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Retropharyngeal Abscess

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Retropharyngeal Abscess, Parapharyngeal abscess

  • Definitions
  1. Retropharyngeal Abscess
    1. Purulent collection between pharynx and Cervical Spine
    2. Typically occurs from Trauma or URI spread to retropharyngeal lymph nodes
  2. Parapharyngeal abscess
    1. Purulent collection between pharynx and lateral neck
  • Epidemiology
  1. Disease of infants and young children (age <4-6 years old)
    1. Young children have prominent retropharyngeal lymph nodes
  • Pathophysiology
  1. Retropharyngeal lymph nodes not atrophied in children
  2. Accumulation of pus in retropharyngeal space
  3. Mixed aerobic and anaerobic flora
  • Risk Factors
  1. Children under age 6 years
  2. Upper airway Trauma (see causes below)
  3. Immunocompromised Condition
    1. HIV Infection
    2. Diabetes Mellitus
  • Causes
  • Mechanism
  1. Upper Respiratory Infection (children)
    1. Spreads posteriorly to retropharyngeal lymph nodes
  2. Trauma (adults and children)
    1. Vertebral Fracture
    2. Fish bone ingestion
    3. Upper airway instrumentation (Endotracheal Intubation, Nasogastric Tube placement)
  • Symptoms
  1. Neck Pain (out of proportion to findings)
  2. Dysphagia
  3. Odynophagia
  4. Drooling
  5. Fever
  6. Palliative measures
    1. Patients prefer supine position (less encroachment on airway)
  • Signs
  1. May be difficult to appreciate pharyngeal fullness
  2. Airway compromise may be present
    1. Respiratory distress (e.g. Tachypnea)
    2. Inspiratory Stridor
    3. Muffled voice or hot potato voice
  3. Torticollis
  4. Trismus
  • Differential Diagnosis
  • Imaging
  1. Lateral neck XRay
    1. Bulging of posterior pharyngeal wall
    2. Prevertebral soft tissue width increased
      1. C2 level prevertebral space >7 mm (adults and children)
      2. C6 level prevertebral space >14 mm (children) or >22 mm (adults)
  2. CT Neck
    1. May demonstrate abscess extent
  • Management
  1. Hospitalize
  2. Airway observation
  3. Intravenous Antibiotics
    1. Clindamycin 600-900 mg IV every 8 hours OR
    2. Penicillin G 24 MU every 24 hours AND Metronidazole 1 g IV every 12 hours OR
    3. Piperacillin-Tazobactam (Zosyn) 3.375 g IV every 6 hours OR
    4. Ampicillin-Sulbactam (Unasyn) 3 g IV every 6 hours
  4. Early, emergent ENT Consultation for surgical drainage
    1. Incision and Drainage in operating room
  • Complications
  1. Airway obstruction (most common fatal complication)
  2. Atlantoaxial separation (transverse ligament erosion)
  3. Carotid Artery erosion
  4. Jugular Vein thrombosis
    1. Secondary risk of septic Thrombophlebitis (and Lemierre Syndrome)
  5. Mediastinitis
  6. Meningoencephalitis
  7. Esophageal Perforation
  8. Horner Syndrome
  9. Cranial Nerve palsy (CN 9, CN 10, CN 11, CN 12)
  • References
  1. Aldden and Rosenbaum (2017) Emergency Medicine Board Review, Wolters Kluwer
  2. (2019) Sanford Guide, accessed 6/27/2019