Consider a retropharyngeal abscess when faced with a drooling child who has a severe sore throat, according to Dr. Marisol Figueira of Boston University.
“Retropharyngeal abscess is a commonly seen pathology secondary to acute infection of the throat,” Dr. Figueira said in an interview. “It is a result of suppuration of the retropharyngeal lymph nodes, secondary to infection in the adenoid, nasopharynx, posterior pharyngeal wall, sinuses, and tonsils.”
A high index of suspicion is needed to diagnose retropharyngeal abscess, and the diagnosis is made based on clinical manifestations and radiologic studies.
Prompt diagnosis is important, because treatment delays could lead to life-threatening complications such as a blocked airway, jugular vein thrombosis, or mediastinitis, Dr. Figueira explained in a presentation at a conference on infectious diseases held in Cambridge, Mass.
The retropharyngeal space extends from the base of the skull to the level of the T1 or T2 vertebra, and includes the space behind the muscles of the pharynx but in front of the prevertebral fascia.
An infection in the retropharyngeal space is most common in young children. Data from one 35-year review of cases at a California hospital showed that 50% of patients with a retropharyngeal abscess were younger than 3 years and 71% were younger than 6 years, Dr. Figueira said.
The abscess may follow an upper respiratory infection, group A β-hemolytic streptococcal pharyngitis (GABHS), or even trauma.
The predominant bacterial species are Streptococcus pyogenes, Staphylococcus aureus, and respiratory anaerobes (including Fusobacteria, Prevotella, and Veillonella species). Haemophilus species also are occasionally found.
The clinical presentation can involve a spectrum of common symptoms including fever, severe sore throat, dysphagia, drooling, respiratory distress, and a muffled voice. The classic symptoms of neck stiffness and bulging of the posterior pharyngeal wall are present in fewer than 50% of patients, Dr. Figueira said.
On physical examination, the child can present with anterolateral neck swelling, hyperextension of the neck, or an enlarged cervical lymph node, she explained at the meeting, which was sponsored by the university.
Imaging is needed to confirm a diagnosis of a retropharyngeal abscess. A lateral x-ray of the neck area may show soft tissue swelling, and a CT scan of the neck can be helpful if the x-ray findings are uncertain and the clinical suspicion is high.
Immediate treatment includes airway maintenance, pain management, and hydration before admitting the child to the hospital. Consult an ear, nose, and throat specialist when the diagnosis is confirmed or if the child has an obstructed airway. The treatment plan for a retropharyngeal abscess includes incising and draining the abscess, and treating the child with parenteral antibiotics such as clindamycin or a combination of ampicillin and sulbactam.
“Prompt diagnosis and treatment of pharyngitis or upper respiratory infections will generally prevent retropharyngeal abscess,” Dr. Figueira said. “Also, it is important to know that this condition can lead to laryngeal edema with possible airway obstruction, mediastinitis, and aspiration pneumonia, but with prompt treatment a patient can make a full recovery.”