Snapshot A 4-year-old boy presents to the emergency department with neck pain and shortness of breath. His mother reports that he has been having difficulty with walking and has been complaining of neck pain 1 day prior to presentation. On physical exam, the patient is in the tripod position, drooling, and is unable to speak or cough. Otolaryngology and anesthesiology are consulted to secure his airway. The patient is urgently brought into the operating room for surgical drainage. Introduction Definition infection of the retropharyngeal space Microbiology Streptococcus pyogenes Staphylococcus aureus respiratory anaerobes Epidemiology Incidence most common in children < 5 years of age in adults, the most common cause is trauma Risk factors recent infection, such as otitis media pharyngitis sinusitis immunosuppression ETIOLOGY Pathogenesis the retropharyngeal space contains lymph nodes that drain the nasal cavity, paranasal sinuses, nasopharynx, oropharynx, and hypopharynx infections involving these structures can lead to a lymphadenitis, which may progress to the formation of a retropharyngeal abscess Presentation Symptoms/physical exam classic triad stiff neck (e.g., torticollis or an inability to extend the neck) fever odynophagia drooling Imaging CT scan of the neck with contrast indication imaging study of choice in evaluating retropharyngeal abscesses indicated in peritonsillar abscesses in patients > 35 years of age to rule out malignancy Studies Making the diagnosis this is a clinical diagnosis confirmed with radiographic imaging Differential Epiglotitis differentiating factors "thumb sign" on radiography of the neck Ludwig angina infection of submental, submandibular, and sublingual space associated with poor dental hygiene intubate if airway threatened intubate early even if oxygen saturation normal treat with broad spectrum antibiotics + incision and drainage Treatment Medical empiric intravenous antibiotics indication abscess < 2.5 cm2 presence of phlegmon Operative surgical drainage indication signs of severe respiratory distress well defined abscess > 2.5 cm2 comment antibiotic choice should target S. pyogenes, S. aureus, and respiratory anaerobes e.g., ampicillin-clavulanate and vancomycin Procedural emergent intubation indication in patients with signs of significant airway obstruction "tripod positioning" respiratory distress cyanosis unable to speak or cough Complications Airway obstruction Mediastinitis Internal jugular vein thrombosis Septicemia