Retropharyngeal abscess (RPA) produces the symptoms of sore throat, fever, neck stiffness, and stridor. RPA occurs less commonly today than in the past because of the widespread use of antibiotics for suppurative upper respiratory infections. The incidence of RPA in the United States is rising, however. Once almost exclusively a disease of children, RPA is observed with increasing frequency in adults. It poses a diagnostic challenge for the emergency physician because of its infrequent occurrence and variable presentation.[1]
Early recognition and aggressive management of RPA are essential because it still carries significant morbidity and mortality.
The retropharyngeal space is posterior to the pharynx, bound by the buccopharyngeal fascia anteriorly, the prevertebral fascia posteriorly, and the carotid sheaths laterally. It extends superiorly to the base of the skull and inferiorly to the mediastinum.
Abscesses in this space can be caused by the following organisms:
Aerobic organisms, such as beta-hemolytic streptococci and Staphylococcus aureus
Anaerobic organisms, such as species of Bacteroides and Veillonella
Gram-negative organisms, such as Haemophilus parainfluenzae and Bartonella henselae
The high mortality rate of retropharyngeal abscess is owing to its association with airway obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, necrotizing fasciitis, sepsis, and erosion into the carotid artery.
The incidence of pediatric RPA in the United States more than doubled in the first decade of the 21st century, according to a study of pediatric deep space neck infections. Deriving their statistics from the Kids’ Inpatient Database (KID), Novis et al found that between 2000 and 2009, the incidence of RPA increased from 0.1 cases per 10,000 to 0.22 cases per 10,000. They also found no significant change in the incidence of either peritonsillar or parapharyngeal abscess in those years.[2]
A study by Woods et al, also using the KID, reported the incidence of RPA to have risen, among children under age 20 years, from 2.98 per 100,000 population in 2003 to 4.10 per 100,000 population in 2012.[3]
A review of cases of RPA over an 11-year period at the Children's Hospital of Michigan revealed a 4.5-times increase in the incidence of RPA when compared with the previous 12 years.[4] A later review at the same hospital revealed that the incidence increased 2.8-fold between 2004 and 2010, compared with the incidence from 1993-2003.[5]
Similarly, an 11-year chart review of 162 pediatric patients with RPA at St. Louis Children's Hospital revealed that the number of RPA cases in children increased significantly from 1995 to 2006.[6]
A study by Angajala et al determined that of 119 pediatric patients in the greater Los Angeles community with a neck abscess treated with incision and drainage, 10.1% had an RPA. Patients with neck abscesses requiring incision and drainage tended to reside in lower income neighborhoods.[7]
International
A review of deep neck infections (DNI) in children over a 12-year period at a medical center in Taiwan revealed 50 children with DNI. Nine children had DNI in the retropharyngeal space, 17 in the parapharyngeal space, 21 in the peritonsillar region, and 3 were mixed.[8]
Another study from Taiwan, by Huang et al, found that out of 52 children with DNI, the retropharyngeal space was the third most common site of infection (7 patients), after the parapharyngeal space (22 patients) and the submandibular space (12 patients).[9]
A review of RPAs and parapharyngeal abscesses (PPAs) in children presenting to 2 pediatric tertiary care medical centers in Israel over an 11-year period revealed 39 children with RPA or PPA. The incidence increased during the course of the study.[10]
A retrospective analysis of children diagnosed with RPA and PPA over a 9-year period in a tertiary care medical center in Spain revealed 17 children with RPA, 11 with PPA, and 3 with both.[11]
A study by Yap et al found that in Wales, hospital admissions for RPA, as well as for tonsillitis, PPA, and peritonsillar abscess, rose between 1999 and 2014.[12]
Mortality/Morbidity
Once mediastinitis occurs, mortality approaches 50%, even with antibiotic therapy. Retropharyngeal abscess can also cause internal jugular vein thrombosis, carotid artery erosion, pericarditis, and epidural abscess. In addition to invasion of contiguous structures, retropharyngeal abscess can cause sepsis and airway compromise.
Overall mortality rate was 1% in a review of deep cervical space infections in Taiwan.[13]
In a study of 234 adults with deep space infections of the neck in Germany, the mortality rate was 2.6%. The cause of death was primarily sepsis with multiorgan failure.[14]
In the United States, in 2003, a review of the Kids' Inpatient Database (KID) revealed 1321 pediatric admissions with RPA, with no fatalities.[15]
A case series from Children's National Medical Center in Washington DC presents 4 children of ages ranging from 8 months to 18 months with RPA who developed mediastinitis. All 4 were treated aggressively with antibiotics and surgical drainage of RPA, and 3 patients required thoracoscopic debridement. All 4 children survived without sequelae.[16]
Race
See the list below:
In a 10-year review of retropharyngeal abscess cases treated at Kings County Hospital in Brooklyn, New York, 70% of patients were African American, 25% were white, and 5% were Hispanic.
A study of pediatric patients with retropharyngeal abscess at Wayne State University in Detroit revealed 43% of cases occurred in blacks, 54% in whites, 1% in Hispanics, and 1% in biracial.[17]
In the United States, in 2003, a review of the Kids' Inpatient Database (KID) revealed 1321 pediatric admissions with retropharyngeal abscess, of which 37.4% were white, 11.7% were African American, 11.1% were Hispanic, 2% were Asian, 3.8% were other races, and the race was not recorded in the rest of the patients.[15]
Sex
Retropharyngeal abscess is more common in males than in females, with generally reported male preponderance of 53-55%.
Children's Hospital of Michigan reports 54% of cases of RPA in males in a 2012 study.[5]
A study of children with retropharyngeal abscess in Toronto reported 67% of cases in males.
A study of retropharyngeal abscess in children in Detroit found 56% of cases in males.[17]
A study of adults with deep space infections of the neck in Germany revealed that 56% of patients were male and 44% were female.[14]
A study of cases in Nigeria found a male-to-female ratio of 1:1.[18]
In the United States, in 2003, a review of the Kids' Inpatient Database (KID) revealed 1321 pediatric admissions with retropharyngeal abscess, of which 63% were male.[15]
Age
Initially, retropharyngeal abscess was thought to be a disease limited to children, but now it is being encountered with increasing frequency in adults.
A review of adults with deep space infections of the neck in Germany revealed a mean age (±standard deviation) of 44.5 (±21.8) years.
A review of retropharyngeal abscess cases at the Hospital for Sick Children in Toronto revealed that 66% of pediatric cases occurred in children younger than 6 years.
A review of 30 cases of retropharyngeal abscess over an 11-year period in Nigeria found the median age to be 21 months, and 77% of patients were younger than 5 years. Eighty-three percent of retropharyngeal abscesses occurred in children, and 17% occurred in adults.[18]
A 10-year review at Kings County Hospital in Brooklyn, New York, revealed that 30% of the cases were in pediatric patients aged 16 months to 8 years and 70% were in adults aged 21-64 years.
A 35-year review of cases involving children who were treated for retropharyngeal abscess at the Children's Hospital of Los Angeles revealed that 50% of patients were younger than 3 years and 71% were younger than 6 years.
A review or retropharyngeal abscess in children in Detroit found a mean age of 4.1 years, with a range from 2 months to 18 years.
A review in Sydney, Australia, found that, in 55% of pediatric cases of retropharyngeal abscess, the children were younger than 1 year, with 10% diagnosed in the neonatal period.
A review of RPA cases in children in Albuquerque revealed a median age of 36 months, with 75% of patients younger than 5 years and 16% of patients younger than 1 year.[19]
In the United States, in 2003, a review of the Kids' Inpatient Database (KID) revealed 1321 pediatric admissions with retropharyngeal abscess, with an average age of 5.1 years (SD, 4.4).[15]
An 11-year chart review of 162 pediatric patients with retropharyngeal abscess at St. Louis Children's Hospital revealed an average age of 4.9 years (range, 6 d to 17 y).[6]
A 5-year review of 11 children with parapharyngeal abscess in Portugal revealed an average age of 3.3 years (range, 0-12 y).[20]
A 12-year retrospective review of 50 pediatric patients with deep neck infections in Taipei revealed that all of the retropharyngeal abscesses occurred in children younger than 10 years.[8]
Patients with retropharyngeal abscess may present with signs of airway obstruction, but often they do not. Individuals who do not exhibit signs of airway obstruction initially may progress to airway obstruction. The most common presenting signs may be different for adult and pediatric patients.
Physical signs in adults
Posterior pharyngeal edema (37%)
Nuchal rigidity
Cervical adenopathy
Fever
Drooling
Stridor
Torticollis[21]
Trismus[21]
Physical signs in infants and children
Cervical adenopathy (36%)[20]
Retropharyngeal bulge (55%; do not palpate in children)[20]
Fever (64%)[20]
Stridor (3%)
Torticollis (18%)
Neck stiffness (64%)[20]
Drooling (22%)
Agitation (43%)
Neck mass (55%)[20]
Lethargy (42%)
Respiratory distress (4%)
Associated signs including tonsillitis, peritonsillitis, pharyngitis, and otitis media
Retropharyngeal abscess develops secondary to lymphatic drainage or contiguous spread of upper respiratory or oral infections. Pharyngeal trauma from endotracheal intubation, nasogastric tube insertion,[22] endoscopy, foreign body ingestion, and foreign body removal may cause a subsequent retropharyngeal abscess. Patients who are immunocompromised or chronically ill, such as persons with diabetes, cancer, alcoholism, or AIDS, are at increased risk for retropharyngeal abscess.
A study by Kim et al indicated that in adolescents and adults, but not in children aged 14 years or younger, tonsillectomy raises the risk of retropharyngeal and parapharyngeal abscesses, with the post-tonsillectomy adjusted hazard ratio for deep neck infection being 1.43 (1.12 in children and 1.87 in patients aged 15 years or older).[23]
A study by Qureshi et al indicated that retropharyngeal abscess is occurring at an increasing rate among adult inpatients in the United States with peritonsillar abscess. The investigators, who used data from the National (Nationwide) Inpatient Sample, found that between 2003 and 2010 the annual rate at which retropharyngeal abscess occurred concurrently with peritonsillar abscess rose from 0.5% to 1.4% among inpatients aged 18 years or older. The study also indicated that patient age affects concurrence of the two conditions, with the likelihood that retropharyngeal abscess will complicate peritonsillar abscess increasing in patients aged 40 years or older.[24]
The most common organisms causing retropharyngeal abscesses include aerobes and anaerobes; gram-negative organisms also may be observed. Often, mixed flora is cultured. The incidence of RPA caused by methicillin-resistant Staphylococcus aureus (MRSA) is increasing.[5]
Organisms causing retropharyngeal abscess in adults include the following[25] :
Organisms causing retropharyngeal abscess in children include the following:
S aureus[17]
MRSA[5, 27, 31, 32]
Haemophilus species
Beta-hemolytic streptococcus (Streptococcus pyogenes)[17] : The incidence is increasing (54%), according to review of cases at the Children's Hospital of Michigan.[4]
The mean white blood cell (WBC) count in one study was 17,000, with a range of 3100-45,900.
WBC counts in 18% of the patients were less than 8000; thus, a normal WBC count does not rule out the diagnosis of retropharyngeal abscess.
In a study in Germany, the mean WBC (±standard deviation was 14,700 [±10,500]), with a range from 200-114,000.
Blood cultures are indicated before administration of intravenous antibiotics, but culture results may be negative in as many as 82% of retropharyngeal abscess cases.
A culture of pus, aspirated at the time of surgical drainage of the retropharyngeal abscess, can grow one or more organisms 91% of the time.
C-reactive protein
In one study of adults and children with deep cervical space infections, patients with C-reactive protein level greater than 100 had longer hospital stays.
In a German study, mean (±standard deviation) C-reactive protein level was 15.7 (±12.9), with a range from 0.0-74.
A study in Taiwan reveals that deep neck infection patients with C-reactive protein values greater than 100 tend to develop complications and have prolonged hospitalizations.[37]
Widening of the retropharyngeal soft tissues was observed in 88% of patients with retropharyngeal abscess in a series that defined soft tissue swelling as more than 7 mm at C2 and more than 14 mm at C6. Most authors define retropharyngeal soft tissue swelling as more than 7 mm at C2 and more than 22 mm at C6; thus, lateral neck radiographs may be considerably less sensitive for detecting retropharyngeal abscess than this study indicates.
Generally, the anteroposterior diameter of the prevertebral soft tissue space in children should not exceed that of the contiguous vertebral bodies.
In addition to showing widening of the prevertebral space, the lateral neck radiograph rarely may show a gas-fluid level, gas in the tissues, or a foreign body.
A hospital in Ireland reports a case series of 3 children with RPA who had negative lateral soft tissue neck x-ray films. Diagnosis was made using CT scan in all 3 cases.[38]
View Image
A 5-year-old boy presented to the ED with 2 days of neck pain and fever but with no sore throat. The child had vomited once, and the mother reported t....
View Image
An 8-month-old infant boy presented with fever and a stiff neck. According to the mother, the baby was not moving his neck as much as usual. The mothe....
CT scan of the neck
A CT scan of the neck with intravenous contrast is very useful in the diagnosis and management of retropharyngeal abscess. Retropharyngeal abscess appears as a hypodense lesion in the retropharyngeal space with peripheral ring enhancement. Other findings on CT scan include soft-tissue swelling, obliterated fat planes, and mass effect.
Obtain a CT scan of the neck with intravenous contrast when the findings on the lateral neck radiograph are equivocal or if the clinical suspicion for retropharyngeal abscess is high in patients with negative findings on lateral neck radiograph. Lateral neck radiographic findings may be misleading, especially in young children.
A CT scan of the neck with intravenous contrast also may be useful if the radiographic findings are positive because the CT scan can differentiate between retropharyngeal abscess and cellulitis. The CT scan also shows the extent of the retropharyngeal abscess and its relation to the great vessels, which is very helpful to the surgeon.
CT scan of the neck can also differentiate between retropharyngeal abscess and retropharyngeal lymphadenopathy in children, which may help the ear, nose, and throat (ENT) surgeon decide whether to treat with intravenous antibiotics alone or intravenous antibiotics plus surgical drainage.
A chest radiograph is indicated to look for aspiration pneumonia and mediastinitis.
An MRI with gadolinium enhancement may demonstrate a retropharyngeal abscess, but this modality has not been used widely.
Ultrasonography may demonstrate the presence of a retropharyngeal abscess, but its use has not yet been clarified.
A review of the literature did not reveal a role for nasopharyngolaryngoscopy use in the diagnosis of retropharyngeal abscess.
Safety of this procedure in the setting of retropharyngeal abscess is unclear.
Nasopharyngolaryngoscopy has been performed preoperatively in 2 adults; no reports of its use in children exist.
Endotracheal intubation
Securing the airway may be required if the patient with retropharyngeal abscess is exhibiting signs of impending upper airway obstruction. Endotracheal intubation may be attempted, but it may be difficult because of distortion of the upper airway.
Prophylactic intubation for a patient with retropharyngeal abscess but without respiratory distress generally is not indicated unless an interhospital transfer is planned.
If a patient with signs of upper airway obstruction cannot be intubated, a surgical or needle cricothyrotomy may be required.
A tracheostomy may be required as definitive airway management in patients with retropharyngeal abscess and respiratory distress.
Supplemental oxygen and attention to upper airway patency are the essential components of prehospital care in patients with suspected retropharyngeal abscess.
If a child exhibits respiratory distress, the sniffing position may be beneficial.
Occasionally, endotracheal intubation or cricothyrotomy may be required if the patient exhibits signs of upper airway obstruction.
ED management of retropharyngeal abscess includes attention to the airway, fluid resuscitation if necessary, antibiotic treatment, and preparation for an emergency operation. Frequent vital sign checks and continuous oxygen saturation monitoring are essential.
Airway management
Apply supplemental oxygen. In young children, this can be completed in a nonthreatening way by letting the parent direct blow-by oxygen at the child's face.
Endotracheal intubation may be required if the patient has signs of upper airway obstruction. It may be difficult because of upper airway swelling.
Cricothyrotomy (surgical or needle) may be required in the patient with upper airway obstruction who cannot be intubated. Tracheostomy may be required for definitive airway management.
Intravenous fluids are required if the patient is dehydrated because of fever and difficulty swallowing.
An emergent consultation with an ENT specialist is necessary. Consult an ENT specialist as soon as the diagnosis of retropharyngeal abscess is established or as soon as the diagnosis is suspected if the patient is exhibiting signs of upper airway obstruction.
If an abscess is present, an ENT specialist can drain it in the operating room. An ENT specialist also may perform a tracheostomy.
A prospective study in South Korea compared intravenous antibiotics plus surgical drainage with intravenous antibiotics with or without needle drainage. One case of mediastinitis occurred in the nonsurgical group. The authors concluded that, in conjunction with neck CT scanning, selected cases of parapharyngeal abscesses may be treated conservatively without early open surgical drainage.[39]
An 11-year chart review of 162 pediatric patients with retropharyngeal abscess at St. Louis Children's Hospital revealed that 126 of the patients required surgery initially, and, of the 36 patients treated medically initially, 17 required surgery.[6]
Of 24 pediatric RPAs in children treated at Starship Pediatric Hospital in Auckland, Australia, between 1999 and 2005, 10 (41.7%) required surgery, while 14 (58.3%) did not require surgery.[40]
According to a systematic review, medical treatment of pediatric deep neck abscesses may be a safe alternative to surgical drainage of these lesions, but the investigators cautioned that further studies will be needed before a more solid conclusion can be drawn.[41]
A retrospective study by Kosko and Casey suggested that in pediatric patients with a retropharyngeal or parapharyngeal abscess, intravenous antibiotic therapy alone is more likely to fail, and surgery more likely to be required, when the abscess is larger than 2 cm in diameter.[42]
The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications. Intravenous broad-spectrum antibiotic coverage is indicated in the treatment of retropharyngeal abscess.
Clinical Context:
This drug combination of beta-lactamase inhibitor with ampicillin interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. It is an alternative to amoxicillin in patients who are unable to take medication orally.
Clinical Context:
Clindamycin is a semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.
Clinical Context:
Second DOC, penicillin G interferes with the synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Clinical Context:
Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits the biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication.
Clinical Context:
Metronidazole is active against various anaerobic bacteria and protozoa. Cells of microorganisms that contain nitroreductase absorb metronidazole. Unstable intermediate compounds are then formed that bind DNA and inhibit synthesis, causing cell death.
Gram-positive organisms (including beta-lactamase – producing microbes), gram-negative organisms, and anaerobes must be covered. The Sanford Guide to Antimicrobial Therapy recommends adding empiric vancomycin to the regimen if the patient is in a high-risk group.[43]
Some recommend the following regimens: penicillin and oxacillin, second- or third-generation cephalosporin and clindamycin, penicillinase-resistant penicillin combined with either clindamycin or metronidazole, or third-generation cephalosporin in combination with clindamycin, nafcillin, or both (triple therapy).
In a review of retropharyngeal infections in children, Wald recommended adding vancomycin or linezolid to the regimen in patients who do not respond to clindamycin and in those who present with severe disease, in order to cover MRSA.[44]
Once the diagnosis of retropharyngeal abscess is established, initiate intravenous antibiotics and admit the patient to the hospital.
If any signs of respiratory distress are present, admit the patient to the intensive care unit.
Careful monitoring of airway status is essential and may require intensive care unit admission, even in the absence of respiratory distress in the ED.
The ENT physician decides whether to incise and drain the abscess in the operating room or whether a trial of medical therapy is indicated first (eg, retropharyngeal cellulitis).
An 11-year chart review of 162 pediatric patients with retropharyngeal abscess at St. Louis Children's Hospital revealed that 126 of the patients required surgery initially, and, of the 36 patients treated medically initially, 17 required surgery.[6]
Of 24 pediatric RPAs in children treated at Starship Pediatric Hospital in Auckland, Australia, between 1999 and 2005, 10 (41.7%) required surgery, while 14 (58.3%) did not require surgery.[40]
Incision and drainage of retropharyngeal abscess in the ED may lead to aspiration and generally is not recommended.
Patients should be brought to the ED immediately if they develop the inability to swallow or have difficulty breathing in conjunction with a sore throat.
For patient education information, see Medscape Drugs & Diseases' Infections Center, as well as Skin Abscess and Antibiotics.
What is a retropharyngeal abscess (RPA)?What is the pathophysiology of a retropharyngeal abscess (RPA)?What is the prevalence of retropharyngeal abscess (RPA) in the US?What is the global prevalence of retropharyngeal abscess (RPA)?What is the mortality and morbidity associated with retropharyngeal abscess (RPA)?What are the racial predilections of retropharyngeal abscess (RPA)?What are the sexual predilections of retropharyngeal abscess (RPA)?Which age groups have the highest prevalence of retropharyngeal abscess (RPA)?What are the signs and symptoms of a retropharyngeal abscess (RPA) in children?What are the signs and symptoms of a retropharyngeal abscess (RPA) in infants?What are the signs and symptoms of a retropharyngeal abscess (RPA) in adults?Which physical findings are characteristic of a retropharyngeal abscess (RPA) in infants and children?Which physical findings are characteristic of a retropharyngeal abscess (RPA) in adults?What causes a retropharyngeal abscess (RPA)?Which organisms cause retropharyngeal abscess (RPA) in adults?Which organisms cause retropharyngeal abscess (RPA) in infants and children?Which conditions are included in the differential diagnoses of retropharyngeal abscess (RPA)?What are the differential diagnoses for Retropharyngeal Abscess?What is the role of lab tests in the workup of retropharyngeal abscess (RPA)?What is the role of imaging studies in the workup of retropharyngeal abscess (RPA)?What procedures are used in airway management of a retropharyngeal abscess (RPA)?What is the role of nasopharyngolaryngoscopy in the workup of retropharyngeal abscess (RPA)?What is included in prehospital care of a retropharyngeal abscess (RPA)?How is a retropharyngeal abscess (RPA) treated?Which specialist consultations are beneficial to patients with a retropharyngeal abscess (RPA)?What is the efficacy of nonsurgical treatment of retropharyngeal abscess (RPA)?What is the role of medications in the treatment of a retropharyngeal abscess (RPA)?Which medications in the drug class Antibiotics are used in the treatment of Retropharyngeal Abscess?What is the role of surgery in the treatment of a retropharyngeal abscess (RPA)?When is patient transfer indicated for the treatment of retropharyngeal abscess (RPA)?How is a retropharyngeal abscess (RPA) prevented?What are the possible complications of a retropharyngeal abscess (RPA)?What is the prognosis of retropharyngeal abscess (RPA)?What is included in patient education about retropharyngeal abscess (RPA)?
Joseph H Kahn, MD, Director of Medical Student Education, Associate Professor, Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine
Disclosure: Nothing to disclose.
Specialty Editors
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Chief Editor
Gil Z Shlamovitz, MD, FACEP, Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC
Disclosure: Nothing to disclose.
Additional Contributors
Michael Glick, DMD, Dean, University of Buffalo School of Dental Medicine
Disclosure: Nothing to disclose.
Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Disclosure: Nothing to disclose.
Acknowledgements
Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center
Croche SB, Prieto D P A, Madrid C, et. al. [Retropharyngeal and parapharyngeal abscess: experience in a tertiary-care center in Seville during the last decade]. An Pediatr (Barc). October 2011. 75:266-72.
A 5-year-old boy presented to the ED with 2 days of neck pain and fever but with no sore throat. The child had vomited once, and the mother reported that he was irritable. The child's temperature was 101.7° F, pulse was 118 beats per minute, respirations were 24 per minute, and blood pressure was 122/65 mm Hg. A decreased range of motion of the neck and a right anterior cervical node were observed; the child refused to swallow. Lateral neck radiographic findings show increased retropharyngeal space (white arrow). The CT scan did not demonstrate an abscess. The child was seen by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved for 2-3 days and then worsened. Repeat neck CT scan findings demonstrated a retropharyngeal abscess. Incision and drainage was performed in the operating room. Cultures of the pus grew group A beta-hemolytic streptococci and alpha-streptococci, both sensitive to clindamycin. He improved and was discharged on the tenth hospital day on oral clindamycin.
An 8-month-old infant boy presented with fever and a stiff neck. According to the mother, the baby was not moving his neck as much as usual. The mother also reported decreased oral intake. His temperature was 100° F, pulse was 104 beats per minute, respirations were 48 per minute, oxygen saturation was 98% (room air [RA]). The left tympanic membrane (TM) was inflamed and nonmobile. Left submandibular and left postauricular nodes were noted. The lateral neck radiograph shows increased retropharyngeal space. The CT scan demonstrated a small retropharyngeal abscess. The WBC count was 26,000 (24 polymorphonuclear leukocytes [P], 5 bands [B], 63 lymphocytes [L], 8 monocytes [M]). The baby was examined by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved over the next few days and was discharged on the fifth hospital day on oral clindamycin with a plan for repeat CT scans of the neck on an outpatient basis.
A 5-year-old boy presented to the ED with 2 days of neck pain and fever but with no sore throat. The child had vomited once, and the mother reported that he was irritable. The child's temperature was 101.7° F, pulse was 118 beats per minute, respirations were 24 per minute, and blood pressure was 122/65 mm Hg. A decreased range of motion of the neck and a right anterior cervical node were observed; the child refused to swallow. Lateral neck radiographic findings show increased retropharyngeal space (white arrow). The CT scan did not demonstrate an abscess. The child was seen by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved for 2-3 days and then worsened. Repeat neck CT scan findings demonstrated a retropharyngeal abscess. Incision and drainage was performed in the operating room. Cultures of the pus grew group A beta-hemolytic streptococci and alpha-streptococci, both sensitive to clindamycin. He improved and was discharged on the tenth hospital day on oral clindamycin.
An 8-month-old infant boy presented with fever and a stiff neck. According to the mother, the baby was not moving his neck as much as usual. The mother also reported decreased oral intake. His temperature was 100° F, pulse was 104 beats per minute, respirations were 48 per minute, oxygen saturation was 98% (room air [RA]). The left tympanic membrane (TM) was inflamed and nonmobile. Left submandibular and left postauricular nodes were noted. The lateral neck radiograph shows increased retropharyngeal space. The CT scan demonstrated a small retropharyngeal abscess. The WBC count was 26,000 (24 polymorphonuclear leukocytes [P], 5 bands [B], 63 lymphocytes [L], 8 monocytes [M]). The baby was examined by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved over the next few days and was discharged on the fifth hospital day on oral clindamycin with a plan for repeat CT scans of the neck on an outpatient basis.
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