In a patient with a suspected retropharyngeal abscess who presents with cervical rigidity, what does this sign indicate and what is the recommended urgent work‑up and management?

Cervical Rigidity in Retropharyngeal Abscess

Cervical rigidity in a patient with retropharyngeal abscess is an ominous sign indicating potential extension to the prevertebral space with spondylodiscitis, epidural abscess, or impending spinal cord compression—this mandates immediate MRI of the cervical spine with and without IV contrast and urgent multidisciplinary consultation for airway management and surgical drainage. 1, 2, 3

Clinical Significance of Cervical Rigidity

• Cervical rigidity (neck stiffness, torticollis, or limited range of motion) in retropharyngeal abscess suggests inflammatory irritation of the prevertebral muscles, cervical nerves, or vertebrae, and may indicate progression beyond simple abscess to more serious complications 4, 5
• The presence of torticollis or severe neck contracture specifically raises concern for:
  • Cervical vertebral osteomyelitis and discitis (spondylodiscitis) with potential vertebral destruction 3, 4
  • Epidural abscess with risk of spinal cord compression—a feared complication with potential for permanent neurologic deficit 1, 2
  • Inflammatory spasm of prevertebral muscles from deep fascial spread of infection 5

Urgent Diagnostic Work-Up

Immediate Imaging Protocol

• Obtain MRI of the cervical spine without and with IV contrast emergently—this is the gold standard with 96% sensitivity and 94% specificity for detecting epidural abscess, spinal cord compression, vertebral osteomyelitis, and extent of soft tissue involvement 1
• MRI provides optimal visualization of the epidural space, spinal cord, intervertebral discs, vertebral endplates, and paraspinal soft tissues that CT cannot adequately assess 1
• If MRI is contraindicated or unavailable, obtain contrast-enhanced CT of the cervical spine, though sensitivity for epidural abscess is only 6% and it will miss early marrow edema and ligamentous involvement 1

Critical Imaging Findings to Identify

• Epidural abscess or fluid collection causing spinal canal compromise (>50% canal narrowing indicates advanced disease requiring immediate surgical intervention) 1
• Vertebral body or disc space involvement suggesting osteomyelitis/discitis, which may appear as marrow edema, endplate irregularity, or frank vertebral lysis 1, 3, 4
• Extent of retropharyngeal collection and degree of airway compromise 3, 6
• Mediastinal extension of the abscess, which can occur along fascial planes and carries high mortality 6

Laboratory Assessment

• Blood cultures (positive in hematogenous spread cases) 3
• Complete blood count, inflammatory markers (ESR, CRP) 1, 4
• Blood glucose (diabetes is a significant risk factor and comorbidity) 4
• Consider tuberculin skin testing in endemic areas, as tuberculosis can present as retropharyngeal abscess with vertebral involvement 4

Airway Management Considerations

Securing the airway takes absolute priority before any surgical intervention, as retropharyngeal abscess can cause life-threatening airway obstruction. 3, 6

Specific Airway Approach with Cervical Pathology

• Use videolaryngoscopy rather than direct laryngoscopy for intubation, as it reduces cervical spine movement (Grade A recommendation) 1
• Remove only the anterior portion of the cervical collar during intubation attempts to minimize cervical spine motion while maintaining some posterior support 1
• Employ jaw thrust rather than head tilt-chin lift for airway opening maneuvers to limit cervical spine movement 1
• Consider awake fiberoptic intubation in cooperative patients with significant airway distortion or when cervical spine instability is confirmed 1
• Have immediate access to emergency front-of-neck airway equipment (surgical cricothyroidotomy) as retropharyngeal masses can make intubation extremely difficult 1

Urgent Management Algorithm

Step 1: Immediate Stabilization

• Secure IV access, initiate broad-spectrum IV antibiotics covering Staphylococcus aureus, streptococci, and gram-negative organisms (including E. coli in immunocompromised patients) 3, 4
• NPO status and airway monitoring in ICU setting 3, 6

Step 2: Multidisciplinary Consultation

• Otolaryngology for transoral drainage of retropharyngeal component 2, 4, 6
• Neurosurgery if epidural abscess or spinal cord compression is identified on MRI 1, 2
• Anesthesiology for difficult airway planning 1

Step 3: Surgical Intervention

• Transoral incision and drainage is the standard approach for isolated retropharyngeal abscess 4, 6
• Posterior cervical laminectomy with epidural abscess evacuation if spinal canal compromise is present 1, 2
• In cases with concurrent epidural and retropharyngeal collections, a posterior approach can address both via transcervical catheter drainage of the ventral collection under fluoroscopic guidance 2
• Transcervical approach may be required for extensive collections or when transoral access is inadequate 4, 6

Critical Pitfalls to Avoid

• Do not delay imaging for clinical observation—cervical rigidity indicates advanced disease requiring immediate visualization of deep structures 1, 3
• Do not rely on plain radiographs alone—while they may show prevertebral soft tissue thickening or vertebral lysis, they miss epidural extension and early osteomyelitis 4
• Do not attempt intubation without senior anesthesia support and backup airway plan—these patients have both difficult anatomy and unstable cervical spines 1
• Do not miss diabetes or immunocompromise—these conditions dramatically increase risk of complications and may require ICU-level glycemic control 4
• Do not forget to assess for mediastinal extension—imaging should extend to the upper thorax as descending necrotizing mediastinitis carries mortality rates exceeding 40% 6

Prognosis and Follow-Up

• With prompt surgical drainage and appropriate antibiotics, outcomes are generally favorable even in complicated cases 4, 5, 6
• Patients with epidural abscess and neurologic deficits require urgent decompression within hours to prevent permanent spinal cord injury 1
• Traction therapy may be beneficial adjunct for torticollis related to muscle spasm once infection is controlled 5
• Close orthopedic or neurosurgical follow-up is mandatory when vertebral involvement is present to monitor for spinal instability 5