Rosen & Barkin's 5-Minute Emergency Medicine Consult (618 page)

• CBC (WBC >12,000 in 91% of children):
  
  • Nonspecific
    
• Blood cultures (both aerobic and anaerobic)
  
• Throat cultures
  

• Portable films appropriate if concern for airway compromise
  
• Lateral neck radiographs:
  
  • Film taken in inspiration with neck slightly extended
    
  • May not get good exposure of soft tissue if cannot adequately extend neck due to pain or difficulty cooperating in young age
    
  • Increased suspicion if:
    
    • Retropharyngeal space anterior to C2 >7 mm or 2× the diameter of the vertebral body (sensitivity 90%)
      
    • Space anterior to C6 >14 mm in preschool children or 22 mm in adults
      
    • Loss of normal cervical lordosis
      
• Chest radiograph:
  
  • Indicated if abscess identified to assess for inferior spread of infection and/or aspiration of ruptured abscess contents
    
  • Mediastinal widening is suggestive of mediastinitis and possible rupture
    
• US of neck:
  
  • Low sensitivity
    
  • Not recommended
    
• CT of neck with IV contrast:
  
  • Now preferred imagining modality
    
  • Obtain when x-rays nondiagnostic or to determine exact size and location of abscess noted on x-ray
    
  • Abscess appears as hypodense lesion with peripheral ring enhancement in retropharyngeal space
    
  • Sensitivity: 64–100%
    
  • Specificity: 45–88%
    
  • Can aid in operative planning, revealing extent of invasion into retro/parapharyngeal spaces
    
  • Unclear if it reliably can distinguish abscess from cellulitis and lymphadenitis
    
  • Due to radiation exposure and need for sedation, CT should only be obtained in young children if x-rays are nondiagnostic
    
• MRI:
  
  • More sensitive than CT
    
  • Also useful for imaging vascular lesions such as jugular thrombophlebitis
    

• Surgical drainage/needle aspiration should be performed in OR:
  
  • Presence of pus is gold standard for making diagnosis
    
  • Abscess should be completely evacuated
    
  • Pus should be sent for Gram stain and culture
    
• No role for nasopharyngolaryngoscopy
  

• Tonsillopharyngitis
  
• Epiglottitis
  
• Peritonsillar abscess
  
• Croup
  
• Foreign body
  
• Tracheitis
  
• Meningitis
  
• Retropharyngeal hemorrhage
  
• Dystonic reactions
  
• Cervical osteomyelitis
  
• Dental infections
  
• Mononucleosis
  
• Epidural abscess
  
• Other deep space infection of the neck
  

TREATMENT

• Keep child in position of comfort:
  
  • Forcing child to sit up or flex neck may occlude airway
    
• Pulse oximetry, cardiac monitor
  
• Supplemental oxygen
  
• Adequate hydration
  
• Suction, endotracheal tube, tracheostomy equipment ready for potential emergent intubation
  
• Airway control will be required for:
  
  • Airway compromise
    
  • Prior to long transport
    

• Assess and control airway
  
• Provide supplemental oxygen
  
• IV access:
  
  • Avoid if signs of airway compromise
    

• Early endotracheal intubation or tracheostomy for patients with respiratory distress or impending obstruction:
  
  • Caution must be used with induction, as sedation medications may lead to relaxation of airway muscles causing complete obstruction
    
  • Rescue airway equipment such as a laryngeal mask airway available, as pharyngeal swelling may make intubation difficult
    
  • Cricothyrotomy may be required if upper airway is obstructed
    
• Surgical consultation (ear/nose/throat if available)
  
• Early administration of IV antibiotics
  

Empiric IV antibiotic therapy to cover group A streptococci,
S. aureus
(including MRSA), and respiratory anaerobes:

• Antibiotic tailored to local preferences and susceptibilities
  
• Coverage is narrowed when culture results and sensitivities return
  
• Use of corticosteroids is controversial and recommended only after consultation with ear/nose/throat
  
• Immunocompromised, diabetics, IV drug users, institutionalized patients, and young children (<1 yr) at high risk for MRSA
  

Several antibiotic regimens are available:

• Clindamycin: 600–900 mg (peds: 25–40 mg/kg/24 h) IV q8h (max. 4.8 g/d)
  
• Clindamycin + Metronidazole (loading dose 15 mg/kg IV not to exceed 4 g/d followed by 7.5 mg/kg PO/IV)
  
• Penicillin G + Metronidazole
  
• Cefoxitin 1 g IV q6–8h/3–4 g/d max.
  
• Ticarcillin/Clavulanate 3.1 g IV q4–6h
  
• Piperacillin/Tazobactam 3.375 g IV q6h
  

If patients do not respond or there is concern for MRSA:

• Vancomycin: 15–20 mg/kg (peds: 40–60 mg/kg/24 h IV q6–8h) IV q12h
  
• Linezolid: 600 mg (peds: 0–11 yr: 30 mg/kg/24 h q8h; >12 yr: Adult dose) IV/PO q12h
  

FOLLOW-UP

• All patients with retropharyngeal abscess should be admitted to the hospital for IV antibiotics and possible surgical drainage
  
• Criteria for surgical drainage:
  
  • Airway compromise or other life-threatening complications
    
  • Large (>2 cm hypodense area on CT)
    
  • Failure to respond to parenteral antibiotic therapy
    
• ICU admission for patients with:
  
  • Airway compromise
    
  • Sepsis
    
  • Altered mental status
    
  • Hemodynamic instability
    
  • Infants and toxic-appearing children
    
  • Major comorbidities
    

Patients with retropharyngeal abscesses should not be discharged

Transfer should be considered if facility does not have the ability to drain infection:

• Airway should be stabilized prior to transfer
  

• Diagnosis should be considered in all children who present with fever, stiff neck, or dysphagia:
  
  • High clinical suspicion is required in children, as they present with nonspecific signs and symptoms
    
• Adult cases most often present in the setting of underlying illness, recent intraoral procedures, neck trauma, or head and neck infections
  
• When imaging is nondiagnostic and clinical suspicion remains high, surgery should be consulted
  
• Early surgical consultation and administration of IV antibiotics is essential to prevent complications such as airway compromise and extension into mediastinal structures
  

• Chow AW. Deep neck space infections. UpToDate February 17, 2012. Available at
  http://www.uptodate.com/contents/deep-neck-space-infections
  .
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2010.
  
• Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children.
  Otolaryngol Head Neck Surg
  . 2008;138:300–306.
  
• Reynolds SC, Chow AW. Severe soft tissue infections of the head and neck: A primer for critical care physicians.
  Lung
  . 2009;187:271–279.
  
• Wald ER. Retropharyngeal infections in children. UpToDate August 17, 2012. Available at
  http://www.uptodate.com/contents/retro pharyngeal-infections-in-children
  .
  

See Also (Topic, Algorithm, Electronic Media Element)

• Epiglottitis
  
• Peritonsillar Abscess
  

CODES

478.24 Retropharyngeal abscess

BASICS