AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Retropharyngeal abscess (RPA) produces the symptoms of sore throat, fever, neck stiffness, and stridor. Retropharyngeal abscess occurs much less commonly today than in the past because of the widespread use of antibiotics for suppurative upper respiratory infections. Retropharyngeal abscess, once almost exclusively a disease of children, is observed with increasing frequency in adults. Retropharyngeal abscess poses a diagnostic challenge for the emergency physician because of its infrequent occurrence and variable presentation.

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

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 can be caused by the following organisms:

• Aerobic organisms, such as beta-hemolytic streptococci and Staphylococcus aureus
• Anaerobic organisms, such as species of Bacteroides and Veillonella
• Gram-negative organisms, such as Haemophilus parainfluenzae and Bartonella henselae

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.

Frequency

United States

A review of cases of retropharyngeal abscess over an 11-year period at the Children's Hospital of Michigan revealed a 4.5 times increase in the incidence of retropharyngeal abscess when compared with the previous 12 years.¹

Mortality/Morbidity

Once mediastinitis occurs, mortality approaches 50%, 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.

Overall mortality rate was 1% in a review of deep cervical space infections in Taiwan.²

In a recent 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.³

Race

• In a 10-year review of retropharyngeal abscess cases treated at Kings County Hospital in Brooklyn, New York, 70% of patients were African American, 25% were white, and 5% were Hispanic.
• A recent 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.⁴

Sex

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

• 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.
• A study of adults with deep space infections of the neck in Germany revealed that 56% of patients were male and 44% were female.
• A study of cases in Nigeria found a male-to-female ratio of 1:1.⁵

Age

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

• 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.⁵
• 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.⁶

CLINICAL

Section 3 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
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• Follow-up
• Miscellaneous
• Multimedia
• References

History

History is variable, depending on the age group. Symptoms 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
• • Sore throat (84%)
  • Fever
  • Neck stiffness
  • Odynophagia
  • Cough
• Symptoms in infants
• • Fever (85%)
  • Neck swelling (97%)
  • Poor oral intake (55%)
  • Rhinorrhea (55%)
  • Lethargy (38%)
  • Cough (33%)

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 (37%)
  • Nuchal rigidity
  • Cervical adenopathy
  • Fever
  • Drooling
  • Stridor
• Physical signs in infants and children
• • Cervical adenopathy (83%)
  • Retropharyngeal bulge (43%; do not palpate in children)
  • Fever (86%)
  • Stridor (3%)
  • Torticollis (18%)
  • Neck stiffness (59%)
  • Drooling (22%)
  • Agitation (43%)
  • Neck mass (91%)
  • Lethargy (42%)
  • Respiratory distress (4%)
  • 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, endoscopy, foreign body ingestion, and 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 most common organisms causing retropharyngeal abscesses include aerobes and anaerobes; gram-negative organisms also may be observed. Often, mixed flora are cultured.

• Organisms causing retropharyngeal abscess in adults
• • Beta-hemolytic streptococci
  • Streptococcus viridans
  • S aureus
  • MRSA
  • Klebsiella pneumoniae
  • Bacteroides species
  • Staphylococcus epidermidis
  • Anaerobic streptococci
  • Bartonella henselae
  • Eikenella corrodens
  • Escherichia coli
  • Prevotella species
  • Mycobacterium tuberculosis
• Organisms causing retropharyngeal abscess in children
• • S aureus
  • Haemophilus species
  • Beta-hemolytic streptococcus (Streptococcus pyogenes) - The incidence is increasing (54%) according to recent review of cases at the Children's Hospital of Michigan.¹
  • Bacteroides species
  • Peptostreptococcus species
  • Fusobacterium species
  • Prevotella species
  • Staphylococcus coagulase negative
  • Brucella species

DIFFERENTIALS

Section 4 of 11  

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• Miscellaneous
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Other Problems to be Considered

Airway obstruction (In a study in Germany, 20 of 234 patients with deep space infections of the neck had airway compromise requiring tracheostomy.³), sepsis, pneumonia, mediastinitis, epidural abscess.
A case report of a 4-year old with compression of his internal carotid artery and internal jugular vein by a retropharyngeal abscess was documented.

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

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

Imaging Studies

• 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. Most authors define retropharyngeal soft tissue swelling as more than 7 mm at C2 and more than 22 mm at C6; thus, lateral neck radiographs may be considerably less sensitive for detecting retropharyngeal abscess than this study indicates.
  • Generally, the anteroposterior diameter of the prevertebral soft tissue space in children should not exceed that of the contiguous vertebral bodies.
  • 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.
• 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.
• A chest radiograph is indicated to look for aspiration pneumonia and mediastinitis.
• An MRI with gadolinium enhancement may demonstrate a retropharyngeal abscess, but this modality has not been used widely.
• Ultrasonography may demonstrate the presence of a retropharyngeal abscess, but its use has not yet been clarified.

Procedures

• 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 2 adults; no reports of its use in children exist.
• 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.
  • Prophylactic intubation for a patient with retropharyngeal abscess but without respiratory distress generally is not indicated unless an interhospital transfer is planned.
• If a patient with signs of upper airway obstruction cannot be intubated, a surgical or needle cricothyrotomy may be required.
• A tracheostomy may be required as definitive airway management in patients with retropharyngeal abscess and respiratory distress.

TREATMENT

Section 6 of 11  

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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.
• 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. 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. Tracheostomy may be required for definitive airway management.
• Intravenous fluids are required if the patient is dehydrated because of fever and difficulty swallowing.

Consultations

An emergent consultation with an ENT specialist is necessary.

• Consult an ENT specialist as soon as the diagnosis of retropharyngeal abscess is established or as soon as the diagnosis is suspected 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.
• 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.⁷
• An ENT specialist also may perform a tracheostomy.

MEDICATION

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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.

Drug Category: Antibiotics

Gram-positive organisms (including beta-lactamase producing), gram-negative organisms, and anaerobes must be covered. The list of antibiotic regimens in the table below is from The Sanford Guide to Antimicrobial Therapy 2007.⁸

Some recommend the following regimens, which were not mentioned in The Sanford Guide to Antimicrobial Therapy: penicillin and oxacillin, second- or third-generation cephalosporin and clindamycin, penicillinase-resistant penicillin combined with either clindamycin or metronidazole, or third-generation cephalosporin in combination with clindamycin, nafcillin, or both (triple therapy).

Drug Name	Penicillin G (Pfizerpen) and metronidazole (Flagyl)
Description	Second DOC, penicillin G interferes with the synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. Metronidazole is active against various anaerobic bacteria and protozoa. Cells of microorganisms that contain nitroreductase absorb metronidazole. Unstable intermediate compounds are then formed that bind DNA and inhibit synthesis, causing cell death.
Adult Dose	24 million U/d IV by continuous infusion or divided q4-6h, plus metronidazole 1 g IV loading dose, followed by metronidazole 500 mg IV q6h
Pediatric Dose	25,000 U/kg IV q6h, plus metronidazole 30 mg/kg/d IV divided q8h
Contraindications	Documented hypersensitivity
Interactions	Penicillin G: Probenecid can increase effects; coadministration of tetracyclines can decrease effects Metronidazole: May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Penicillin G: Caution in impaired renal function Metronidazole: Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

Drug Name	Cefoxitin (Mefoxin)
Description	Considered an alternative therapy. A second-generation cephalosporin indicated for the management of infections caused by susceptible gram-positive cocci and gram-negative rods. Many infections caused by gram-negative bacteria resistant to some cephalosporins and penicillins respond to cefoxitin.
Adult Dose	2 g IV q8h
Pediatric Dose	80-160 mg/kg/d IV divided q6h
Contraindications	Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Interactions	Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis

Drug Name	Ticarcillin and clavulanate (Timentin)
Description	Alternative treatment that inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive organisms, most gram-negative organisms, and most anaerobes.
Adult Dose	3.1 g IV q6h
Pediatric Dose	100 mg/kg IV q8h
Contraindications	Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage
Interactions	Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Perform CBCs before initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Drug Name	Piperacillin and tazobactam (Zosyn)
Description	Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits the biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication.
Adult Dose	3.375 g IV q6h or 4.5 g q8h
Pediatric Dose	75 mg/kg IV q6h
Contraindications	Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage
Interactions	Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Perform CBCs before initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Drug Name	Ampicillin and sulbactam (Unasyn)
Description	Drug combination that utilizes a beta-lactamase inhibitor with ampicillin, which covers skin, enteric flora, and anaerobes but is not ideal for nosocomial pathogens.
Adult Dose	3 g IV/IM q6h
Pediatric Dose	25 mg/kg IV/IM q6h
Contraindications	Documented hypersensitivity
Interactions	Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

FOLLOW-UP

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Further Inpatient Care

• Once the diagnosis of retropharyngeal abscess is established, initiate intravenous antibiotics and admit the patient to the hospital.
• If any signs of respiratory distress are present, admit the patient to the intensive care unit.
• 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 (eg, retropharyngeal cellulitis).
• Incision and drainage of retropharyngeal abscess in the ED may lead to aspiration and generally is not recommended.

Transfer

• 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

• Good oral hygiene
• Antibiotic therapy of bacterial oral and pharyngeal infections

Complications

• Airway obstruction
• Mediastinitis
• Pleural involvement
• Atlantooccipital dislocation
• Epidural abscess
• Sepsis
• 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)
• Septic thrombosis of jugular vein or hemorrhage secondary to erosion into carotid artery
• Compression of carotid artery and internal jugular vein
• Facial nerve palsy

Prognosis

• 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 excellent patient education resources, visit eMedicine's Infections Center. Also, see eMedicine's patient education articles Abscess and Antibiotics.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Diagnosis may be overlooked if patients with retropharyngeal abscess are treated for an uncomplicated sore throat and released with or without antibiotics.
• When patients with retropharyngeal abscess must be sent to the radiology department, emergency airway equipment and staff experienced with its use should accompany the patient.
• Incising a retropharyngeal abscess in a child in the ED may lead to aspiration.
• Intubation may be difficult because of swelling of the upper airway. Involve an ENT physician and an anesthesiologist if time permits. If intubating the patient proves difficult, vigorous bagging with high-flow oxygen may help.
• Patients may need to be intubated before transport, depending on their respiratory status.

MULTIMEDIA

Section 10 of 11  

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Media file 1:  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.
	View Full Size Image
Media type:  Radiograph

Media file 2:  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.
	View Full Size Image
Media type:  X-RAY

REFERENCES

Section 11 of 11

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1. Abdel-Haq NM, Harahsheh A, Asmar BL. Retropharyngeal abscess in children: the emerging role of group A beta hemolytic streptococcus. South Med J. Sep 2006;99(9):927-31. [Medline].
2. Wang LF, Kuo WR, Tsai SM, Huang KJ. Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases. Am J Otolaryngol. Mar-Apr 2003;24(2):111-7. [Medline].
3. Ridder GJ, Technau-Ihling K, Sander A, Boedeker CC. Spectrum and management of deep neck space infections: an 8-year experience of 234 cases. Otolaryngol Head Neck Surg. Nov 2005;133(5):709-14. [Medline].
4. Coticchia JM, Getnick GS, Yun RD, Arnold JE. Age-, site-, and time-specific differences in pediatric deep neck abscesses. Arch Otolaryngol Head Neck Surg. Feb 2004;130(2):201-7. [Medline].
5. Nwaorgu OG, Onakoya PA, Fasunla JA, Ibekwe TS. Retropharyngeal abscess: a clinical experience at the University College Hospital Ibadan. Niger J Med. Oct-Dec 2005;14(4):415-8. [Medline].
6. Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics. Jun 2003;111(6 Pt 1):1394-8. [Medline].
7. Oh JH, Kim Y, Kim CH. Parapharyngeal abscess: comprehensive management protocol. ORL J Otorhinolaryngol Relat Spec. 2007;69(1):37-42. [Medline].
8. Sanford JP, Gilbert DN, Moellering RC Jr. Parapharyngeal space infection. In: The Sanford Guide to Antimicrobial Therapy. 37^th ed. 2007.
9. Agada FO, Sharma R, Makura ZG. Atypical presentation of cutaneous tuberculosis and a retropharyngeal neck abscess. Ear Nose Throat J. Jan 2006;85(1):60-2. [Medline].
10. Bank DE, Krug SE. New approaches to upper airway disease. Emerg Med Clin North Am. May 1995;13(2):473-87. [Medline].
11. Beasley DJ, Amedee RG. Deep neck space infections. J La State Med Soc. May 1995;147(5):181-4. [Medline].
12. Daya H, Lo S, Papsin BC, Zachariasova A, Murray H, Pirie J, et al. Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int J Pediatr Otorhinolaryngol. Jan 2005;69(1):81-6. [Medline].
13. Elliott M, Yong S, Beckenham T. Carotid artery occlusion in association with a retropharyngeal abscess. Int J Pediatr Otorhinolaryngol. Feb 2006;70(2):359-63. [Medline].
14. Fogeltanz KA, Pursel KJ. Retropharyngeal abscess presenting as benign neck pain. Journal of Manipulative & Physiological Therapeutics. February 2006;29:174-8. [Medline].
15. Gaglani MJ, Edwards MS. Clinical indicators of childhood retropharyngeal abscess. Am J Emerg Med. May 1995;13(3):333-6. [Medline].
16. Har-El G, Aroesty JH, Shaha A, Lucente FE. Changing trends in deep neck abscess. A retrospective study of 110 patients. Oral Surg Oral Med Oral Pathol. May 1994;77(5):446-50. [Medline].
17. Hughes J, Martin RJ, Clutterbuck EJ. Retropharyngeal infection with Staphylococcus aureus in a haemodialysis patient. Am J Nephrol. 1993;13(6):435-6. [Medline].
18. Kelly CP, Isaacman DJ. Group B streptococcal retropharyngeal cellulitis in a young infant: a case report and review of the literature. J Emerg Med. Aug 2002;23(2):179-82. [Medline].
19. Lazor JB, Cunningham MJ, Eavey RD, Weber AL. Comparison of computed tomography and surgical findings in deep neck infections. Otolaryngol Head Neck Surg. Dec 1994;111(6):746-50. [Medline].
20. Philpott CM, Selvadurai D, Banerjee AR. Paediatric retropharyngeal abscess. J Laryngol Otol. Dec 2004;118(12):919-26. [Medline].
21. Pontell J, Har-El G, Lucente FE. Retropharyngeal abscess: clinical review. Ear Nose Throat J. Oct 1995;74(10):701-4. [Medline].
22. Pynn BR, Sands T, Pharoah MJ. Odontogenic infections: Part one. Anatomy and radiology. Oral Health. May 1995;85(5):7-10, 13-4, 17-8 passim. [Medline].
23. Sato K, Izumi T, Toshima M, Nagai T, Muroi K, Komatsu N, et al. Retropharyngeal abscess due to methicillin-resistant Staphylococcus aureus in a case of acute myeloid leukemia. Intern Med. Apr 2005;44(4):346-9. [Medline].
24. Schroeder LL, Knapp JF. Recognition and emergency management of infectious causes of upper airway obstruction in children. Semin Respir Infect. Mar 1995;10(1):21-30. [Medline].
25. Sethi DS, Stanley RE. Deep neck abscesses--changing trends. J Laryngol Otol. Feb 1994;108(2):138-43. [Medline].
26. Shefelbine SE, Mancuso AA, Gajewski BJ, Ojiri H, Stringer S, Sedwick JD. Pediatric retropharyngeal lymphadenitis: differentiation from retropharyngeal abscess and treatment implications. Otolaryngol Head Neck Surg. Feb 2007;136(2):182-8. [Medline].
27. Simsek S, Yigitkanli K, Kazanci A, Belen D, Bavbek M. Medically treated paravertebral Brucella abscess presenting with acute torticollis: case report. Surg Neurol. Feb 2007;67(2):207-10. [Medline].
28. Takao M, Ido M, Hamaguchi K, Chikusa H, Namikawa S, Kusagawa M. Descending necrotizing mediastinitis secondary to a retropharyngeal abscess. Eur Respir J. Sep 1994;7(9):1716-8. [Medline].
29. Tannebaum RD. Adult retropharyngeal abscess: a case report and review of the literature. J Emerg Med. Mar-Apr 1996;14(2):147-58. [Medline].
30. Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, Gonzalez-Valdepeña H, Bluestone CD. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg. Mar 1995;112(3):375-82. [Medline].
31. Vural C, Gungor A, Comerci S. Accuracy of computerized tomography in deep neck infections in the pediatric population. Am J Otolaryngol. May-Jun 2003;24(3):143-8. [Medline].
32. Watanabe M, Ohshika Y, Aoki T, Takagi K, Tanaka S, Ogata T. Empyema and mediastinitis complicating retropharyngeal abscess. Thorax. Nov 1994;49(11):1179-80. [Medline].

Article Last Updated: Jan 23, 2008