Retropharyngeal Abscess Treatment & Management

Updated: Jan 08, 2021
  • Author: Joseph H Kahn, MD; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
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Approach Considerations

A prospective study in South Korea compared intravenous antibiotics plus surgical drainage with intravenous antibiotics with or without needle drainage. One case of mediastinitis occurred in the nonsurgical group. The authors concluded that, in conjunction with neck CT scanning, selected cases of parapharyngeal abscesses may be treated conservatively without early open surgical drainage. [58]

An 11-year chart review of 162 pediatric patients with retropharyngeal abscess at St. Louis Children's Hospital revealed that 126 of the patients required surgery initially, and, of the 36 patients treated medically initially, 17 required surgery. [17]

Of 24 pediatric RPAs in children treated at Starship Pediatric Hospital in Auckland, Australia, between 1999 and 2005, 10 (41.7%) required surgery, while 14 (58.3%) did not require surgery. [59]

According to a systematic review, medical treatment of pediatric deep neck abscesses may be a safe alternative to surgical drainage of these lesions, but the investigators cautioned that further studies will be needed before a more solid conclusion can be drawn. [60]

A retrospective study by Kosko and Casey suggested that in pediatric patients with a retropharyngeal or parapharyngeal abscess, intravenous antibiotic therapy alone is more likely to fail, and surgery more likely to be required, when the abscess is larger than 2 cm in diameter. [61]

Li and Kiemeney reported an association between abscess size greater than 2.2 cm and the need for surgical intervention. [12]

Vinckenbosch et al reported that surgery is indicated if the abscess size is greater than 2 cm or if there are complications or worsening of symptoms during medical treatment. [33]

Wilkie et al reported that selected pediatric deep neck space infections can be managed medically but that that abscess size greater than 2.5 cm significantly predicts whether surgical intervention is required. [56]


Prehospital Care

See the list below:

  • 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.


Emergency Department Care

ED management of retropharyngeal abscess includes attention to the airway, fluid resuscitation if necessary, antibiotic treatment, and preparation for an emergency operation, if indicated. Frequent vital sign checks and continuous oxygen saturation monitoring are essential.

  • Airway management

    • Apply supplemental oxygen. In young children, this can be completed in a nonthreatening way by letting the parent direct blow-by oxygen at the child's face.

    • Endotracheal intubation may be required if the patient has signs of upper airway obstruction. It may be difficult because of upper airway swelling.

    • Cricothyrotomy (surgical or needle) may be required in the patient with upper airway obstruction who cannot be intubated, but the procedure may be difficult to perform due to tissue edema and distortion.

    • Tracheostomy may be required for definitive airway management, but the procedure may be difficult to perform due to tissue edema and distortion. [9]

    • Airway management in the operating room is preferred, with surgeon and anesthesiologist present, if clinical condition and time allow it. [8]

  • Intravenous fluids are required if the patient is dehydrated because of fever and difficulty swallowing.

  • Antibiotic treatment (see the Medication section)



An emergent consultation with an ENT specialist is necessary. This specialist should be consulted as soon as the diagnosis of retropharyngeal abscess is suspected, especially if the patient is exhibiting signs of upper airway obstruction.

If an abscess is present, an ENT specialist can drain it in the operating room. An ENT specialist may also perform a tracheostomy.