Retropharyngeal abscess (RPA) is a deep neck space infection that can pose an immediate life-threatening emergency, with potential for airway compromise and other catastrophic complications.
Signs and symptoms
Patients with an RPA are likely to experience a constellation of symptoms, including fever, malaise, decreased appetite, irritability, sore throat, dysphagia, odynophagia, trismus, or torticollis. The overall presentation can be insidious, even stemming from a recent upper respiratory tract infection that has not completely resolved. In view of the clinical ambiguity, especially early in the infectious course, it is important to maintain a high index of suspicion.
Physical examination findings that are commonly found in children with RPA include the following:
Tender lymphadenopathy (often unilateral)
Decreased or painful range of motion of the neck or jaw
Dysphonia (“hot potato” voice)
Stridor and drooling are indications of possible airway compromise, which necessitate emergency intervention with respect to airway stabilization. Finally, bulging of the posterior pharyngeal wall is common and is usually asymmetric.
The clinical course may appear unremarkable in the early stages, resembling that of uncomplicated pharyngitis. However, later stages may result in dysphagia, dysphonia, or respiratory compromise. If labored breathing or posturing is present, it is imperative to rule out airway obstruction and secure the airway if deemed clinically necessary. However, blind endotracheal intubation should be avoided because of the possibility of rupturing the abscess and causing either further airway obstruction or aspiration pneumonia.
Upon initial evaluation, patients in whom there is concern about a possible RPA should be evaluated and stabilized by both pediatric hospitalists and pediatric otolaryngologists. Blood tests typically obtained include the following:
Complete blood count with differential
Imaging studies that may be considered include the following:
Lateral neck radiograph
Contrast-enhanced computed tomography (CT) scan of the neck
Radiography has a lower sensitivity and often precedes CT. CT is the modality of choice for identifying the abscess or determining its location.
Treatment with intravenous broad-spectrum antibiotics should also be promptly initiated, typically including a penicillin plus an antipenicillinase (eg, ampicillin-sulbactam). When possible methicillin-resistant Staphylococcus aureus infection is a concern, clindamycin or vancomycin should be considered for empiric therapy. Antibiotic planning should take into account that the microbiology of RPA is likely to include multiple pathogens, most likely gram-negative rods and anaerobes.
Sole medical management is typically employed in a monitored hospital setting for up to 72 hours to determine adequacy; surgical intervention via transoral or transcervical approaches is often indicated if the clinical picture does not improve.