What is the approach for managing a retropharyngeal abscess in an 18-year-old with neck pain for 2 days?

Management of Retropharyngeal Abscess in an 18-Year-Old with Neck Pain

Retropharyngeal abscess in an 18-year-old with neck pain for 2 days requires immediate diagnosis with contrast-enhanced CT imaging, prompt surgical drainage, and empiric broad-spectrum antibiotic therapy to prevent life-threatening complications.

Initial Assessment and Diagnosis

• Clinical Presentation: Evaluate for:

  • Neck pain and limited movement/torticollis
  • Dysphagia or feeling of something stuck in throat
  • Fever
  • Respiratory compromise (present in ~29% of cases) 1
  • Neck swelling

• Diagnostic Imaging:

  • Contrast-enhanced CT scan of the neck is the gold standard for diagnosis 2, 3
  • Plain lateral neck radiograph may show air levels or widening of the retropharyngeal space 4

Management Algorithm

Step 1: Airway Assessment and Stabilization

• Evaluate for signs of airway compromise
• If respiratory distress is present, secure airway before proceeding with other interventions
• Position patient appropriately (may use Trendelenburg position during drainage) 4

Step 2: Obtain Cultures and Initiate Empiric Antibiotics

• Obtain cultures before starting antibiotics 2
• Initiate broad-spectrum IV antibiotics immediately:
  • First-line: Amoxicillin-clavulanate (875/125 mg PO twice daily or IV equivalent) 2, 5
  • For suspected MRSA: Add coverage with clindamycin, trimethoprim-sulfamethoxazole, or doxycycline 2

Step 3: Surgical Management

• Incision and drainage is the cornerstone of treatment 2
  • Transoral approach is most common (70% of cases) 1
  • External cervical approach may be needed in some cases (20%) 1
  • Combined approach in complex cases (10%) 1
• Complete evacuation of purulent material is essential 2
• Consider placing a drain to prevent premature closure 2

Step 4: Post-Drainage Care

• Continue IV antibiotics for 5-7 days 5
• Consider adding steroids to reduce inflammation 5
• Monitor for complications:
  • Airway obstruction
  • Mediastinitis
  • Jugular vein thrombosis 5
  • Recurrent laryngeal nerve palsy 1
• Transition to oral antibiotics when clinically improving

Step 5: Discharge Criteria

• Documented overall clinical improvement including:
  • Decreased fever for at least 12-24 hours
  • Improved level of activity and appetite 6
  • Stable vital signs without tachypnea or tachycardia 6
  • Ability to tolerate oral medications 6
  • Normal oxygen saturation (>90%) in room air for 12-24 hours 6

Special Considerations

• Potential Complications:

  • Airway obstruction (most immediate life-threatening risk)
  • Spread to deep facial spaces
  • Necrotizing mediastinitis
  • Pulmonary empyema 4

• Follow-up:

  • Reassess after 48-72 hours
  • Follow-up imaging (CT scan) at 3-6 weeks to confirm resolution 5

Pitfalls to Avoid

1. Delayed diagnosis: Retropharyngeal abscess can present atypically with only neck pain and limited movement, without classic signs of infection 4, 7

2. Inadequate drainage: Ensure all loculations are broken down to prevent recurrence 2

3. Insufficient antibiotic coverage: Use broad-spectrum antibiotics targeting both aerobic and anaerobic organisms 2

4. Failure to monitor for complications: Close observation is necessary due to risk of life-threatening complications 4, 1

5. Premature discharge: Ensure patients meet all discharge criteria before sending home 6