Abstract
The patient suffering from retropharyngeal abscess initially presents with sore throat, neck pain, and painful and difficult swallowing. This pain becomes more intense and localized as the abscess increases in size and compresses adjacent structures. Low-grade fever and vague constitutional symptoms, including malaise and anorexia, progress to frank sepsis with a high-grade fever, rigors, and chills. At this point, the mortality rate associated with retropharyngeal abscess rises dramatically, despite treatment with appropriate antibiotics and surgical drainage of the abscess. Because many retropharyngeal abscesses are caused by Staphylococcus aureus, the initial antibiotic regimen should include vancomycin to treat staphylococcal infection. Gram-negative and anaerobic antibiotic coverage should also be started empirically immediately after blood and urine culture samples are taken. Antibiotic therapy can be tailored to the culture and sensitivity reports as they become available.
Keywords
retropharyngeal abscess, sepsis, posterior pharynx, antibiotics, dysphagia, fever, rigors, chills
ICD-10 CODE J39.0
The Clinical Syndrome
Once a disease almost exclusively seen in children, retropharyngeal abscess is occurring more commonly in the adult population. It may occur as a sequela of upper respiratory tract infection, trauma to the posterior pharynx (e.g., difficult endotracheal intubation), or perforation from a foreign body, among other causes ( Fig. 20.1 ). Often misdiagnosed, retropharyngeal abscess can result in life-threatening complications and, if untreated, death. The mortality and morbidity associated with retropharyngeal abscess are primarily the result of airway obstruction, mediastinitis, spread of infection to the epidural space, necrotizing fasciitis, erosion into the carotid artery, and, in immunocompromised patients, overwhelming sepsis. Lying posterior to the pharynx, the retropharyngeal space is bound by the prevertebral fascia posteriorly, the buccopharyngeal fascia anteriorly, and the carotid sheaths laterally ( Fig. 20.2 ). Extending from the base of the skull inferiorly to the mediastinum, the retropharyngeal space is susceptible to infection by aerobic organisms such as Streptococcus, Staphylococcus, and Haemophilus and anaerobic organisms such as Bacteroides. Rarely, fungal and mycobacterial infections of the retropharyngeal space have been reported in immunocompromised patients.
The patient suffering from retropharyngeal abscess initially presents with sore throat, neck pain, and painful and difficult swallowing ( Fig. 20.3 ). This pain becomes more intense and localized as the abscess increases in size and compresses adjacent structures. Low-grade fever and vague constitutional symptoms, including malaise and anorexia, progress to frank sepsis with a high-grade fever, rigors, and chills. At this point, the mortality rate associated with retropharyngeal abscess rises dramatically, despite treatment with appropriate antibiotics and surgical drainage of the abscess.
Signs and Symptoms
The patient with retropharyngeal abscess initially presents with ill-defined pain in the general area of the infection. At this point, the patient may have mild pain on swallowing and range of motion of the cervical spine. The physical examination at this point may reveal posterior pharyngeal swelling. A low-grade fever or night sweats may be present. Theoretically, if the patient has received steroids, these constitutional symptoms may be attenuated, or their onset may be delayed. As the abscess increases in size, the patient appears acutely ill with fever, rigors, and chills. Drooling may be present as the patient finds it increasingly difficult to swallow. Nuchal rigidity and respiratory stridor may also be evident. Spread to the mediastinum and central nervous system is associated with a high mortality rate in spite of aggressive medical and surgical treatment.
Testing
Lateral radiography of the neck reveals widening of the retropharyngeal soft tissues in more than 80% of patients suffering from retropharyngeal abscess; clearly defined soft tissue masses with air-fluid levels suggestive of abscess are seen in less than 10% of patients ( Fig. 20.4 ). In this era of readily available magnetic resonance imaging (MRI) and high-speed computed tomography (CT) scanning, it may be more prudent to obtain this noninvasive testing first, given the highly specific diagnostic information obtained ( Figs. 20.5 and 20.6 ). Both MRI and CT are highly accurate in the diagnosis of retropharyngeal abscess and should be obtained on an urgent basis in all patients suspected of suffering from this condition. Ultrasonography may also be useful in identifying retropharyngeal abscess.
