Review Question - QID 217162

This patient presenting with a sore throat, progressive dysphagia, fever, pain with neck extension, a muffled voice in the setting of recent esophageal instrumentation, and a large fluid collection on CT scan most likely has a retropharyngeal abscess. Retropharyngeal abscesses are treated with empiric coverage with broad-spectrum antibiotics such as ceftriaxone plus metronidazole and surgical drainage for large abscesses.

Retropharyngeal abscesses are caused by an extension of parapharyngeal infections or infection of retropharyngeal lymph nodes. Local spread of infection should be suspected in cases of penetrating trauma in the neck or recent instrumentation of the esophagus. Retropharyngeal abscesses present with sore throat, dysphagia, trismus, odynophagia, and pain with neck extension. Diagnosis can be confirmed with a CT scan of the neck. Treatment is with empiric broad-spectrum antibiotic coverage for Streptococci, Haemophilus influenzae, and anaerobes along with surgical drainage of large abscesses or toxic-appearing patients. Medical treatment only with antibiotic coverage is acceptable for small abscesses in well-appearing patients.

Sanchez and Angulo review the presentation and complications of retropharyngeal abscesses. They note that the most common etiology is foreign body impaction and the most common complication is necrotizing mediastinitis. They recommend considering this diagnosis in patients with odynophagia and cervical pain.

Incorrect Answers:
Answer 1: Clindamycin only is incorrect because clindamycin does not provide adequate coverage for gram-negative organisms such as Haemophilus influenzae. In addition, large retropharyngeal abscesses typically require surgical drainage.

Answer 2: Non-invasive positive pressure ventilation is incorrect because while patients with retropharyngeal abscess may develop signs of airway compromise (e.g., inspiratory stridor, pooling of secretions, tripod position) and require airway support, such support is in the form of endotracheal intubation, not non-invasive positive pressure ventilation.

Answer 3: Surgical drainage and clindamycin are incorrect because clindamycin does not provide adequate coverage against Haemophilus influenzae, which is a common cause of retropharyngeal abscess.

Answer 5: Symptomatic care only is the treatment for viral pharyngitis, not a retropharyngeal abscess. Viral pharyngitis typically presents with a sore throat but does not cause a muffled voice or pain with neck extension; retropharyngeal abscess is more likely given this patient’s recent history of instrumentation.

Bullet Summary:
Retropharyngeal abscess presents with fever, sore throat, dysphagia, and pain with neck extension in the setting of recent foreign body impaction (e.g., fish bone) or tracheal/esophageal instrumentation; it is treated with empiric antibiotics and surgical drainage for large abscesses or those causing airway compromise.