History

Fact Explanation
Fever Refers to the infection and accumulation of purulent discharge within the retropharyngeal and parapharyngeal spaces. These usually develop as a complication of a primary infection elsewhere in the head and neck region, mainly nasopharynx, oropharynx, paranasal sinuses or middle ear.[3] Other causes includes pharyngeal trauma and foreign body ingestion.[1] Causative agents of these are usally polymicrobial with a mixture of aerobes and anaerobes. (Most commonly encountered are group A beta-haemolytic Streptococcus (GABHS) and Staphylococcus aureus.)[5] Note that Retropharyngeal abscess is encountered more frequently in children than adults.[2] Due to the abundance of retropharyngeal lymph nodes that may regress with age.[4] Patient will be febrile due to the systemic response to infection.
Odynophagia Due to external compression of the esophagus from the abscess causing diffused muscle spasms.
Dysphagia Due to external compression of the esophagus from the abscess causing partial or complete obstruction of the esophageal lumen.
Dyspnea Narrowing of airway lumen due to swelling of the abscess towards the posterior pharyngeal wall.
Loss of appetite / Refusal to feed Due to discomfort in swallowing caused by the bulging oropharyngeal mass.
Sore throat Due to the presence of concomitant pharyngitis.
References
  1. BRITO-MUTUNAYAGAM S, CHEW YK, SIVAKUMAR K, PREPAGERAN N. Parapharyngeal and retropharyngeal abscess: anatomical complexity and etiology. Med J Malaysia [online] 2007 Dec, 62(5):413-5 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18705479
  2. JAIN S, KUMAR S, KUMAR N, PUTTEWAR MP, NAGPURE PS. Deep-neck space infections -- a diagnostic dilemma! Indian J Otolaryngol Head Neck Surg [online] 2008 Dec, 60(4):349-352 [viewed 21 August 2014] Available from: doi:10.1007/s12070-008-0103-0
  3. RIJUNEETA, PARIDA PK, BHAGAT S. Parapharyngeal and retropharyngeal space abscess: an unusual complication of chronic suppurative otitis media. Indian J Otolaryngol Head Neck Surg [online] 2008 Sep, 60(3):252-5 [viewed 23 August 2014] Available from: doi:10.1007/s12070-008-0001-5
  4. MARQUES PM, SPRATLEY JE, LEAL LM, CARDOSO E, SANTOS M. Parapharyngeal abscess in children: five year retrospective study. Braz J Otorhinolaryngol [online] 2009 Nov-Dec, 75(6):826-30 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20209282
  5. RAFTOPULOS MH, JEFFERSON ND, KERTESZ T. Retropharyngeal abscess in a six-week-old child: an approach to management. JRSM Short Rep [online] 2013, 4(11):2042533313499558 [viewed 23 August 2014] Available from: doi:10.1177/2042533313499558

Examination

Fact Explanation
Cervical Lymphadenopathy Draining of infected material to these glands from the affected sites.
Torticolis Retropharyngeal edema and swollen lymph nodes causing the laxity of the ligaments and structures at the atlantoaxial level resulting asymmetrical head or neck position.[2]
Oropharyngeal swelling Posterior pharyngeal edema caused by the swollen abscess.
Trismus Anterior parapharyngeal abscesses can cause spasm of jaw muscles resulting difficulty in opening of the mouth.
Stridor Commonly seen in infants.[1] occurs due to the narrowing of the airway lumen.
Drooling Commonly encountered among the pediatric population. Note that stridor and drooling are signs which indicate potential airway compromise.
Neck pain and stiffness Compression of the adjacent group of neck muscles and soft tissues by the abscess causing inflammatory response.[2]
References
  1. MARTINS RH, CASTILHO EC, WEBER ST, SEMENZATI GDE O, CAMPOS LM. Retropharyngeal abscess and stridor in infants. Braz J Otorhinolaryngol [online] 2009 Mar-Apr, 75(2):319 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19575125
  2. HASEGAWA J, TATEDA M, HIDAKA H, SAGAI S, NAKANOME A, KATAGIRI K, SEKI M, KATORI Y, KOBAYASHI T. Retropharyngeal abscess complicated with torticollis: case report and review of the literature. Tohoku J Exp Med [online] 2007 Sep, 213(1):99-104 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17785958

Differential Diagnoses

Fact Explanation
Acute Epiglottitis Important differential to exclude as it is potentially a life threatening condition which can lead to fatal airway obstruction. Patient may have a similar clinical picture.[1]
Foreign body aspiration Commonly encountered among the pediatric age group. Sudden onset of paroxysms of cough, stridor and dyspnea are important clinical findings. High degree of suspicion is usually required to make the diagnosis. Hence important differential to consider.
Meningitis Important to consider as fever and neck stiffness are classical signs of meningeal irritation.[2]
Peritonsillar Abscess and Cellulitis Usually presents with a history of preceding episodes of tonsillitis. Common symptoms include sore throat, odynophagia and fever.[3] On examination there will be inflamed peritonsillar swelling extending to the soft palate and displacement of the uvula to the contralateral side.[4]
Vertebral Osteomyelitis Consider if prominent neck pain is present with associated neurological defects. Patient may have a preceding history of tuberculosis.[5]
Retropharyngeal calcific tendinitis Presents with acute neck pain, neck stiffness and dysphagia or odynophagia. Awareness of its existence is crucial in the differential diagnosis. As it may prevent additional discomfort to the patient caused by unnecessary surgical or pharmaceutical interventions.[6]
References
  1. LON SA, LATEEF M, SAJAD M. Acute epiglottitis: A review of 50 patients. Indian J Otolaryngol Head Neck Surg [online] 2006 Apr, 58(2):178-80 [viewed 22 August 2014] Available from: doi:10.1007/BF03050781
  2. KU BD, PARK KC, YOON SS. Medically treated deep neck abscess presenting with occipital headache and meningism. J Headache Pain [online] 2008 Feb, 9(1):47-50 [viewed 22 August 2014] Available from: doi:10.1007/s10194-008-0005-2
  3. Result ONG YK, GOH YH, LEE YL. Peritonsillar infections: local experience. Singapore Med J [online] 2004 Mar, 45(3):105-9 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15029410
  4. DILKES MG, SPRAGGS PD. Clinical findings in needle aspiration of peritonsillar abscess. Arch Emerg Med [online] 1990 Sep, 7(3):212-4 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2152464
  5. COLMENERO JD, RUIZ-MESA JD, SANJUAN-JIMENEZ R, SOBRINO B, MORATA P. Establishing the diagnosis of tuberculous vertebral osteomyelitis. Eur Spine J [online] 2013 Jun:579-86 [viewed 22 August 2014] Available from: doi:10.1007/s00586-012-2348-2
  6. RAZON RV, NASIR A, WU GS, SOLIMAN M, TRILLING J. Retropharyngeal calcific tendonitis: report of two cases. J Am Board Fam Med [online] 2009 Jan-Feb, 22(1):84-8 [viewed 23 August 2014] Available from: doi:10.3122/jabfm.2009.01.080034

Investigations - for Diagnosis

Fact Explanation
Lateral neck radiography Widening of the retropharyngeal space with prevertebral soft tissue thickening and straightening of cervical spine resulting from muscle spasm can be noted.[1],[2] Note that care must be taken to ensure patient's neck is in extended position and the image should be taken at the point of complete inspiration. (due to widening of the retropharyngeal space while the neck is flexed.)[4]
Contrast enhanced computer tomography Contributes greatly towards diagnosis and to determine the extent of the abscess.[1] May help differentiating cellulitis from an abscess.[3]
Magnetic Resonance Imaging Useful in evaluation of potential adjacent vascular complications.[4]
Ultrasound Useful in differentiating retropharyngeal cellulitis from an abscess.
Chest X Ray Useful if mediastinal involvement is suspected.[5]
Complete Blood Count May show neutrophil leucocytosis and raised ESR count as a response to the ongoing infection.
References
  1. NAZIR KA, FOZIA PA, UL ISLAM M, SHAKIL A, PATIGAROO SA. Paediatric acute retropharyngeal abscesses: an experience. Afr J Paediatr Surg [online] 2013 Oct-Dec, 10(4):327-35 [viewed 22 August 2014] Available from: doi:10.4103/0189-6725.125438
  2. BABL FE, PASCUCCI R. Images in clinical medicine. Retropharyngeal abscess. N Engl J Med [online] 1997 Aug 14, 337(7):472 [viewed 22 August 2014] Available from: doi:10.1056/NEJM199708143370706
  3. COULTHARD M, ISAACS D. Retropharyngeal abscess. Arch Dis Child [online] 1991 Oct, 66(10):1227-30 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1953008
  4. IDE C, BODART E, REMACLE M, DE COENE B, NISOLLE JF, TRIGAUX JP. An early MR observation of carotid involvement by retropharyngeal abscess. AJNR Am J Neuroradiol [online] 1998 Mar, 19(3):499-501 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9541306
  5. PANDURANGA KAMATH M, SHETTY AB, HEGDE MC, SREEDHARAN S, BHOJWANI K, PADMANABHAN K, AGARWAL S, MATHEW M, RAJEEV KUMAR M. Presentation and management of deep neck space abscess Indian J Otolaryngol Head Neck Surg [online] 2003 Oct, 55(4):270-275 [viewed 22 August 2014] Available from: doi:10.1007/BF02992436

Management - General Measures

Fact Explanation
Airway management Is of utmost importance in a patient with compromised airway. Endotracheal intubation may be required to secure and maintain the patency.[1] However it may be difficult because of the upper airway swelling. In such instances cricothyrotomy or tracheostomy will be required.[2]
Intravenous fluids Due to the dehydrated status of the patient with electrolyte imbalances and metabolic derangements as a result of poor oral intake.[2]
References
  1. ROTTA AT, WIRYAWAN B. Respiratory emergencies in children. Respir Care [online] 2003 Mar, 48(3):248-58; discussion 258-60 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12667275
  2. RAO MS, LINGA RAJU Y, VISHWANATHAN P. Anaesthetic management of difficult airway due to retropharyngeal abscess. Indian J Anaesth [online] 2010 May, 54(3):246-8 [viewed 23 August 2014] Available from: doi:10.4103/0019-5049.65376

Management - Specific Treatments

Fact Explanation
Intravenous broad spectrum antibiotics The cornerstone of management consists in antimicrobial therapy, which aids in eradicating the infection,reducing morbidity, and prevention of complications. Empiric antibiotic therapy should be commenced as soon as possible.Mainly targeted at gram positive cocci, with pencillin or clindamycin and anaerobes with metronidazole.[1] However choice of empirical antibiotic therapy may depend on the local sensitivity pattern.
Surgical drainage. Is indicated when the patient presents with airway compromise or unsatisfactory improvement following administration of antibiotics. Aids in prevention of severe complications such as carotid artery erosion, internal jugular venous thrombosis.[2] Note - External approach is used when the infection involves the parapharyngeal space.[3]
References
  1. PANDURANGA KAMATH M, SHETTY AB, HEGDE MC, SREEDHARAN S, BHOJWANI K, PADMANABHAN K, AGARWAL S, MATHEW M, RAJEEV KUMAR M. Presentation and management of deep neck space abscess. Indian J Otolaryngol Head Neck Surg [online] 2003 Oct, 55(4):270-5 [viewed 22 August 2014] Available from: doi:10.1007/BF02992436
  2. JAIN S, KUMAR S, KUMAR N, PUTTEWAR MP, NAGPURE PS. Deep-neck space infections - a diagnostic dilemma! Indian J Otolaryngol Head Neck Surg [online] 2008 Dec, 60(4):349-52 [viewed 22 August 2014] Available from: doi:10.1007/s12070-008-0103-0
  3. NAZIR KA, FOZIA PA, UL ISLAM M, SHAKIL A, PATIGAROO SA. Paediatric acute retropharyngeal abscesses: an experience. Afr J Paediatr Surg [online] 2013 Oct-Dec, 10(4):327-35 [viewed 22 August 2014] Available from: doi:10.4103/0189-6725.125438