Updated: 12/17/2021

Retropharyngeal Abscess

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  • 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
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(M2.ET.13.10) A 62-year-old homeless man presents to the emergency department with severe chest pain. The patient states he has felt unwell for the past several days and endorses lower back pain, chest pain, pain with swallowing, a cough, and a subjective fever. Several weeks ago, the patient had dental pain which he has been treating by drinking alcohol. His temperature is 104°F (40.0°C), blood pressure is 114/64 mmHg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 92% on room air. Exam is notable for submandibular erythema and a coarse, rasping sound when auscultating the heart sounds. A CT of the chest is performed as seen in Figure A and an ECG is performed as seen in Figure B. Laboratory values are notable for a troponin of 1.0 ng/mL (normal < 0.4 ng/mL) and a creatinine of 2.5 mg/dL. Which of the following is the most likely diagnosis?

QID: 104440
FIGURES:

Esophageal rupture

15%

(3/20)

Ludwig angina

15%

(3/20)

Mediastinitis

20%

(4/20)

Myocardial infarction

20%

(4/20)

Pulmonary embolism

30%

(6/20)

M 6 E

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