Excerpt from Retropharyngeal Abscess

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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

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