AUTHOR AND EDITOR INFORMATION

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• 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

A retropharyngeal abscess is an infection in one of the deep spaces of the neck. An abscess in this location is an immediate life-threatening emergency, with potential for airway compromise and other catastrophic complications. Physicians must be familiar with the diagnosis and treatment of a retropharyngeal abscess.

In order to understand deep space infections, a working knowledge of the anatomy of the various fascial planes in the neck is necessary. Several layers of superficial and deep fascia are found in the neck. While some are tightly adherent to their adjacent structures, potential spaces (ie, soft tissue planed bordered by fascia) separate other layers of fascia. Normally, no actual space exists; however, an infection can create a real space with rapid spread of inflammation and pus in the space between the fascial layers.

The retropharyngeal space is located immediately posterior to the nasopharynx, oropharynx, hypopharynx, larynx, and trachea. The visceral (ie, buccopharyngeal) fascia, which surrounds the pharynx, trachea, esophagus, and thyroid, forms the anterior border of the retropharyngeal space. Bounded posteriorly by the alar fascia, the retropharyngeal space is bounded laterally by the carotid sheaths and parapharyngeal spaces. It extends superiorly to the base of the skull and inferiorly to the mediastinum at the level of the tracheal bifurcation (see anatomy figure in Image 1).

Two other potential spaces (ie, danger space, prevertebral space) also are present. The danger space is formed anteriorly by the alar fascia and posteriorly by the prevertebral fascia. The prevertebral space is bounded anteriorly by the prevertebral fascia and posteriorly by the longus colli muscles of the spine. The danger space extends down the mediastinum to the level of the diaphragm, while the prevertebral space continues to the insertion of the psoas muscles.

Some authors consider the danger space as part of the retropharyngeal space, while others consider the danger space to be part of the prevertebral space. Still other authors refer to all 3 deep potential spaces as the retropharyngeal space.

Pathophysiology

The retropharyngeal space can become infected in 2 ways. Either infection spreads from a contiguous area or the space is inoculated directly secondary to penetrating trauma. Typically, an upper respiratory infection (URI) causes spread to retropharyngeal lymph nodes, which form chains in the retropharyngeal space on either side of the superior constrictor muscle. Sources of infection can include pharyngitis, tonsillitis, adenitis, otitis, sinusitis, and other infections (ie, nasal, salivary, dental). Infectious sources (eg, osteomyelitis of the spine) also can spread anteriorly from the prevertebral space.

Penetrating trauma is involved prominently in retropharyngeal space infection. Accidental lacerations are not uncommon in children who run and fall down after they have placed an object (eg, toy, stick, frozen popsicle, lollipop, toothbrush) in their mouths. Foreign bodies (eg, fishbones) also have been implicated in penetrating trauma to the retropharyngeal space. Iatrogenic causes of inoculation to this space include instrumentation with laryngoscopy, endotracheal intubation, surgery, endoscopy, feeding tube placement, and dental injections and procedures.

Complications of retropharyngeal abscesses are secondary to mass effect, rupture of the abscess, or spread of infection. The most urgent complication involves the abscess expanding against the pharynx or trachea, causing airway compression. Rupture of the abscess can cause aspiration of pus, resulting in asphyxiation or pneumonia. The infection can spread, resulting in inflammation and destruction of adjacent tissues. Spread of the infection to the mediastinum can result in mediastinitis, purulent pericarditis and tamponade, pyopneumothorax, pleuritis, empyema, or bronchial erosion. Spread of the infection laterally can involve the carotid sheath and cause jugular vein thrombosis or carotid artery rupture. Posterior spread of infection can result in osteomyelitis and erosion of the spinal column, causing vertebral subluxation and spinal cord injury. The infection itself can evolve into necrotizing fasciitis, sepsis, and death.

Frequency

United States

Since the advent and widespread use of antibiotics in treatment of URIs, incidence of retropharyngeal abscess has declined considerably, and it is now relatively uncommon.

International

With less access to health care and less availability of antibiotics, deep space infection is a more common complication of URIs in third world nations. Also, Pott disease from tuberculosis is more common in underdeveloped areas of the world. Cold abscesses can form with subsequent spread to the deep spaces of the neck. Consider antimycobacterial therapy for infections that are not responding to conventional therapy.

Mortality/Morbidity

• Airway compromise must be identified and addressed first in patients with retropharyngeal abscess; consider consultation with a surgeon specializing in airway management and treatment in an operating room. The abscess can compress the pharynx or trachea, causing suffocation. The abscess also can rupture, causing asphyxiation or aspiration and pneumonia. Positioning the airway correctly and avoiding unnecessary manipulation is essential. Closely monitor patients with airway compromise and do not allow these patients to leave the acute care area until deemed sufficiently stable. Sedation and paralytics can relax airway muscles, leading to complete obstruction. Endotracheal intubation is dangerous unless performed under direct visualization. If direct visualization is not possible secondary to trismus or anatomic distortion, consider fiberoptic intubation or a surgical airway (eg, cricothyroidotomy, tracheotomy).
• Spread of infection to adjacent structures in the neck can be catastrophic. Carotid artery rupture has a 20-40% mortality rate. Even if the artery is ligated successfully, long-term morbidity secondary to stroke is common. Jugular vein thrombosis had a mortality rate of 60% prior to the use of antibiotics. Identifying this complication is essential. Osteomyelitis and vertebral erosion can cause subluxation and subsequent spinal cord injury. Atlantooccipital separation secondary to erosion of the transverse ligament of the atlas has been reported.These complications are rare in children in the postantibiotic era. Children have a different pathophysiologic disease process than adults. In young children (ie, preschool, elementary), the abscess starts from a suppurative node that ruptures or a ruptured node. In older children and adults, the disease spreads directly into the fascial planes and is a more deadly disease that must receive immediate surgical treatment.
• Spread of infection into the chest has significant complications. Mediastinitis has a 40-50% mortality rate secondary to sepsis. Acute necrotizing mediastinitis and purulent pericarditis with tamponade also can be fatal. Mediastinal abscess, bronchial erosion, pyopneumothorax, pleuritis, and empyema have significant morbidity and mortality.

Race

No racial predilection has been described in the literature.

Sex

Although no sex predilection has been described in the literature, several studies have noted a higher incidence of deep neck infections in boys.

Age

Retropharyngeal abscess is almost exclusively a pediatric diagnosis. Most incidents occur in children aged 6 months to 6 years, with a mean age of 3-4 years. Other deep neck abscesses (eg, parapharyngeal, peritonsillar) are observed more frequently in adults and older children.

In children, retropharyngeal abscess usually is caused by an infection that spreads to the retropharyngeal lymph nodes, with subsequent cellulitis and abscess formation. Due to repeated infection throughout childhood, fibrosis and atrophy start in these nodes when the individual is aged 4 years. By the time the child is aged 6 years, fibrosis and atrophy have regressed completely.

In older patients, infection of the retropharyngeal space usually occurs from penetrating trauma or direct spread from an adjacent space.

CLINICAL

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History

• Patients with retropharyngeal abscess present with constitutional complaints such as fever, chills, malaise, decreased appetite, and irritability.
• Patients may complain of sore throat, difficulty swallowing (dysphagia), pain on swallowing (odynophagia), jaw stiffness (trismus), or neck stiffness (torticollis).
• Patients also may complain of muffled voice, the sensation of a lump in the throat, and/or pain in the back and shoulders upon swallowing.
• Difficulty breathing is an ominous complaint that signifies impending airway obstruction.
• Patient history is not always straightforward. One study identified the following symptoms in patients: fever (74%); sore throat (47%); dysphagia (38%); trismus (36%); decreased appetite (22%); voice change (18%); odynophagia (17%); neck pain (15%); irritability (11%); and difficulty breathing (8%).
• The course of pharyngeal abscess can be insidious.
• • Sometimes a URI can precede symptoms by weeks.
  • Many patients do not recall (or parents are not aware of) incidences of penetrating trauma.
  • Maintain a high index of suspicion, especially in patients with URIs that do not appear to resolve in a normal course or with conventional therapy.

Physical

• Most patients with retropharyngeal abscess are febrile. Some appear toxic and irritable.
• Cervical lymphadenopathy, usually unilateral, is the most common physical finding in these patients.
• Patients may have decreased or painful range of motion of their necks or jaws.
• A neck mass or tenderness may be appreciated.
• These patients may present with a muffled "hot potato" voice (ie, dysphonia) or with a voice that sounds like a duck quack (ie, cri du canard).
• Upon inspection of the oral cavity (usually with a tongue blade), the physician may be able to appreciate a mass in the posterior pharyngeal wall.
• • As many as 30% of patients have this mass, according to 1 study.
  • This is not midline, due to the presence of the raphe in the retropharyngeal space caused by the superior constrictor muscle; midline masses are usually in the prevertebral space.
  • While this mass has been described as fluctuant to palpation, deferring this part of the examination probably is best; at least use extreme caution, especially in a combative child. This maneuver has led to abscess rupture and subsequent aspiration.
  • "Tracheal rock sign" elicits pain while gently moving the larynx and trachea from side to side.
• Patients in respiratory distress or those who present with stridor or drooling have potential airway compromise.
• • These patients prefer to lie supine with their necks extended, maximizing their airway patency.
  • Sitting up or flexing their necks worsens their respiratory distress.
• Address vascular complications in the physical examination.
• • Jugular vein thrombophlebitis may manifest as tender induration at the anterior sternocleidomastoid border, vocal cord paralysis, or sepsis of an unknown source.
  • Carotid artery rupture can be heralded by sentinel bleeding from the ear, nose, or mouth.
  • Ecchymosis may be detected in the lateral neck.

Causes

• Most retropharyngeal space infections are spread from various sources in the upper respiratory tract to the retropharyngeal lymph nodes. The lymphadenitis can form a cellulitis, which then can become an abscess.
• • Possible predisposing infections can include pharyngitis, tonsillitis, otitis, adenitis, sinusitis, and nasal, salivary, and dental infections.
  • Retropharyngeal infections also are spread from contiguous spaces, such as the parapharyngeal space (eg, abscesses), submandibular space (eg, Ludwig angina), or prevertebral space (eg, osteomyelitis, diskitis).
• The retropharyngeal space also can be inoculated directly secondary to penetrating trauma.
• • Children like to run, and they fall down frequently. Running and falling down after putting something in their mouths (eg, toy, stick, popsicle, lollipop, toothbrush) is not unusual in children. Because parents may be unaware of these predisposing events, diagnosis is even more elusive.
  • Foreign bodies (eg, sharp fishbones) can become lodged in the posterior pharynx. While this can happen in the pediatric age group, a foreign body lodged in the posterior pharynx is the most common cause of abscess formation in adults.
• Deep space infections can be iatrogenic secondary to instrumentation of the upper respiratory tract. All of the following can predispose to abscess formation:
• • Laryngoscopy
  • Endoscopy
  • Feeding tube insertion
  • Endotracheal intubation
  • Head and neck surgery
  • Dental procedures
  • Injections
• Patients with diabetes or those who are debilitated, elderly, or immunocompromised are more likely to get infections.
• Bacteria are often polymicrobial, with gram-positive organisms and anaerobes predominating, but gram-negative bacteria also have been isolated. The source is usually oropharyngeal flora.
• • The most common cause is group A beta-hemolytic streptococci. Other nonhemolytic streptococci can be present. Staphylococcus aureus is also fairly common, especially secondary to osteomyelitis. The most common anaerobes are Bacteroides species.
  • Other causative agents include Haemophilus parainfluenzae and Veillonella, Peptostreptococcus, Fusobacterium, and Eikenella species.
  • The incidence of beta-lactamase production is high. One study noted 22% beta-lactam resistance.
  • Suspect mycobacterium tuberculosis and coccidiosis in patients who may be predisposed, especially if they are not responding to more conventional therapy.

DIFFERENTIALS

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Other Problems to be Considered

Branchial cleft cyst
Thyroglossal duct cyst
Retropharyngeal thyroid tissue
Retropharyngeal tumor
Aneurysm
Hematoma
Tendonitis of longus colli muscle
Superficial abscess
Ludwig angina
Other deep neck space infections
Epstein-Barr virus infection

WORKUP

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Lab Studies

• Lab findings are nonspecific.
• • WBC counts can be elevated, with a mean level of 17,000.
  • One study recorded ranges of 4,000-45,000.
• Send any aspirated or drained pus to the lab for culture and sensitivity. A Gram stain can help direct early empiric antibiotic therapy.
• If an incision and drainage is performed, sending a piece of the abscess wall to pathology helps increase the yield of culture and sensitivity testing.

Imaging Studies

• A lateral soft tissue neck x-ray is helpful in making the diagnosis of a retropharyngeal abscess. Obtain the film during inspiration with the neck held in normal extension.
• • An abscess occupies the soft tissue space, which can be observed between the radiolucent airway (ie, pharynx, trachea) and the spine.
  • Widening of these soft tissues is pathologic until proven otherwise. Measuring at the level of C2, the distance from the anterior surface of the vertebrae to the posterior border of the airway should be 7 mm or less, regardless of the patient's age. At C6, this distance should be 14 mm or less in children younger than 15 years. A distance of 22 mm is considered normal in an adult. A simpler (but less precise) rule is that the soft tissue plain should be less than one half the width of the corresponding vertebral body.
  • A plain film also may demonstrate gas or a foreign body (eg, fishbone) in the retropharyngeal space. The normal spinal lordosis may be reversed. With a child's head extended, the width of the soft tissue is no more than a vertebral body width in an average child. Obtaining the film with the head extended is important.
  • Lateral plain film is not very sensitive or specific. One study demonstrated a 33% false-negative rate. False-positive rates are also high. Poor neck extension or an expiratory view can produce a false-positive result. A few authors have suggested that plain films are an unnecessary diagnostic step.
  • Please see x-ray studies in Image 2.
• A plain film of the chest is necessary to exclude mediastinal or pulmonary complications.
• CT scanning is currently the imaging modality of choice. Obtain a study with intravenous contrast to help demarcate the lesion and determine if vascular involvement is present. Inform the radiologist of the purpose of the study in advance, because a standard CT scan of the neck may not use thin enough slices (3-5 mm) and may not scan through the entire extent of the retropharyngeal space (the base of the skull to T2).
• • An abscess is found in the deep spaces of the neck. It is an area of low attenuation, surrounded by an enhanced ring. Gas sometimes is present within the abscess cavity. The nearby soft tissue is edematous, and fat planes may be obliterated. Neighboring structures, including the airway, can be compressed.
  • A CT scan can be used to determine the presence of an abscess and help distinguish it from cellulitis (an abscess has a central area of lucency). The study also can assist in determining the location of the abscess, extent of abscess spread, and presence of any complications.
  • CT scan provides much information not readily determined by plain film. Depending on the study, CT scan can be more than 90% sensitive. The false-positive rate (11-25%) is better than that of x-ray. The false-negative rate is 10-15%. Overall accuracy is 75% in most large studies (ie, those with >30 subjects).
  • The disadvantage of CT scan is that it is not located in a monitored setting. Ensure that patients with impending airway compromise are stabilized prior to leaving the acute care area. A portable plain film may have to suffice. Also, younger children may not tolerate a CT scan without sedation. Such medications can cause airway muscle relaxation with ensuing occlusion.
  • Please see the CT scans in Image 3.
• MRI produces images superior to the other studies, but this is usually unnecessary and rarely used, unless a concern is present that the abscess has spread to the CNS. Additionally, this study requires a protracted period of time when the patient is in an unmonitored setting. Children usually require sedation for this test, which is also dangerous in any patient with a potentially unstable airway.
• Ultrasound is an imaging modality that is gaining popularity. It is safer than CT scan, since it is portable and does not use radiation. Ultrasound is also less traumatic to children, requiring less frequent use of sedation. In experienced hands, ultrasound can help determine the presence and location of an abscess and can allow the clinician to distinguish an abscess from cellulitis with some accuracy. Further studies are needed to explore the practical use of ultrasound.

Procedures

• Needle aspiration of a suspected abscess can be performed.
• • Aspiration can help determine the presence of an abscess and help distinguish it from cellulitis. It can be diagnostic and therapeutic.
  • An intraoral route usually is indicated, except when an abscess is isolated lateral to the carotid sheath. In this case, an external approach can be used. CT scan or ultrasound can help guide the aspiration. With an abscess involving multiple spaces, perform needle aspiration with an open external approach.
  • Only a qualified surgeon should perform this procedure. Needle aspiration never should be performed outside the operating room suite. Definitive airway management must be imminently available throughout the procedure.

Histologic Findings

A Gram stain of drained pus can be used to help determine the predominance of organisms. However, finding a polymicrobial infection, with gram-positive, gram-negative, and anaerobic cocci and rods, is not unusual.

TREATMENT

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Medical Care

• Determining airway stability remains a top priority. Allow patients to remain in a position of comfort, which is usually supine with their necks extended. Neck flexion or forcing a child to sit up can occlude the airway.
• • Sometimes positioning is all that is necessary to maintain airway patency. Administer supplemental oxygen as needed. Provide a definitive airway only under direct visualization. If this is not possible due to trismus or distorted anatomy, abort the attempt. Excessive manipulation or blind oral or nasotracheal intubation can cause abscess rupture with catastrophic consequences. Consider either fiberoptic intubation or a surgical airway.
  • Only a physician experienced in difficult airway management should attempt a definitive procedure. Remember that sedatives and paralytics can cause relaxation of airway muscles with subsequent complete occlusion.
• After obtaining a CBC and blood cultures, initiate empiric antibiotic therapy without delay.
• • Broad-spectrum coverage is indicated. Clindamycin is first-line treatment. Given the increasing frequency of resistant bacteria, treatment may be initiated alone or in combination with cefoxitin or a beta-lactamase–resistant penicillin, such as ticarcillin/clavulanate, piperacillin/tazobactam, or ampicillin/sulbactam.
  • Patients with cellulitis can be treated with parenteral antibiotics alone. Closely observe these patients for development of an abscess. Some authors advocate the use of antibiotics alone for small abscesses. These patients need to be monitored closely for improvement. A CT scan may be helpful in distinguishing cellulitis from an early abscess.

Surgical Care

• Surgical airway control may be necessary in patients whose airways are difficult to visualize or are obstructed completely. Depending on the age of the patient and the experience of the physician, perform needle cricothyroidostomy or cricothyroidotomy only if the child cannot be transported to the operating room safely or quickly enough to secure the airway there. Alternatively, a qualified surgeon can perform a tracheotomy.
• Needle aspiration of an abscess can be performed both to assist in diagnosis and to treat an abscess. This only should be performed by a qualified surgeon in the operating suite. Definitive airway management should be immediately available.
• • A small retropharyngeal abscess can be aspirated with an 18-gauge needle by the intraoral route.
  • Larger abscesses require incision and drainage using either an intraoral or transcervical approach or both, depending on the location of the carotid sheath in relationship to the abscess.
  • Completely evacuate pus from the abscess. Send a specimen to the lab for Gram stain, culture, and sensitivity.
  • Abscesses in the parapharyngeal space isolated lateral to the carotid sheath can be aspirated by an external approach.
  • CT scan or ultrasound may be used to help guide the aspiration.
  • The patient should remain intubated. Place the patient in an ICU setting for several days postoperatively to stabilize the airway.
• Abscesses with extensive spread or those involving multiple deep spaces must be incised and drained via an external approach and transoral approach as necessary.
• • Make an incision along the anterior border of the sternocleidomastoid. Retract the carotid sheath and open and evacuate the deep spaces. Send a specimen of the abscess wall, along with some pus, to pathology for culture and sensitivity.
  • If mediastinal involvement is present, an open incision and drainage of the neck can be extended down to the level of T4. Alternatively, the surgeon can perform a thoracotomy.
• Empyema and pyopneumothorax may require multiple chest tubes. Carotid artery rupture most likely requires ligation.

Consultations

Consultations with the appropriate specialists are mandatory and should take place on an emergent basis. Pursue early surgical consultation with a specialist in otolaryngology or oromaxillofacial or pediatric surgery. Inform a pediatric anesthesiologist about the patient as well. Radiology consultation may be necessary to order or interpret imaging studies.

Diet

Initially prohibit patients with retropharyngeal abscess from taking anything by mouth (NPO).

Activity

For patients with retropharyngeal abscess, advise bed rest to avoid compromise of their airways during activity. Allow patients to remain supine for optimal airway positioning.

MEDICATION

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Initiate empiric parenteral antibiotic therapy early. Provide broad-spectrum coverage for gram-positive and gram-negative aerobes and anaerobes. Although penicillin G and metronidazole once were considered the mainstays of therapy, the increasing presence of beta-lactamase–producing bacteria has forced current practice away from this combination. Now clindamycin is considered first-line treatment. Treatment may be initiated alone or in combination with cefoxitin or a beta-lactamase–resistant combination penicillin (eg, ticarcillin/clavulanate, piperacillin/tazobactam, ampicillin/sulbactam).

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

FOLLOW-UP

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Further Inpatient Care

• Admit patients with retropharyngeal abscess to a monitored setting or send them directly to the operating room.

Further Outpatient Care

• Do not discharge patients until resolution of the infection has been confirmed.

In/Out Patient Meds

• Administer parenteral antibiotics until the infection has resolved.

Transfer

• Transfer patient if facility does not have the capability or personnel required to adequately drain the infection. This should take place only after the airway has been secured or deemed stable enough for transport.

Deterrence/Prevention

• Regardless of antibiotic therapy, monitor patients diagnosed with URIs. If a patient's symptoms do not resolve or if symptoms worsen in an appropriate amount of time, suspect infection of the deep spaces of the neck.

Complications

• Complications of retropharyngeal abscess occur from mass effect, rupture, or spread.
• The mass of the abscess in the retropharyngeal space can compress the airway, which lies immediately anterior to it. Because this is the most immediately life-threatening complication of retropharyngeal abscess, address this complication first. Secure the airways of patients in respiratory distress, or in those with stridor or drooling.
• • Attempt airway stabilization by repositioning the neck and head.
  • If repositioning the neck and head is not successful, provide definitive airway control, which can be accomplished by endotracheal intubation (under direct visualization), fiberoptic intubation, needle cricothyroidostomy, cricothyroidotomy, or surgical tracheotomy.
• Abscess rupture can lead to asphyxiation or aspiration pneumonia. The abscess can rupture spontaneously, or it can be ruptured iatrogenically during vigorous physical examination or attempted intubation. Obtain a chest x-ray to assess for pneumonia. Abscess rupture requires aggressive airway management, including suctioning and broad-spectrum antimicrobial therapy.
• Infection can spread either laterally or posteriorly to adjacent structures in the neck, or it can progress inferiorly to the mediastinum.
• • Infection can spread laterally to the carotid sheath, where it can cause vascular complications. Jugular vein thrombosis manifests as tenderness over the anterior border of the sternocleidomastoid, vocal cord paralysis, or sepsis without an obvious source. Aggressive antimicrobial therapy is indicated. Carotid artery rupture, which presents as ecchymosis in the neck, usually is heralded by a sentinel bleed from the nose, mouth, or ear. Immediate surgical repair usually requires ligation, which can lead to stroke.
  • Infection also can spread posteriorly, affecting the cervical spine. Osteomyelitis requires long-term antibiotics. Erosion of the ligaments can cause subluxation and subsequent spinal cord injuries. Destruction of the transverse ligament of the atlas has been known to cause atlantooccipital dislocation.
  • Inferior spread of infection can cause several life-threatening complications. A chest x-ray is indicated in the initial workup. Inflammation in the mediastinum can cause mediastinitis, purulent pericarditis, pericardial tamponade, bronchial erosion, and mediastinal abscess. Spread to the adjacent pleura can cause pleuritis, pyopneumothorax, or empyema. In addition to antibiotics, drainage of pus via pericardiocentesis, pericardial window, chest tube thoracostomy, or open thoracotomy may be necessary.
  • The infection also can evolve into overwhelming sepsis or necrotizing fasciitis in the neck or mediastinum.

Patient Education

• Advise a follow-up appointment for parents and/or caregivers of children diagnosed with URIs. Advise these parents and/or caregivers to return immediately if the patient develops clinical manifestations of deep space infection, such as difficulty swallowing, swelling in the back of throat or neck, muffled voice, jaw or neck stiffness, or worsening of symptoms (or if symptoms do not resolve after a reasonable course of time). Advise parents to remain especially alert for signs of airway compromise, such as shortness of breath, drooling, or noisy breathing.
• 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

• Failure to diagnose and aggressively treat a retropharyngeal abscess or its complications in a patient with a refractory or complex URI can lead to airway compromise and other catastrophic morbidity and mortality.

MULTIMEDIA

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Media file 1:  A schematic of the anatomy of the deep spaces of the neck, as illustrated in lateral and cross-sectional views. The fascial planes, defined by the color key, surround the potential spaces.The retropharyngeal space is bounded anteriorly by the buccal pharyngeal fascia, which invests the pharynx, trachea, esophagus, and thyroid. The retropharyngeal space is bounded posteriorly by the alar fascia and laterally by the carotid sheaths and parapharyngeal spaces. It extends from the base of the skull to the mediastinum at the level of the tracheal bifurcation.Note the danger space located between the alar fascia and the prevertebral fascia. This space sometimes is considered part of either the retropharyngeal space or the prevertebral space.
	View Full Size Image
Media type:  Image

Media file 2:  Plain film soft tissue views of the lateral neck. The top x-ray exhibits an obvious widening of the soft tissues, with anterior displacement of the airway. The soft tissues are measured from the anterior border of the cervical vertebrae to the posterior border of the radiolucent airway. Soft tissues are considered widened if they are measured greater than 7 mm at the level of C2 or greater than 14 mm at the level of C6 (22 mm in adults). Careful study of the top film reveals gas in the soft tissue. The bottom x-ray is much more subtle. The soft tissue is widened at the level of C2. An easier (but less precise) way to remember soft tissue widths is that they should be less than one half the width of the corresponding vertebral body.
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Media type:  X-RAY

Media file 3:  The 2 CT scan images performed with IV contrast. Note the abscess on the patient's left side. It is an area of hypoattenuation surrounded by ring enhancement, tissue edema, and compressed neighboring structures. Retropharyngeal abscesses usually appear off-center due to the presence of the midline raphe formed by the superior constrictor muscle. Midline abscesses are usually in the prevertebral space.
	View Full Size Image
Media type:  CT

REFERENCES

Section 11 of 11

• Authors and Editors
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• Choi SS, Vezina LG, Grundfast KM. Relative incidence and alternative approaches for surgical drainage of different types of deep neck abscesses in children. Arch Otolaryngol Head Neck Surg. Dec 1997;123(12):1271-5. [Medline].
• Marra S, Hotaling AJ. Deep neck infections. Am J Otolaryngol. Sep-Oct 1996;17(5):287-98. [Medline].
• Nicklaus PJ, Kelley PE. Management of deep neck infection. Pediatr Clin North Am. Dec 1996;43(6):1277-96. [Medline].
• Ungkanont K, Yellon RF, Weissman JL, et al. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg. Mar 1995;112(3):375-82. [Medline].

Article Last Updated: Mar 28, 2006