Retropharyngeal Abscess
These patients prefer to lie flat vs. epiglottitis patients prefer to sit up/tripoding - Brit Long & Michael Gottlieb
image by: Lacy Fallis
HWN Suggests
Retropharyngeal Abscess – Look for limited neck mobility.
Retropharyngeal abscesses typically occur in children <5 yrs of age (as the retropharyngeal lymph tissue atrophy after this time). They can also occur after direct trauma (from a popsicle stick or other foreign objects impaling the adjacent structures) in older kids and “big babies” (AKA adults).
As often occurs, the classic teaching is not the common finding. You may have been taught that retropharyngeal abscesses present with signs of respiratory distress (stridor, tachypnea, drooling)… and this can occur; however, if you wait for the purulent puss pocket to cause such symptoms it has grown large enough to encroach upon the airway. It would be beneficial for all…
Resources
Retropharyngeal Abscess in an Adult
Diagnosing deep space neck infections is important since they can cause respiratory compromise. A differential including peritonsilar abscess, retropharyngeal abscess, Ludwigs angina, epiglottitis, meningitis, and Lemierre syndrome should be considered in the patient who presents with trismus, muffled voice and limited neck mobility.
What Are the Potential Complications of a Retropharyngeal Abscess?
Retropharyngeal abscesses (RPA) occur in the potential space bound anterior to the prevertebral fascia, posterior to the pharyngeal constrictor muscles and their fascia and laterally by the carotid sheaths and parapharyngeal space (another potential space lying laterally to the pharynx). The retropharyngeal potential space runs superiorally from the base of the skull to the mediastinum distally. It is the most common deep neck infection. In children under 4 years of age, retropharyngeal lymph nodes are present which regress after this age.
Medical Malpractice Insights: It may be more than “just a sore throat”
Symptoms of retro- or parapharyngeal abscess include fever, dysphagia (difficulty swallowing), odynophagia (pain with swallowing), neck tenderness, and sometimes dyspnea. Neck stiffness and swelling are more common in infants and children. Because this is uncommon, one must remember to think of it in any case of severe sore throat, especially when the “throat” itself looks normal.
Retropharyngeal Abscess – Look for limited neck mobility.
Look for neck stiffness or limited range of motion of the neck. Limited ROM of the neck may present as dramatically as torticollis or more subtly as the patient refusing to look in a direction.
Access EM
The peak incidence occurs in 3- to 5-year-olds. It is rare beyond 6 years of age as the retropharyngeal lymph nodes involute.
Core EM
Lateral neck soft tissue XRAY: Evaluation of prevertebral soft tissue. Should be obtained in extension on inspiration: Flexion of the neck, expiration and crying may result in pseudo-enlargement.
Elemental EM: Retropharyngeal Abscess
How do you diagnose retropharyngeal abscess? Lateral neck X-ray or CT scan.Anteroposterior (AP) diameter of soft tissues along anterior bodies of C1- 4 should be less than 40% of the AP diameter of the vertebral body behind it.
PEM Currents: The Pediatric Emergency Medicine Podcast
Ted Brenkert sticks his neck out to educate you on retropharyngeal abscesses. RPAs can be an especially worrisome diagnosis in young children who will present with fever, sore throat and limitation of neck movement.
Pharyngitis Mimics
Pearl: these patients prefer to lie flat (vs. epiglottitis patients prefer to sit up/tripoding)
StatPearls
Retropharyngeal abscesses are uncommon but potentially life-threatening diagnosis. They can occur at any age, although are most commonly found in children under the age of five.
WikEM
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
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