Radiological Cases of the Month John

8-month-old male infant presented to his pediatrician with a 12-hour history of fever, irritability, decreased oral intake, and symptoms consistent with an upper respiratory tract infection. The child had a temperature of 38.8\s=deg\Crectally and was tachycardic, with a heart rate of 160 beats per minute. The patient's physA

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Accepted for publication October 24, 1989. Contributed from the Department of Otolaryngology and Maxillofacial Surgery, Division of Pediatric Otolaryngology, Children's Hospital Medical Center, Elland and Bethesda Avenues, Cincinnati, Ohio. Reprint requests to the Department of Radiology, Childrens Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027 (Dr Wood).

Grosso, MD, Charles M. Myer, MD (Contributors); Beverly P. Wood, MD (Section Editor) ical examination was remarkable for mild neck tenderness and rigidity and right-sided enlarged cervical nodes. The tympanic membranes were dull and erythematous bilaterally. The oropharynx was full, with erythema of the right posterior pharyngeal wall. The patient's white blood cell count was 20\m=x\109/L with a left shift. A lateral neck roentgenogram (Fig 1) was obtained followed by a computed tomographic scan of the neck (Fig 2). The patient was admitted to the hospital and treatment was started with cefuroxime axetil (100 mg/kg per day). He subsequently developed stridor and progressive respiratory distress requiring emergent intubation.

Figure 1.

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On examination in the operating room there was a large fluctuant mass in the right posterior pharyngeal wall. Incision and drainage of the abscess were performed and the patient re¬ mained intubated for 48 hours. The examination in the operating room at the end of that time demonstrated resolution of the abscess, and the pa¬ tient was extubated. Intravenous an¬ timicrobial therapy was continued for 5 days and the infant was discharged home to be treated with amoxicillin/ clavulanate potassium (40 mg/kg per day) for 1 week. The first case of retropharyngeal abscess (RPA) was reported by Galen1 in the second century. Although mor-

Figure 2.

Denouement and Discussion

Retropharyngeal Abscess Fig 1 .—Lateral neck roentgenogram shows widened tissues.

retropharyngeal soft

Fig 2.—Computed tomography of the neck demonstrates a large, right, peritonsillar and retropharyngeal abscess (arrows) causing division of the airway (A) to the left and airway compression.

tality from an RPA has been signifi¬ cantly reduced since the advent of antimicrobial therapy in the 20th cen¬ tury, a delay in diagnosis and treat¬ ment still leads to significant morbid¬ ity and mortality. The retropharyngeal space is lo¬ cated within two layers of deep cervi¬ cal fascia anterior to the spine and posterior to the pharynx. It extends from the skull base to the level of the carina.2 The retropharyngeal space contains adipose tissue, lymphatics, and lymph nodes, which drain the nose,

paranasal sinuses, nasopharynx,

soft palate, and eustachian tube.3 An infectious process in any of these regions may spread via lymphatic channels to the nodes in the retropha¬ ryngeal tissue. Lymph node infection may lead to the formation of a local abscess. In addition to the lymphatic spread of infection to the retropharyn¬ geal space, infection may be the result of direct extension from contiguous areas. For example, following otitis media the infection may spread inferiorly through the skull base into the retropharyngeal tissues. Trauma to the posterior oropharynx from endo¬

scopie procedures

or

trauma may also lead to

in this

penetrating an

infection

area.

Lymphatic spread of infection to the retropharyngeal space is the most

of an RPA in children. It should be noted that the retropha¬ ryngeal nodes usually regress by age 5 years, making lymphatic spread of infection a less likely cause of an RPA in older children or adults.4 A child with an RPA frequently has a history of a recent upper respiratory infection. Fever, irritability, decreased oral intake, and drooling are early symptoms. As the RPA enlarges, up¬ per airway obstruction occurs, with common cause

symptoms of stridor and respiratory distress. A physical examination usu¬ ally reveals an erythematous oropharynx with a unilateral fullness or bulg¬ ing of the posterior pharynx. Although the abscess mass is fluctuant, palpa¬ tion of an RPA is not recommended in children because of the risk of ruptur¬ ing the abscess with consequent aspi¬ ration. The medical history and physical examination are important in the di¬ agnosis, although a thorough exami¬ nation may be difficult in a young child with an RPA. A lateral neck roentgenograph is noninvasive, rapid, and pro¬ vides useful information in the diag¬ nosis of an RPA. Wholey et al.5 have established norms for the width of the

retropharyngeal space by roentgenography. In general, the retropharyn¬ geal space is no wider than the width of the adjacent vertebral body of C-4.G In addition to widening on lateral roentgenography, gas or a gas-fluid level may be present in the retropha¬ ryngeal space. If the findings on phys¬

ical examination and lateral neck

roentgenography are equivocal, a computed tomographic scan of the neck, examination of the oropharynx

under general anesthesia, or an ultrasonographic examination is indicated. An RPA is

a

surgical

emergency.

Initial management must be directed at stabilizing the patient's airway. Emergent endotracheal intubation or tracheotomy may be necessary and should be done under controlled con¬ ditions, if possible. Antimicrobial therapy is empiric, directed at the most common organisms involved in RPA (ie, group A ß-hemolytic streptococcus, Streptococcus viridans, and Staphylococcus aureus) and an

may be later modified according to culture and sensitivity results. Al-

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though antimicrobial therapy is impor¬

an essential aspect of treatment is incision and drainage. This is usu¬ ally performed intraorally under gen¬ eral anesthesia, but it may also be performed through an external lateral cervical approach.7 A complication of an RPA is rupture with aspiration and subsequent pneu¬ monia.8 The infection may also propa¬ gate inferiorly, producing mediastinitis, which carries an extremely high mortality rate. Spread may occur to the carotid sheath and cause internal jugular vein thrombosis or erosion of the carotid artery. As previously de¬ scribed, upper airway obstruction is a potential complication of an RPA. An RPA should be part of the differ¬ ential diagnosis in any young child with a history of swallowing or upper airway respiratory difficulties. The complications of an RPA are signifi¬ cant, and an accurate diagnosis and appropriate treatment for this condi¬ tion will lower the associated morbid¬ ity and mortality.

tant,

References 1. Frank I.

Retropharyngeal abscess.

JAMA.

1921;77:517-22.

2. Paonessa DF, Goldstein JC. Anatomy and physiology of head and neck infections (with emphasis on the fascia of the face and neck). Otolaryngol Clin N Am. 1976;9:561-580. 3. Barratt GE, Koopmann CF, Coulthard SW. Retropharyngeal abscess: a ten-year experience. Laryngoscope. 1984;94:455-463. 4. Grodinsky M. Retropharyngeal and lateral pharyngeal abscesses: an anatomic and clinical study. Ann Surg. 1939;110:177-199. 5. Wholey MH, Bruwer AJ, Baker HL. The lateral roentgenogram of the neck. Radiology.

1958;71:350-356.

6. Seid AB, Dunbar JS, Cotton RT. Retropharyngeal abscesses in children revisited. Laryngoscope. 1979;89:1717-1724. 7. Dean LW. The proper procedure for external drainage of retropharyngeal abscess second-

ary to caries of the vertebrae. Ann Otol Rhinol

Laryngol. 1919;28:566-572. 8. Schlossberg D, Fugate JS. Retropharyngeal cellulitis. Laryngoscope. 1981;91:1738-1742.

Radiological cases of the month. Retropharyngeal abscess.

Radiological Cases of the Month John 8-month-old male infant presented to his pediatrician with a 12-hour history of fever, irritability, decreased o...
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