EM@3AM: Retropharyngeal Abscess

A 3-year-old male is brought in by his mother for severe throat pain and lethargy. She notes that he is playing less, refusing to eat, and preferring to lie supine. Review of systems is remarkable for a recent small fall with his toothbrush in his mouth.

Triage vital signs include BP 91/49, HR 141, T 103.1 temporal, RR 25, SpO2 96% on room air. He appears toxic and is lying supine. The oropharyngeal exam is normal, but the patient has prominent generalized cervical lymphadenopathy, torticollis, and a painful tracheal rock. The patient has no voice changes but does not want to extend his neck. His lungs are clear to auscultation.

What’s the most likely diagnosis?

Answer: Retropharyngeal Abscess^1-12

Epidemiology: 

• Increasing incidence over past 20 years, with 4.10 cases per 100,000 patients under the age of 20 years
• Life-threatening infection between prevertebral fascia and posterior pharyngeal wall which can spread via potential space to mediastinum
• More common in children and younger adults due to larger retropharyngeal lymph nodes which can develop into an abscess
• Often occurs after pharyngitis or posterior pharyngeal trauma (fall with pen or toothbrush), recent ENT procedures
• Can also occur in patients with caustic substance ingestions

Microbiology

• Often polymicrobial, and predominant bacteria include:
  • Streptococcus pyogenes (group A strep), Staphylococcus aureus (MSSA, MRSA)
  • Mouth/respiratory bacteria: Fusobacteria, Prevotella, and Veillonella species
  • Rare gram negatives: Eikenella corrodens, Bartonella henselae, Mycobacterium tuberculosis

Evaluation:

• Patients present with:
  • Fever
  • Respiratory distress
  • Odynophagia
  • Decreased oral intake
  • Cri du canard (duck quack)
  • Voice change
  • Retractions
  • Chest pain if mediastinal spread has occurred
• Presentation is typically slower than epiglottitis
• Perceived neck stiffness in discomfort in extension may mimic meningitis

Examination:

• Prefer to lie supine with neck in extension
• Normal oropharyngeal examination
• Pain with tracheal rock
• Cervical LAD
• Torticollis
• Trismus

Laboratory analysis

• May demonstrate:
  • Leukocytosis
    • 91% of patients demonstrate white blood cell count >12,000
    • Neutrophil to lymphocyte ratio (NLR) >5.4 suggests deep neck space infection as compared to pharyngitis
  • Elevated acute phase reactants
    • C-reactive protein >100 mcg/mL correlated with increased hospitalization duration
  • Dehydration due to odynophagia

Imaging

• Lateral neck radiograph—performed in extension on inspiration to prevent pseudo-enlargement
• Widened prevertebral soft tissue
  • Anteroposterior (AP) diameter of soft tissues along anterior bodies of C1- 4 should be less than 40% of the AP diameter of the vertebral body behind it or C2</= 7mm
• Computed Tomography (CT) with IV contrast of the neck
  • Sensitivity of CT approaches up to 100%
  • Demonstrate phlegmon versus abscess
  • Location for operative planning
    • 21% of patients require second CT to assess progression and aid management

Treatment:

• Position of optimal patient comfort is key
• Airway management may require adjuncts
• Antibiotics:
  • Ampicillin-sulbactam or clindamycin
  • If concerned about MRSA, add vancomycin or linezolid (600 mg IV BID)
• Consider addition of dexamethasone
• Analgesia
• Consult ENT for possible surgical drainage though medical management is becoming more popular
  • Factors suggesting surgical management include abscess with cross-sectional measurement > 2cm² for more than 2 days of symptoms

Pearls

• New data demonstrate decreased rates of drainage when steroids used
• Consider in toxic child preferring to lie flat with normal oropharyngeal exam and painful tracheal rock
• Lateral neck radiographs can be used initially, many patients require neck CT for operative management

Additional FOAM Resources

1. https://coreem.net/core/retropharyngeal-abscess/
2. http://www.emdocs.net/sore-throat-evaluation-management-retropharyngeal-abscess-adult/

References:

1. Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, González-Valdepeña H, Bluestone CD. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg. 1995;112(3):375-382.
2. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol. 2001;110(11):1051-1054.
3. Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics. 2003;111(6 Pt 1):1394-1398. doi:10.1542/peds.111.6.1394
4. Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg. 2008;138(3):300-306. doi:10.1016/j.otohns.2007.11.033
5. Woods CR, Cash ED, Smith AM, et al. Retropharyngeal and Parapharyngeal Abscesses Among Children and Adolescents in the United States: Epidemiology and Management Trends, 2003-2012. J Pediatric Infect Dis Soc. 2016 Sep;5(3):259-68.
6. Goenka PK, Hall M, Shah SS, et al. Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses. Pediatrics. 2021;148(5):e2020037010. doi:10.1542/peds.2020-037010
7. Bolton M, Wang W, Hahn A, Ramilo O, Mejias A, Jaggi P. Predictors for successful treatment of pediatric deep neck infections using antimicrobials alone. Pediatr Infect Dis J.2013;32(9):1034–1036
8. Chen XH, Lin GB, Lin C, et al. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2016;30(17):1388-1393. doi:10.13201/j.issn.1001-1781.2016.17.012
9. Cheng Z, Yu J, Xiao L, Lian Z, Wei Y, Wang J. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2015;50(9):769-772.
10. Caccamese JF Jr, Coletti DP. Deep neck infections: clinical considerations in aggressive disease. Oral Maxillofac Surg Clin North Am. 2008;20(3):367-380. doi:10.1016/j.coms.2008.03.001
11. Baglam T, Binnetoglu A, Yumusakhuylu AC, Gerin F, Demir B, Sari M. Predictive value of the neutrophil-to-lymphocyte ratio in patients with deep neck space infection secondary to acute bacterial tonsillitis. Int J Pediatr Otorhinolaryngol. 2015;79(9):1421-1424. doi:10.1016/j.ijporl.2015.06.016
12. 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. 2003;24(2):111-117. doi:10.1053/ajot.2003.31