What is the treatment for retropharyngeal abscess in pediatric patients?

Treatment of Retropharyngeal Abscess in Pediatric Patients

Retropharyngeal abscess in children requires prompt initiation of intravenous antibiotics with surgical drainage reserved for cases that fail medical management, have significant airway compromise, or demonstrate clear abscess formation on imaging. 1

Initial Assessment and Airway Management

The most critical priority is assessing and securing the airway, as respiratory obstruction occurs in approximately 29% of children at presentation and can be life-threatening. 2, 3

• Immediate airway evaluation is mandatory, looking specifically for stridor, respiratory distress, drooling, and inability to handle secretions 2, 3
• Be prepared for emergent tracheotomy if endotracheal intubation fails, as severe airway obstruction can make intubation impossible even by experienced airway surgeons 3
• Manage these patients in facilities with pediatric intensive care capabilities and experienced airway management teams 2

Medical Management: First-Line Approach

A trial of intravenous antibiotics alone is appropriate for many cases before considering surgical drainage, as approximately 20-40% of retropharyngeal abscesses may resolve with antibiotics alone. 1

Antibiotic Selection

• Broad-spectrum intravenous antibiotics covering common pathogens including Streptococcus pneumoniae and anaerobes 2, 4
• Specific regimens used successfully include meropenem trihydrate plus clindamycin 4
• Continue parenteral antibiotics for at least 5 days, with total duration depending on clinical response 5

Monitoring During Medical Management

• Observe for clinical improvement within 48-72 hours 1
• Watch for worsening respiratory symptoms, persistent fever, or increasing neck swelling that would indicate need for surgical intervention 2

Surgical Drainage: Indications and Approach

Surgical drainage is indicated when:

• Medical management fails after 48-72 hours of appropriate antibiotics 1
• Significant respiratory compromise is present at presentation 2, 3
• Imaging demonstrates a well-defined abscess cavity 1
• Clinical deterioration occurs despite antibiotic therapy 2

Surgical Technique

The transoral approach is preferred by 83% of pediatric otolaryngologists and was used successfully in 70% of cases in major series. 2, 1

• Transoral incision and drainage under general anesthesia is the primary surgical approach 2, 1
• External cervical approach (used in 20% of cases) is reserved for abscesses extending laterally or inferiorly, or when transoral access is inadequate 2
• Combined approaches may be necessary in 10% of cases with extensive disease 2

Critical Complications to Monitor

Mediastinitis is the most serious complication, occurring in approximately 10% of cases, and requires aggressive management with continued antibiotics and possible surgical drainage. 2

• Laryngeal spasm can occur post-operatively and requires immediate recognition and management 5
• Recurrent laryngeal nerve palsy is a rare but recognized complication of surgical drainage 2
• Torticollis from prevertebral muscle spasm may require traction therapy in addition to antibiotics 4
• Rule out epidural abscess and infectious spondylitis when torticollis is present 4

Special Considerations

• Foreign body ingestion accounts for 10% of cases and should be specifically investigated 2
• Tracheotomy and short-term intubation (24-72 hours) are rarely required but must be available 1
• Computed tomography is the preferred diagnostic imaging modality (used by 72% of practitioners), though lateral neck radiography showing widened retropharyngeal space can support diagnosis 1, 5

Common Pitfalls

• Delaying surgical intervention in children with respiratory compromise can be fatal 3, 5
• Underestimating airway obstruction severity—always have backup airway plans including tracheotomy capability 3
• Inadequate antibiotic coverage—ensure coverage for both aerobic and anaerobic organisms 2, 4
• Prior antibiotic administration often results in sterile cultures, so empiric broad-spectrum coverage is essential 5