RETROPHARYNGEAL ABSCESS lymphadenopathies, torticollis, “hot potato” or muffled voice, chest pain due to

CC DOMINIQUE ISHMAIELLE S. HIBIONADA mediastinal extension, and respiratory distress indicated by stridor, tachypnea, and/or
retractions. In infants, they may also present with lethargy, cough, poor intake,
I. Definition rhinorrhea, and agitation. Typically, patients with RPA are febrile and ill-appearing.
An abscess is defined to be a collection of pus that has built up within the tissues of the
body. The retropharyngeal space (RPS) is a potential space and a deep compartment of V. Diagnosis and Evaluation
the head and neck located posterior to the pharynx. Thus, a retropharyngeal abscess Aside from watching out for red flags in the clinical presentation of a patient with RPA,
(RPA) is a collection of pus in the back of the throat behind the posterior pharyngeal wall, other laboratory methods of evaluation including complete blood count, blood cultures,
specifically between the buccopharyngeal and alar fascia. RPA is one of the most and preoperative labs, are necessary if a RPA is suspected. These microbiological studies
dangerous deep neck infections since it can lead to life-threatening emergencies such as may also help direct therapy for the causative pathogen. Imaging is required for
airway obstruction or sepsis. diagnostic confirmation. In the initial evaluation of a suspected RPA, lateral neck
radiographs are often the imaging study of choice, particularly in young children. Lateral
neck radiographs provide less radiation dose and are better tolerated by individuals who
have symptoms of airway compromise. During inspiration, lateral neck x-rays should be
acquired with the neck held in normal extension. Improper imaging procedures can
result in false positives for retropharyngeal infection. In healthy individuals, the upper
limit of normal prevertebral space is 7 mm at C2 and 14 mm at C6 in children. A width of
30 mm at C6 indicates abscess collection. The use of ultrasound in children may also be
used, as in experienced hands, ultrasound can help determine the size and location of
Figure 1. Anatomical illustration of location of RPAs the abscess and does not involve any radiation. However, the most definitive imaging
modality for evaluating patients with a retropharyngeal abscess is a CT of the neck with
intravenous contrast. Findings include hypodense fluid collection with ring enhancement
in the retropharyngeal space, posterior pharynx wall with anterior displacement. The
use of CT of the neck with contrast may detect spread of infection to other spaces and
the presence of foreign bodies and is able to differentiate between cellulitis and abscess.
In cases where there is contraindications to CT, MRI is another modality that can be used.
The findings are similar to CT with improved detection of soft tissues changes, such as
necrosis, and complications, such as extension of abscess to the prevertebral space.

VI. Management
Patients presenting airway compromise should have immediate surgical incision and
drainage performed to relieve their upper airway obstruction. In patients not presenting
with severe respiratory distress or airway compromise, management typically begins
with a 24 to 48 hour trial of intravenous broad-spectrum empiric antibiotic therapy.
Figure 2. Comparison of Normal Anatomy and RPA Initial antibiotic therapy should include either ampicillin-sulbactam (50 mg/kg every 6
hours) or clindamycin (15 mg/kg every 8 hours). If patients appear septic or do not
II. Epidemiology respond to initial antibiotic therapy, vancomycin or linezolid also should be administered.
Uncommon as they are, RPAs typically occur in children between the ages of two and Parenteral antibiotics should be continued until patients are clinically improved and
four years but can occur at any age. It has a male preponderance. afebrile for 24 hours. After 24 to 48 hours of antibiotic therapy, the need for surgical
incision and drainage will be reevaluated by a trained ENT-HNS specialist. After surgery,
III. Pathophysiology and Etiology patients should be kept NPO until all signs of the abscess have subsided. Close
monitoring of the patient is required initially for airway monitoring. After patients
demonstrate clinical improvement and remain afebrile, they may be transitioned to oral
antibiotics. Amoxicillin-clavulanate (45 mg/kg every 12 hours) or clindamycin (13 mg/kg
every 8 hours) are acceptable oral regimens.

VII. Complications and Prevention

The most immediate complication is the possibility of airway obstruction. Other
complications include bronchial erosion, mediastinitis, sepsis, acute respiratory distress
syndrome, cranial nerve palsies, esophageal perforation, erosion into carotid artery or
jugular vein, or meningoencephalitis. In order to prevent the formation of RPAs, there
should be maintenance of good oral hygiene as well as regular visits to the dentist.

VIII. References:
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