture does not improve with antibiotic therapy. It is also important to consider the transition from IV to oral antibiotics; patients typically can be discharged a few days after admission but often are kept on antibiotics for several days after discharge.

In a study by Villanueva-Fernandez et al, steroids were found to play an adjunctive role, along with antibiotics, in conservative treatment of retropharyngeal abscesses in children. ^[25]

Transoral vs transcervical surgical approaches

Kirse and Roberson reported great success with transoral drainage in pediatric patients with RPA and stated that it should be the preferred approach in this population. ^[20] They found it to be the safest approach in pediatric patients if CT revealed that the abscess was medial to the great vessels and was a confined process (within an inflammatory rind). Abscesses with extensive spread and those involving multiple deep spaces must be incised and drained via an external approach as well as a transoral approach, as deemed clinically necessary.

Transoral technique

Transoral needle aspiration and/or incision and drainage (I&D) may be used in the management of RPA. This technique should only be performed by a qualified pediatric otolaryngologist in the operating room (OR).

After endotracheal intubation, a McIvor mouth prop is placed into the oral cavity to allow adequate access to the posterior pharyngeal wall; 0.5% lidocaine with 1:20,000 epinephrine can be injected submucosally for additional hemostatic effect.

The RPA can be localized by palpation to determine the area of greatest fullness and fluctuance. Either CT or ultrasonography (US) may be used to help guide aspiration. Suryadevara and Kellman described a case of transoral incision and drainage with assistance from the InstaTrak image guidance system (CT-based). ^[26] An 18-gauge needle can be introduced under direct visualization, which should reveal purulent material. Aerobic and anaerobic cultures should be sent from the aspirate for pathologic analysis.

Once the RPA pocket has been identified, a vertical incision is made with an electrocautery device. A tonsil clamp is used to break up loculations within the abscess pocket. The wound bed is then copiously irrigated with normal saline.

Transcervical technique

Transcervical I&D may be performed in the management of RPA. Classically, this approach is followed when infection extends inferior to the hyoid bone. This technique should only be performed by a qualified pediatric otolaryngologist in the OR.

After endotracheal intubation, the head is turned away from the operative site. A modified apron incision is designed and marked along the anterior neck. Subplatysmal flaps are raised, and dissection is carried to the anterior border of the sternocleidomastoid, which is retracted laterally. The carotid sheath is retracted laterally to allow blunt opening and evacuation of deep neck spaces. Specimens from the abscess pocket are sent for aerobic and anaerobic culture and pathologic analysis. The wound bed is then irrigated copiously with antibiotic-impregnated saline.

Penrose drains are left in the neck to allow passive egress of fluid. The remainder of the neck is closed in layers. The neck is dressed with fluffed gauze and a stockinette dressing.

If mediastinal involvement is present, consultation with pediatric surgery or pediatric thoracic surgery is strongly advised. Mediastinal washout and thoracotomy may be indicated concomitantly, if deemed clinically necessary.

If the primary admitting facility does not have the capability or personnel needed to drain an RPA adequately, the patient should be transferred to a tertiary care center with pediatric otolaryngology availability. However, transfer should take place only if the airway has already been secured or if the patient is stable enough for medical transport to another facility.

Patients with RPA should not ingest anything orally (nil per os [NPO]) until the possibility of surgical intervention is determined. Postoperatively, children may be started on a clear liquid diet and advanced slowly to a soft diet over a period of several days so as to allow appropriate healing of the surgical site (particularly when intraoral approaches are employed).

Bed rest is advised for patients with RPA so as to avoid airway compromise during activity. Patients should be allowed to remain supine for optimal airway positioning.

Consultations with the following appropriate specialists are mandatory and should take place on an urgent or emergency basis. The primary team should include a pediatrician, and one of or more of the following should be done if appropriate: 

• Obtain a surgical consultation with a specialist in pediatric otolaryngologic surgery
• Inform a pediatric anesthesiologist about the patient regarding perioperative airway management 
• Consider a pediatric radiology consultation to order or interpret imaging studies
• Request assistance from pediatric infectious disease specialists to help determine appropriate antibiotic treatment therapies and regimens

Patients with an RPA should be admitted to a monitored setting or taken directly to the OR for urgent or emergency I&D, if clinically indicated. Most patients can be monitored safely in the pediatric inpatient wards, but patients who are unstable, are at the extremes of age, or have multiple comorbidities may require monitoring in the pediatric intensive acre unit (ICU).

At the time of discharge, transitioning to an oral equivalent of the antibiotic should be considered. Patients with a complicated RPA may need IV access (eg, a peripherally inserted central catheter [PICC]) for prolonged antibiotic courses that may last as long as 4-6 weeks, as determined by pediatric infectious disease specialists.