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:
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Supplemental oxygen and attention to upper airway patency are the essential components of prehospital care in patients with suspected retropharyngeal abscess.
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If a child exhibits respiratory distress, the sniffing position may be beneficial.
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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.
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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]
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Intravenous fluids are required if the patient is dehydrated because of fever and difficulty swallowing.
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Antibiotic treatment (see the Medication section)
Consultations
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.
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A 5-year-old boy presented to the ED with 2 days of neck pain and fever but with no sore throat. The child had vomited once, and the mother reported that he was irritable. The child's temperature was 101.7° F, pulse was 118 beats per minute, respirations were 24 per minute, and blood pressure was 122/65 mm Hg. A decreased range of motion of the neck and a right anterior cervical node were observed; the child refused to swallow. Lateral neck radiographic findings show increased retropharyngeal space (white arrow). The CT scan did not demonstrate an abscess. The child was seen by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved for 2-3 days and then worsened. Repeat neck CT scan findings demonstrated a retropharyngeal abscess. Incision and drainage was performed in the operating room. Cultures of the pus grew group A beta-hemolytic streptococci and alpha-streptococci, both sensitive to clindamycin. He improved and was discharged on the tenth hospital day on oral clindamycin.
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An 8-month-old infant boy presented with fever and a stiff neck. According to the mother, the baby was not moving his neck as much as usual. The mother also reported decreased oral intake. His temperature was 100° F, pulse was 104 beats per minute, respirations were 48 per minute, oxygen saturation was 98% (room air [RA]). The left tympanic membrane (TM) was inflamed and nonmobile. Left submandibular and left postauricular nodes were noted. The lateral neck radiograph shows increased retropharyngeal space. The CT scan demonstrated a small retropharyngeal abscess. The WBC count was 26,000 (24 polymorphonuclear leukocytes [P], 5 bands [B], 63 lymphocytes [L], 8 monocytes [M]). The baby was examined by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved over the next few days and was discharged on the fifth hospital day on oral clindamycin with a plan for repeat CT scans of the neck on an outpatient basis.
