What is the management of a retropharyngeal abscess?

Management of Retropharyngeal Abscess

Initial Treatment Approach

All patients with retropharyngeal abscess require immediate broad-spectrum intravenous antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria, combined with surgical drainage for most cases. 1

Antibiotic Therapy

• Start empiric triple antibiotic coverage immediately upon diagnosis, targeting the polymicrobial nature of these infections 1, 2
• The most commonly isolated organism is Staphylococcus aureus (particularly methicillin-sensitive strains), followed by streptococcal species 3, 4, 2
• More aggressive antibiotic regimens are required for patients with systemic signs of infection or immunocompromised status 1
• Continue antibiotics for approximately 2 weeks based on clinical response and culture sensitivities 2

Surgical Intervention

Surgical drainage should be performed in nearly all cases, particularly when:

• A large abscess is present 4
• Complications develop (mediastinitis, airway compromise) 4, 5
• Inadequate response occurs within 24-48 hours of medical management 4

Surgical Approach Options

The surgical approach depends on abscess location and extent:

• Transoral drainage: Appropriate for accessible abscesses in the oropharyngeal region 3
• Transcervical drainage: Used for lower cervical or extensive abscesses 3
• Combined transoral and transcervical: Required for large, multiloculated collections 3
• Transnasal MRI-guided drainage: Reserved for abscesses near the skull base 3

Airway Management

Airway security is the highest priority in retropharyngeal abscess management:

• Immediate intubation is required when airway obstruction is present or threatened 5
• Intubation should occur in a controlled operating room environment with both an otolaryngologist and anesthesiologist present 5
• Expect difficult intubation (grade 3 or higher) due to anatomical distortion 5
• Post-operative extubation timing varies from immediate to several days in the pediatric intensive care unit, depending on abscess extent and patient age 4

Diagnostic Imaging

CT scan or MRI is essential before surgical intervention to:

• Delineate the full extent of infection 4, 2
• Identify complications such as mediastinitis, epidural abscess, or spondylodiscitis 6, 2
• Guide surgical approach planning 3

Special Populations

Pediatric Patients (especially <5 years)

• Higher risk due to prominent retropharyngeal lymph nodes that undergo suppuration 6, 4
• Require close airway monitoring as deterioration can be rapid 4, 5
• Present with fever, feeding difficulties, neck swelling, and torticollis 6, 4

Adults

• Less common; typically associated with foreign body ingestion, trauma, or immunocompromise 2
• Screen for diabetes and tuberculosis in endemic areas, as these are important comorbidities 2
• Consider tuberculosis etiology if intradermal reaction is positive 2

Common Pitfalls

• Delayed diagnosis leads to life-threatening complications including mediastinitis, airway obstruction, and descending necrotizing mediastinitis 4, 5
• Failure to secure the airway early in patients with respiratory distress or significant neck swelling 5
• Inadequate imaging before attempting drainage can miss extent of disease or complications 4
• Overlooking torticollis as a warning sign of prevertebral muscle spasm or potential epidural extension 6