Is a local anesthesia approach used for the management of retropharyngeal abscess?

Local Anesthesia for Retropharyngeal Abscess Management

Local anesthesia can be used for drainage of retropharyngeal abscess in select high-risk adult patients who are poor candidates for general anesthesia, though general anesthesia remains the standard approach for most cases, particularly in children. 1

Anesthesia Approach Selection

General Anesthesia (Standard Approach)

• General anesthesia is the preferred method for most retropharyngeal abscess cases, particularly in children who require cooperation and airway control during surgical drainage 2, 3
• Surgical drainage under general anesthesia should be performed in an operating room or anesthetic room with appropriate monitoring 4
• General anesthesia is considered safer than sedation in patients with respiratory compromise, which is common with retropharyngeal abscesses 5

Local Anesthesia (Alternative for Select Cases)

• Local anesthesia via intraoral approach can be considered for high-risk adult patients who are not candidates for general anesthesia, including those who are critically ill, immunocompromised, or have significant comorbidities 1
• A 76-year-old woman with multiple comorbidities (hypertension, diabetes, ischemic heart disease) underwent successful drainage through an incision in the posterior oropharyngeal wall under local anesthesia, with immediate symptom relief 1
• This approach avoids the risks of general anesthesia and minimizes postoperative complications in carefully selected patients 1

Awake Fiberoptic Intubation with Local Anesthesia

• For patients with obstructing retropharyngeal abscess and unstable cervical spine, awake fiberoptic intubation under local and topical anesthesia can be performed before surgical drainage 6
• Following local and topical anesthesia, awake endoscopy allows assessment of obstruction extent and possibility of intubation without abscess rupture 6
• This conservative approach to secure the airway can be effective before requiring surgical airway control as a first-line strategy 6

Clinical Decision Algorithm

For children and cooperative patients:

• General anesthesia is mandatory due to need for cooperation and airway control 2, 3
• Local anesthetic should still be infiltrated for postoperative pain control even when general anesthesia is used 4

For high-risk adult patients (multiple comorbidities, poor anesthesia candidates):

• Consider intraoral drainage under local anesthesia as a valuable alternative 1
• Ensure CT imaging is performed beforehand to assess disease extent and plan the surgical approach 1

For patients with airway obstruction and cervical spine instability:

• Perform awake fiberoptic assessment and intubation under local/topical anesthesia before proceeding to surgical drainage 6

Important Caveats

• The initial attempt to secure the airway is of paramount importance in retropharyngeal abscess cases, as these have potential for acute respiratory compromise from obstruction or rupture 6
• CT or MRI imaging is essential before any intervention to assess abscess extent, volume, and relationship to critical structures 7, 3
• The choice of anesthesia must account for the patient's respiratory status, as retropharyngeal abscesses commonly cause airway compromise 5, 6
• Local anesthesia approach should only be attempted by experienced operators in carefully selected adult patients with appropriate monitoring and resuscitation equipment immediately available 1