RETROPHARYNGEAL

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

The retropharyngeal space is posterior to the

pharynx, bound by the buccopharyngeal fascia
anteriorly, the prevertebral fascia posteriorly, and
the carotid sheaths laterally
Abscesses in this space can be caused by the
following organisms:
Aerobic organisms, such as beta-hemolytic

streptococci andStaphylococcus aureus

Anaerobic organisms, such as species

ofBacteroidesandVeillonella

Gram-negative organisms, such asHaemophilus

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

EPIDEMIOLOGY
Retropharyngeal abscess is more common in males than in females, with

generally reported male preponderance of 53-55%.

Initially, retropharyngeal abscess was thought to be a disease limited to

children, but now it is being encountered with increasing frequency in

adults.

HISTORY
History is variable, depending on the age group. Symptoms of

retropharyngeal abscess 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

Symptoms in
infants
Fever (85%)

Sore throat (84%)

Neck swelling (97%)

Fever (64%)[15]

Poor oral intake

Neck stiffness (64%)

[15]

Odynophagia (55%)
[15]

Cough

(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

Physical signs in infants and children

Posterior pharyngeal edema (37%)

Cervical adenopathy (36%)[15]

Nuchal rigidity

Retropharyngeal bulge (55%; do not

palpate in children)[15]

Cervical adenopathy

Fever (64%)[15]

Fever

Torticollis (18%)

Drooling

Neck stiffness (64%)[15]

Stridor

Drooling (22%)

Torticollis[17]

Agitation (43%)

Trismus[17]

Neck mass (55%)[15]

CAUSE
ADULTS

CHILDREN AND INFANTS

Beta-hemolytic streptococci

S aureus[12]

Streptococcus viridans

MRSA[3, 22, 26, 27]

Peptostreptococcusspecies[21]

Haemophilusspecies

Fusobacteriumspecies[21]

Beta-hemolytic streptococcus

S aureus
Methicillin-resistantStaphylococcus

aureus (MRSA)

[22]

(Streptococcus pyogenes)[12
Bacteroidesspecies

Staphylococcuscoagulase negative

Klebsiella pneumoniae

Blood cultures are indicated before administration of intravenous antibiotics, but

culture results may be negative in as many as 82% of retropharyngeal abscess
cases.

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.

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.

Ampicillin and sulbactam (Unasyn)

Clindamycin (Cleocin)
Penicillin G (Pfizerpen-G)
Piperacillin and tazobactam (Zosyn)
Metronidazole (Flagyl, Metro)

 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.

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).

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

COMPLICATION
Airway obstruction
Mediastinitis
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[39]

Compression of carotid artery and internal jugular vein [39]

Facial nerve palsy

H
I
S
A
K
A
M
I
R

E
T

 This drug combination of beta-lactamase inhibitor with ampicillin interferes

with bacterial cell wall synthesis during active replication, causing

bactericidal activity against susceptible organisms. It is an alternative to
amoxicillin in patients who are unable to take medication orally.

Clindamycin is a semisynthetic antibiotic produced by 7(S)-chloro-

substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits

bacterial growth, possibly by blocking dissociation of peptidyl tRNA from
ribosomes, causing RNA-dependent protein synthesis to arrest. Widely
distributes in the body without penetration of CNS. Protein bound and
excreted by the liver and kidneys.

 Second DOC, penicillin G interferes with the synthesis of cell wall

mucopeptide during active multiplication, resulting in bactericidal activity

against susceptible microorganisms.

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits the

biosynthesis of cell wall mucopeptide and is effective during the stage of

active multiplication

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.