Retropharyngeal abscess: Difference between revisions
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==Background== | ==Background== | ||
*Polymicrobial abscess in space between posterior pharyngeal wall and prevertebral fascia | *Polymicrobial [[abscess]] in space between posterior pharyngeal wall and prevertebral fascia | ||
*Adults: Due to direct extension of purulent debris from adjacent site (e.g. Ludwig angina) | *Adults: Due to direct extension of purulent debris from adjacent site (e.g. [[Ludwig's angina]]) | ||
**More likely to extend into the mediastinum | **More likely to extend into the mediastinum | ||
*Children: Due to suppurative changes within a lymph node (primary infection elsewhere in head or neck) | *Children: Due to suppurative changes within a lymph node (primary infection elsewhere in head or neck) | ||
*Trauma: Direct inoculation (e.g. child falling with stick in mouth) | *[[Trauma]]: Direct inoculation (e.g. child falling with stick in mouth) | ||
*Patients may prefer to lay supine to prevent abscess and edematous posterior wall to collapse into airway, so patients should not be forced to sit up | |||
[[File:RPA CT.png|thumb|Retropharyngeal abscess on CT]] | |||
==Clinical Features== | ==Clinical Features== | ||
*Sore throat (76%) | ===Initial symptoms=== | ||
*Fever (65%) | *[[Sore throat]] (76%) | ||
*Torticollis (37%) | *[[Fever]] (65%) | ||
*Dysphagia (35%) | *[[Torticollis]] (37%) | ||
*[[Dysphagia]] (35%) | |||
* | |||
**Involvement of carotid neurovascular sheath | ===Late symptoms=== | ||
*[[Stridor]], [[respiratory distress]], [[chest pain]] ([[mediastinitis]]) | |||
*Drooling, neck stiffness | |||
*Involvement of carotid neurovascular sheath | |||
===Complications=== | |||
*[[Mediastinitis]], [[sepsis]], [[aspiration pneumonia and pneumonitis|aspiration]] from spontaneous abscess formation | |||
*Jugular venous thrombosis, [[Lemierre's syndrome]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{Pediatric stridor DDX}} | {{Pediatric stridor DDX}} | ||
== | ==Evaluation== | ||
*CT neck | [[File:RPA xray.JPG|thumb|A lateral x-ray demonstrating prevertebral soft tissue swelling (marked by the arrow) ]] | ||
*CT neck with IV contrast | |||
**Gold standard | **Gold standard | ||
*XR Soft tissue | *XR Soft tissue | ||
**Neck in extension at end inspiration | |||
**The prevertebral space should be less than 7mm at C2, 14mm at C6 in children regardless of the age | **The prevertebral space should be less than 7mm at C2, 14mm at C6 in children regardless of the age | ||
**The prevertebral space should be less than 22mm at C6 in adults | **The prevertebral space should be less than 22mm at C6 in adults | ||
** | **The prevertebral space should be less than one-half the width of the corresponding vertebral body | ||
**If equivocal XR, order CT | **If equivocal XR, order CT | ||
==Management== | ==Management== | ||
#Emergent ENT consult | #Emergent ENT consult | ||
#*Most patients require I&D | #*Most patients require [[I&D]] | ||
#*Indications for drainage - trismus, rim enhancement on CT | #*Indications for drainage - trismus, rim enhancement on CT | ||
#Secure airway - care must be taken to minimize contact with abscess as rupture is significant risk | #Secure airway - care must be taken to minimize contact with [[abscess]] as rupture is significant risk | ||
##Tracheostomy or fiberoptic intubation may be necessary | ##[[Tracheostomy]] or fiberoptic [[intubation]] may be necessary | ||
##CT or MRI may help prepare for method of definitive airway<ref>Mulimani SM. Anesthetic management of tuberculous retropharyngeal abscess in adult. J Anaesthesiol Clin Pharmacol. 2012 Jan-Mar; 28(1): 128–129.</ref> | ##CT or MRI may help prepare for method of definitive airway<ref>Mulimani SM. Anesthetic management of tuberculous retropharyngeal [[abscess]] in adult. J Anaesthesiol Clin Pharmacol. 2012 Jan-Mar; 28(1): 128–129.</ref> | ||
===[[Antibiotics]]=== | ===[[Antibiotics]]=== |
Revision as of 22:34, 30 September 2019
Background
- Polymicrobial abscess in space between posterior pharyngeal wall and prevertebral fascia
- Adults: Due to direct extension of purulent debris from adjacent site (e.g. Ludwig's angina)
- More likely to extend into the mediastinum
- Children: Due to suppurative changes within a lymph node (primary infection elsewhere in head or neck)
- Trauma: Direct inoculation (e.g. child falling with stick in mouth)
- Patients may prefer to lay supine to prevent abscess and edematous posterior wall to collapse into airway, so patients should not be forced to sit up
Clinical Features
Initial symptoms
- Sore throat (76%)
- Fever (65%)
- Torticollis (37%)
- Dysphagia (35%)
Late symptoms
- Stridor, respiratory distress, chest pain (mediastinitis)
- Drooling, neck stiffness
- Involvement of carotid neurovascular sheath
Complications
- Mediastinitis, sepsis, aspiration from spontaneous abscess formation
- Jugular venous thrombosis, Lemierre's syndrome
Differential Diagnosis
Acute Sore Throat
Bacterial infections
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [1]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Noninfectious
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
Pediatric stridor
<6 Months Old
- Laryngotracheomalacia
- Accounts for 60%
- Usually exacerbated by viral URI
- Diagnosed with flexible fiberoptic laryngoscopy
- Vocal cord paralysis
- Stridor associated with feeding problems, hoarse voice, weak and/or changing cry
- May have cyanosis or apnea if bilateral (less common)
- Subglottic stenosis
- Congenital vs secondary to prolonged intubation in premies
- Airway hemangioma
- Usually regresses by age 5
- Associated with skin hemangiomas in beard distribution
- Vascular ring/sling
>6 Months Old
- Croup
- viral laryngotracheobronchitis
- 6 mo - 3 yr, peaks at 2 yrs
- Most severe on 3rd-4th day of illness
- Steeple sign not reliable- diagnose clinically
- Epiglottitis
- H flu type B
- Have higher suspicion in unvaccinated children
- Rapid onset sore throat, fever, drooling
- Difficult airway- call anesthesia/ ENT early
- H flu type B
- Bacterial tracheitis
- Rare but causes life-threatening obstruction
- Symptoms of croup + toxic-appearing = bacterial tracheitis
- Foreign body (sudden onset)
- Marked variation in quality or pattern of stridor
- Retropharyngeal abscess
- Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension
Evaluation
- CT neck with IV contrast
- Gold standard
- XR Soft tissue
- Neck in extension at end inspiration
- The prevertebral space should be less than 7mm at C2, 14mm at C6 in children regardless of the age
- The prevertebral space should be less than 22mm at C6 in adults
- The prevertebral space should be less than one-half the width of the corresponding vertebral body
- If equivocal XR, order CT
Management
- Emergent ENT consult
- Most patients require I&D
- Indications for drainage - trismus, rim enhancement on CT
- Secure airway - care must be taken to minimize contact with abscess as rupture is significant risk
- Tracheostomy or fiberoptic intubation may be necessary
- CT or MRI may help prepare for method of definitive airway[2]
Antibiotics
- Clindamycin 600-900mg IV OR
- Cefoxitin 2gm IV OR
- Ampicillin/Sulbactam 3g IV
Disposition
- Admit