Retropharyngeal abscesses develop in the retropharyngeal lymph nodes at the back of the pharynx, adjacent to the vertebrae. They can be seeded by infection of the pharynx, sinuses, adenoids, or nose. They occur mainly in children 1 to 8 years because the retropharyngeal lymph nodes begin to recede by 4 to 5 years. However, adults may develop infection after foreign body ingestion or after instrumentation. Common organisms include aerobic (Streptococcus and Staphylococcus species) and anaerobic (Bacteroides and Fusobacterium) bacteria and, increasingly in adults and children, HIV and tuberculosis.
The most serious consequences include airway obstruction, septic shock, rupture of the abscess into the airway resulting in aspiration pneumonia or asphyxia, mediastinitis, carotid rupture, and suppurative thrombophlebitis of the internal jugular veins (Lemierre syndrome).
Symptoms and signs are usually preceded in children by an acute upper respiratory infection and in adults by foreign body ingestion or instrumentation. Children may have odynophagia, dysphagia, fever, cervical lymphadenopathy, nuchal rigidity, stridor, dyspnea, snoring or noisy breathing, and torticollis. Adults may have severe neck pain but less often have stridor. The posterior pharyngeal wall may bulge to one side.
Diagnosis is suspected in patients with severe, unexplained sore throat and neck stiffness, stridor, or noisy breathing.
Lateral soft-tissue x-rays of the neck, taken in the maximum possible hyperextension and during inspiration, may show focal widening of the prevertebral soft tissues, reversal of normal cervical lordosis, air in the prevertebral soft tissues, or erosion of the adjacent vertebral body.
CT can help diagnose questionable cases, help differentiate cellulitis from an abscess, and assess extent of the abscess.
Antibiotics, such as a broad-spectrum cephalosporin (eg, ceftriaxone 50 to 75 mg/kg IV once/day) or clindamycin, may occasionally be sufficient for children with small abscesses. However, most patients also require drainage through an incision in the posterior pharyngeal wall. Endotracheal intubation is done preoperatively and maintained for 24 to 48 hours.
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