Case 1 :

a 14-month-old previously healthy female patient who had a high-grade fever for 7 days,
associated with neck stiffness and restriction of neck movements to the right side. Her parents
noticed decreased oral intake associated with dysphagia, muffled quality of voice, and obstructive
sleep apnea. However, the patient had no clinical signs of mechanical obstruction on examination.
A contrast-enhanced CT scan of the neck showed a large retropharyngeal septated fluid
collection measuring 8 × 3 × 6 cm, which was categorized as a large retropharyngeal abscess
that was complicated by descending mediastinitis. The patient was taken immediately to the
operation theater for incision and drainage under general anesthesia, after which she was started
on intravenous antibiotics.

Case 2 :

10-month old Asian infant weighing 8.2 kg. The patient presented with fever, right-sided neck
swelling, hoarseness of voice, and respiratory distress. The clinical and radiological findings were
suggestive of airway obstruction complicated by retropharyngeal abscess.
The patient was urgently taken to the operating room and underwent (grade 3) intubation. After
stabilization, the patient underwent endoscopic trans-oral incision and drainage, during which 5 cc
pus was aspirated. Antibiotics were prescribed for 2 weeks following the procedure based on the
sensitivity result of the pus culture.

Case 3 :

A 13-month-old boy was admitted with cough, stridor, and difficulty in breathing. He had fever and
rhinorrhea for 3 days, a week ago. On admission, his body temperature was 37°C, heart rate was
114/min, and respiratory rate was 36/min. His physical examination was otherwise normal, except
stridor. Head movements were normal. White blood cell count 13.600/mm3, C-reactive protein
146 mg/L, erithrocyte sedimentation rate 111/hr. Chest X-Ray, viral PCR (nasopharyngeal swab),
serum viral serologies were normal. His complaints did not resolve with nebulized racemic
epinephrine (0.05 mL/kg/dose) and oral dexamethasone (0.15 mg/ kg/dose).
On the second day of hospitalization, limitation in head movements, difficulty in swallowing, and
increase in secretions were seen. Lateral X-Ray showed prevertebral soft tissue thickening (2 cm)
that was extending to upper mediastinum, narrowing of pharyngeal air column, and anterior
displacement of tracheal air column. Posteroanterior chest X-Ray showed slightly deviation of
upper tracheal air column to right side. CT of neck region revealed a retropharyngeal fluid
collection between C1-T4, and 6.5 x 3 x 9.5 cm in diameters. The abscess was drained and
ampicillin-sulbactam (200 mg/kg/day), and clindamycin (40 mg/kg/day) treatments were started.
Histopathological examination of the abscess fluid was compatible with infection and culture grew
methicillin sensitive Staphylococcus aureus. He improved clinically and after 14 days duration of
intravenous antibiotic.

Case 4 :

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 ENT 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.

Case 5 :

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 ENT 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.
 Retro-pharyngeal Abscesses

Overview :

Retropharyngeal abscess (RPA) produces the symptoms of sore throat, fever, neck stiffness, and
stridor.

Retro-pharyngeal abscess is divided into

Acute and Chronic

Acute RPA is more common in children.

Chronic RPA is usually due to TB of the cervical lymph nodes or TB of the spine.

Pathophysiology :

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).

• Anaerobic organisms, such as species of Bacteroides, Veillonella, Prevotella,

Peptostreptococcus, Fusobacterium, and Porphyromonas.

• Gram-negative organisms, such as Pseudomonas (in high-risk groups), Haemophilus

influenzae, H parainfluenzae, and others.

Epidemiology :

Race :
70% of patients were Black, 25% were White, and 5% were Hispanic.

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

Age :
In children, retropharyngeal abscesses develop most frequently between the ages of 2 and 4
years.

Retropharyngeal Abscess Clinical Presentation :

Symptoms in children older than 1 year :

• 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 Examination:

signs in infants and children :

• 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
• 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, 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.

Organisms causing retropharyngeal abscess in children include the following :

• Group A streptococcus (Streptococcuspyogenes)

• S aureus
• MRSA
• Haemophilus species
• Bacteroides species
• Peptostreptococcus species
• Fusobacterium species
• Prevotella species
• Veillonella species
• Staphylococcus coagulase negative
• Brucella species

Retropharyngeal Abscess Differential Diagnoses :

• Acute Torticollis
• Angioedema
• Bacterial Pneumonia
• Bacterial Sepsis
• Caustic Ingestions
• Dental, Infections
• Diphtheria
• Emergent Management of Acute Otitis Media
• Emergent Management of Croup (Laryngotracheobronchitis)
• Emergent Management of Pediatric Epiglottitis
• Emergent Management of Pediatric Patients with Fever
• Epidural Infections (Spinal Epidural Abscess) and Subdural Infections (Subdural Empyema)
• Epiglottitis
• Esophagitis
• Gastrointestinal Foreign Bodies
• Kawasaki Disease
• Lymphomas of the Head and Neck
• Mediastinitis in Emergency Medicine
• Meningitis
• Infectious Mononucleosis (IM) in Emergency Medicine Neonatal Sepsis
• Pediatric Foreign Body Ingestion
• Pediatric Pharyngitis
• Pediatric Pneumonia
• Pediatric Sepsis
• Pediatrics, Meningitis and Encephalitis
• Peritonsillar Abscess in Emergency Medicine Pharyngitis
• Sinusitis (Rhinosinusitis) Imaging
• Trachea Foreign Bodies

Retropharyngeal Abscess Workup :

Laboratory Studies :
• Complete blood count
• Blood cultures
• A culture of pus
• C- reactive protein
• Erythrocyte sedimentation rate
• COVID-19 test

Imaging Studies :

• Lateral neck radiography :

Widening of the retropharyngeal soft tissues was observed in 88% of patients.

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

• CT with contrast of the neck :

Is the gold standard.
Retropharyngeal abscess appears as a hypodense lesion in the retropharyngeal space with
peripheral ring enhancement.

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

• MRI
• Ultrasonography
Retropharyngeal Abscess Treatment & Management :

Prehospital Care :

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.

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 :

• supplemental oxygen
• Endotracheal intubation may be required if the patient has signs of upper airway obstruction
• Cricothyrotomy (surgical or needle) may be required in the patient with upper airway obstruction
who cannot be intubated
• Tracheostomy may be required for definitive airway management

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

Consultations :
An emergent consultation with an ENT specialist is necessary.

Retropharyngeal Abscess Medication :

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.

Empiric Therapy :

Ceftriaxone + metronidazole
Levofloxacin + clindamycin
Ampicillin-sulbactam

Directed/Specific Therapy :

Positive culture or high risk for S aureus:

add vancomycin
Positive culture of high risk for P aeruginosa:
Piperacillin-tazobactam
Cefepime + metronidazole

Surgical incision and drainage :

surgery is indicated if the abscess size is greater than 2 cm or if there are complications or
worsening of symptoms during medical treatment.

Trans-oral incision of retro-pharyngeal abcess (Video) :

[Link]

Prevention of retropharyngeal abscess :

• Good oral hygiene

• Antibiotic therapy of bacterial oral and pharyngeal infections

Complications :

• Airway obstruction
• Acute necrotizing mediastinitis - 25% mortality in adults
• Aspiration pneumonia
• Sepsis
• Pleural involvement
• Atlanto-occipital dislocation
• Epidural abscess
• Acute respiratory distress syndrome (ARDS)
• 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 :

Prognosis generally is good if retropharyngeal abscess is identified early, managed aggressively,

and complications do not occur.

However, The mortality rate associated with retropharygeal abscess may be as high as 40-50% in
patients in whom serious complications develop.
References :
- Medscape