URTObstruction - Diseases
Introduction Physical Examination Differential Diagnosis Specific Diseases Epiglottitis Viral croup Foreign body aspiration Retropharyngeal abscess References Other Lectures		The usual age for retropharyngeal abscess (RPA) formation is 6 months to 3 years. It is rare over the age of 3 because of a normal regression in the size of the retropharyngeal lymph nodes with age. It begins with a URI which localizes to the retropharyngeal lymph nodes over several days. Dysphagia and refusal to feed occur before significant respiratory distress. Because the disease begins posteriorly, stridor is a late finding. These children are usually toxic-appearing, febrile and have drooling, dysphagia, sore throat and a stiff neck. Characteristically, they assume an almost opisthotonic posture. Those patients with stridor can present similarly to epiglottitis, with fever and drooling. In fact, RPA has recently been dubbed "the epiglottitis of the new millennium", in part because of this similar clinical appearance and also because of the rising incidence of RPA coupled with the declining incidence of epiglottitis. The diagnostic test is a lateral neck Xray. If this is equivocal or normal and the diagnosis is still suspected clinically, CT of the neck can be very helpful, especially in distinguishing those children with actual abscess formation from those with retropharyngeal cellulitis and edema alone. Physical exam of the pharynx shows a retropharyngeal mass which can often be seen with a tongue blade and flashlight. Palpation of the mass is dangerous, as it may lead to rupture of the abscess. Treatment is high-dose IV antibiotics. Common organisms include S. aureus, S. pyogenes and S. viridans, however gram-negatives or anaerobes may be involved. Most people recommend either clindamycin or nafcillin together with a third-generation cephalosporin. If fluctuation or severe respiratory distress occurs, an incision and drainage of the abscess should be done in a controlled manner in the OR by an experienced otolaryngologist. Many people recommend surgical drainage for all cases of CT-documented abscess. Complications include respiratory failure from obstruction, rupture of the abscess into the airway causing either asphyxia or bronchopneumonia and spread of the abscess into the adjacent soft tissues of the neck. Return to top of page