Retropharyngeal abscess
Retropharyngeal abscess is a suppurative infection of the retropharyngeal space that follows antecedent pharyngitis, classically in children 6 months to 6 years, and threatens the airway. Diagnosis begins with lateral neck radiography and is confirmed by contrast CT, and treatment is airway assessment, IV antibiotics against oral flora, and surgical drainage for frank abscess or antibiotic failure.
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What this article covers
- Overview
Suppurative infection of the retropharyngeal space: a deep neck space infection that most often follows an antecedent pharyngitis or upper respiratory infection, distinct from the more superficial peritonsillar abscess.
- Epidemiology
Age concentrated in early childhood: the classic age range is 6 months to 6 years of age.
- Risk factors
Recent pharyngitis or upper respiratory infection: the most consistent antecedent, with symptoms progressing despite antibiotic treatment for the presumed pharyngitis.
- Pathophysiology
Antecedent pharyngitis seeds the retropharyngeal space: infection begins in or spreads from the pharynx and establishes itself in the retropharyngeal space posterior to the pharyngeal wall.
- Clinical features
Fever with a history of pharyngitis that has not improved on antibiotics: the presentation typically follows an antecedent pharyngeal infection and the pain becomes unilateral as the abscess develops.
- Differential diagnosis
Epiglottitis: also presents with drooling, muffled voice, and rapid airway compromise, but the airway must be secured before any oropharyngeal examination; lateral neck x-ray shows a swollen…
- Diagnosis
The diagnosis is confirmed as the final, definitive step by contrast-enhanced CT of the neck, once suspected clinically, showing a rim-enhancing fluid collection in the retropharyngeal space and…
- Management
Assess and secure the airway first: evaluate for stridor, drooling, or respiratory distress before any other intervention; a compromised or threatened airway is managed with early, controlled airway…
- Complications
Airway obstruction: the immediate life-threatening risk from retropharyngeal space swelling compressing the airway.
- Prognosis
Favorable with prompt drainage and antibiotics: outcomes are good when the airway is secured early and source control (drainage when a discrete abscess is present) is achieved promptly.
- Prevention
Complete a full 10-day course of antibiotics for confirmed group A streptococcal pharyngitis: amoxicillin 50 mg/kg PO once daily (maximum 1000 mg) for 10 days, or cephalexin 20 mg/kg PO twice daily…
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- Peritonsillar abscess
Peritonsillar abscess is the most common deep-space neck infection, presenting with unilateral sore throat, trismus, a muffled hot potato voice, and uvula deviation away from the affected side, treated with prompt drainage plus antibiotics covering group A streptococcus, Staphylococcus aureus, and oral anaerobes.
- Ludwig angina
Ludwig angina is a rapidly progressive, usually odontogenic cellulitis of the submandibular, sublingual, and submental spaces that can cause airway obstruction from posterior tongue displacement. Airway assessment and securing take priority over every other step, followed by broad-spectrum IV antibiotics and drainage of any organized abscess.
- Epiglottitis
Epiglottitis is a rapidly progressive supraglottic infection that can obstruct the airway within hours; the exam is limited to inspection only, and airway control precedes any diagnostic confirmation in an unstable patient.
- Deep neck space infection
Infection tracking through the fascial spaces of the neck, most often from an odontogenic, tonsillar, or salivary source, that threatens the airway and can spread to the mediastinum. Diagnosis rests on contrast-enhanced CT of the neck; treatment is airway protection, intravenous antibiotics, and surgical drainage of any organized collection.
- Streptococcal pharyngitis
Streptococcal pharyngitis is an acute infection of the tonsils and pharynx caused by group A Streptococcus pyogenes, presenting with rapid-onset sore throat, fever, tonsillar exudates, and tender anterior cervical lymphadenopathy without cough; diagnosis relies on the Centor criteria to guide rapid antigen testing, and treatment with penicillin or amoxicillin prevents suppurative complications and acute rheumatic fever.