Retropharyngeal Abscess in Children: Clinical Presentation, Utility of Imaging, and Current Management
* Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico
Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Medical Center, Salt Lake City, Utah
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Objective. We sought to describe the clinical presentation of patients with retropharyngeal abscess (RPA), utility of imaging studies, and implications on management.
Methods. A retrospective chart review was performed at a tertiary-care, pediatric hospital with cases identified by a discharge diagnosis of RPA; posttraumatic RPA cases were excluded. Patients without confirmatory radiographic findings, fluoroscopy, or computed tomography (CT) were excluded.
Results. Sixty-four cases involving 64 patients were studied. The median age of the patients was 36 months; 48 (75%) of the 64 patients were younger than 5 years. The most common chief complaints were neck pain (38%), fever (17%), sore throat (17%), neck mass (16%), and respiratory distress or stridor (5%). In 29 children (45%), it was noted that there was limitation of neck extension, in 23 (36.5%) torticollis, and in 8 (12.5%) limitation of neck flexion. The physical examination revealed stridor with wheezing in only 1 patient (1.5%) and wheezing in 1 other (1.5%). Twenty-seven patients (42%) underwent surgery; 37 (58%) were treated with antibiotics only. Performance of a surgical procedure was significantly associated with CT scan findings. Ten (37%) of 27 patients with defined abscess on CT scan were treated with antibiotics alone. There were no treatment failures in either the antibiotic-only group or the antibiotics-plus-surgery group.
Conclusions. Children with RPA present with limitation of neck movement, especially difficulty extending their neck to look up. They rarely present with respiratory distress or stridor. CT scan is useful to distinguish patients with RPA from those with retropharyngeal cellulitis. Most patients with retropharyngeal cellulitis and some with RPA can be treated successfully without surgery.
Key Words: retropharyngeal abscess • children • pediatric
Abbreviations: RPA, retropharyngeal abscess • CT, computed tomography • PCMC, Primary Children’s Medical Center • CSF, cerebrospinal fluid • RPC, retropharyngeal cellulitis
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Retropharyngeal abscess (RPA) is a potentially serious deep space neck infection. Complications include airway compromise, invasion of contiguous structure, and sepsis. RPA can be of medical or traumatic origin. Nontraumatic RPA is largely a disease of younger children, as a result of developmental aspects of the neck lymphatic system.
The presentation of RPA is sometimes subtle, and the constellation of findings are apparently variable. One textbook suggests a similar presentation to epiglottitis with fever, stridor, drooling, and sometimes meningismus,1 and it was recently dubbed the "epiglottitis of the new millennium."2 It is noted that children present with fever, neck swelling, and stridor,3 or all cases have airway obstruction.4 This contrasts with Swishchuk’s suggestion that stridor is not a prominent feature.5 Other authors emphasize nonspecific symptoms (refusal to eat, irritability, and fever) with hyperextension of the head, neck rigidity and tenderness, tachypnea, and stridor,6 whereas a recent study suggested a "paucity of physical findings."7 The clinical picture of RPA is either highly variable or changing; our institutional experience seemed inconsistent with classic teaching and previous reports.
Diagnosis of RPA is based on clinical suspicion with supportive imaging studies. Plain radiographs show widened prevertebral soft tissues on lateral view of the neck.5,8 Computed tomography (CT) is also useful in diagnosing this illness2,5,9 and is now the preferred imaging technique.10 How improved imaging methods influence management and outcome is uncertain.
Treatment of children who have a diagnosis of RPA is evolving. Traditional management of RPA has been surgical drainage of the pus collection, with intraoral incision and drainage currently the preferred technique,10 yet some cases are managed with antibiotics alone.11 We sought to describe the clinical presentation of patients with RPA in the current era, utility of imaging studies, and implications on management.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A retrospective chart review was performed at Primary Children’s Medical Center (PCMC) in Salt Lake City, Utah. PCMC is a tertiary-care, pediatric hospital that serves a large geographical area, including most of Utah and portions of Idaho, Nevada, and Wyoming. Cases were identified for inclusion by a discharge diagnosis of RPA and age younger than 16 years. Patients with posttraumatic RPA were excluded. Patients without confirmatory radiographic findings, either on fluoroscopy or on CT scan, were excluded. The review covered a 5-year period (1993–1998), and all charts were abstracted by 1 of the authors (FC) and a research assistant. The reviewer was aware of the descriptive nature of this study. There was no other independent review of charts. Charts were reviewed for age, date of visit, presenting complaint(s), neck examination findings, respiratory examination findings (presence of stridor or wheezes), imaging studies and interpretation, laboratory results, hospital course, and surgical interventions. Interpretation of all imaging studies was performed by pediatric radiologists. Dictated radiology reports were reviewed; original imaging studies were not. Treatment failure was defined as recurrent abscess, readmission, or repeat surgical procedure after the initial hospital stay. Institutional (PCMC) Medical Records Research Committee approval was obtained before chart review.
Analysis of data was performed using simple descriptive statistics. 
2 analysis was used to assess differences between groups with regard to binomial outcomes and Mann-Whitney U test to compare nonparametric variables. A commercially available statistical program (Statview; Abacus Concepts, Inc, Berkeley, CA) was used for analysis.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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During the 5-year period, 71 patients were discharged with a diagnosis of RPA. Six cases of traumatic RPA were excluded from additional analysis. One additional case was excluded despite an abnormal lateral neck radiograph because no confirmatory study was performed; a CT scan performed on the fifth hospital day was normal. The remaining 64 cases involving 64 patients formed the basis for the analysis. The median age of the patients was 36 months. Overall, 48 (75%) of the 64 patients were younger than 5 years, and 10 (16%) were younger than 1 year (see Fig 1).
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There were a variety of clinical presentations. The most common chief complaints were neck pain (38%), fever (17%), sore throat (17%), neck mass (16%), and respiratory distress or stridor (5%). When all complaints were examined, fever was present in 50 (78%) of 64, neck pain in 43 (67%) of 64, sore throat in 24 (38%) of 64, and cough in 13 (20%) of 64. The mean and median temperature was 38.1°C (standard error of the mean: 0.12°C). Twenty-nine children (45%) had limitation of neck extension, 23 (36.5%) had torticollis, and 8 (12.5%) had limited neck flexion. In only 11 patients (17%) was there no mention of limited neck movement in the chart. Neck mass was noted in 55%. The physical examination revealed stridor and wheezing in 1 patient (1.5%) and wheezing in 1 other (1.5%). Five patients (8%) had examinations describing mild alterations in level of consciousness (eg, lethargic, listless).
Pretreatment with antibiotics before diagnosis of RPA occurred in 31 (48%) of the 64 cases. Antibiotics used most commonly were amoxicillin (13), ceftriaxone (6), and amoxicillin/clavulanate (5). Documented reasons for antibiotic use included positive rapid streptococcal test (8) pharyngitis (6), streptococcal pharyngitis (4), adenitis (4), concern for meningitis (2), streptococcal infection in family (1), tonsillitis (1), otitis media (1), abscess (1), and fever (1).
Confirmation of abnormal anatomy through imaging studies was necessary for inclusion in the study, but an isolated abnormal lateral neck radiograph was not sufficient. Plain radiographs were obtained in 44 patients (69%), interpreted as abnormal in 38 (86%) of 44, normal in 3 (7%) of 44, and equivocal in 3 (7%) of 44. Fluoroscopy was performed and abnormal in 6 patients. Overall, 62 (97%) of 64 patients had abnormal CT scans. Interpretation of the CT scan for the presence of a defined abscess included abscess present in 27 (43.5%), no abscess in 22 (35.5%), and possible abscess in 13 (21%). In 2 patients, RPA confirmation occurred solely on the basis of abnormal neck fluoroscopy.
Although bacteriologic studies were not performed on all patients, 20 patients had a blood culture; 1 was positive for Staphylococcus aureus. Intraoperative cultures were obtained in 20 cases, and bacteriologic growth occurred in 17 (85%), including group A Streptococcus (13), S aureus (2), Haemophilus influenzae (1), and anaerobes (1). Five patients underwent lumbar puncture; 4 patients had no cerebrospinal fluid (CSF) pleocytosis and CSF cultures without growth. One patient, with no antibiotic pretreatment, had a lumbar puncture that revealed 28 white blood cells/mm3. Blood and CSF cultures were negative, but an intraoperative culture grew S aureus.
All but 1 patient was hospitalized and received intravenous antibiotics. That patient had neck pain, limited neck movement, and an equivocal lateral neck radiograph, but positive neck fluoroscopy. He was placed on amoxicillin/clavulanate and treated as an outpatient at his physician’s request; he did not require subsequent admission or surgery. Antibiotic choices for hospitalized patients most commonly included clindamycin (50%) and ampicillin/sulbactam (28%). Twenty-seven patients (42%) underwent surgery during their hospitalization, whereas 37 (58%) were treated with antibiotics alone (see Table 1). Surgery was performed on the first or second hospital day in 63%; the latest surgery was on day 4. Performance of a surgical procedure was significantly associated with CT scan findings as outlined in Table 1 (P < .001). In the 27 patients with abscess noted on CT scan, 10 (37%) were treated with antibiotics alone. Length of stay ranged from 1 to 13 days with 84% hospitalized for 5 days or fewer. The average length of stay for patients who underwent surgery was longer than those who did not (5.1 day vs 3.2 days; P < .001 by Mann-Whitney U). There were no treatment failures in either the antibiotic-only group or the antibiotics-plus-surgery group.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A deep tissue neck infection, RPA is serious and occasionally life-threatening partly as a result of the anatomic location and the potential to obstruct the upper airway. In a case series from Australia, there were 2 deaths before 1965.3 In our report, there were no deaths, similar to recent reports.7,12–14
RPAs are thought to occur as a consequence of infections of the nasopharynx, paranasal sinuses, or middle ear. The infectious foci extend to lymph nodes located in the space between the posterior pharyngeal wall and the prevertebral fascia. These lymph nodes likely atrophy after the first 3 or 4 years of life, although some suggest that this occurs around puberty.15 RPA from nontraumatic causes occurs predominantly in early childhood. Regional trauma, foreign body ingestion, complication of procedures, or an immunocompromised state account for the majority of adult cases.16,17 Our study emphasizes the predominance of RPA in early childhood; 75% of our cases occurred in children younger than 5 years, a finding similar to other pediatric series.3,4,7,12 This supports the contention that atrophy of regional lymph nodes with increasing age decreases disease risk.
Our series differs from other pediatric reports with regard to the microbiology. In our study, group A Streptococcus and S aureus predominated, whereas anaerobic organisms were noted infrequently. Brook18 reported 14 children with RPA undergoing needle aspiration. All 14 patients were found to have anaerobes, and 12 of the 14 had mixed flora. Predominant anaerobic species were Bacteroides, Peptostreptococcus, and Fusobacterium, and 
and 
hemolytic streptococci, S aureus, H influenzae, and group A ß-hemolytic streptococci were the predominant aerobes.18 Similar results were reported by Asmar15 with mixed organisms in 15 of 17 cases: aerobes in all cases, and 53% had anaerobes. Anaerobic organisms were recovered much less frequently in our study; this may reflect technical issues of sample collection or, less likely, differences in bacteriologic pathogenesis within our sample population.
Our study emphasizes an area in which traditional teaching about RPA may be misleading. RPA is frequently listed in the differential diagnosis for stridor or airway obstruction, and some suggest a similarity in the presentation of this condition to epiglottitis.1,2,19 Coulthard and Isaacs3 found stridor in 71% of patients who were younger than 1 year and in 43% of patients who were older than 1 year. Stridor occurred in 23% of patients in the series of Thompson et al,13 whereas Morrison and Pashley12 noted stridor or airway obstruction in most patients. A recent review referred to RPA as a "distinctive cause of airway obstruction in childhood."20 Respiratory findings occurred in 3% of the patients in our series (stridor in 1 patient). Recent experience from another children’s hospital noted no cases of respiratory distress while patients were awake.7 This infrequency of respiratory signs represents a significant departure from classic teaching. The absence of evolving airway obstruction might be attributable to a changing spectrum of the disease or, more likely, earlier diagnosis before airway compromise.
Because respiratory difficulty and stridor is a rare finding, limited neck mobility should be the clinical clue to diagnosing RPA. Specifically, we note that most patients prefer to keep the neck neutral, have pain with neck extension, and use eye movements with a stationary head to look up. This differs from claims by others that hyperextension of the neck or head is a common feature of this condition.6,12,21,22 Other series have noted abnormalities with neck mobility or torticollis in children with RPA. Thompson et al13 noted neck stiffness in only 12%. Others have suggested that the neck stiffness is similar to that seen in meningitis12; however, the limitation in meningitis usually involves neck flexion. In our series, 5 patients underwent lumbar puncture for evaluation of meningitis presumably because of the presence of fever and a stiff neck. Our series suggests that children with RPA often have a remarkable degree of neck stiffness in the absence of clinical "toxicity"; only 8% were described as listless or lethargic. RPA should be considered in young patients with limited range of motion of the neck and fever, even in the absence of any respiratory findings.
Recent studies have helped clarify the role of specific imaging tests in diagnosing RPA. Studies such as those by Haug et al23 helped to establish norms for the lateral neck radiograph so that determination of abnormally enlarged retropharyngeal soft tissue shadow could be more accurate. This author and others23,24 have emphasized the importance of proper positioning (true lateral orientation, neck in extension) and full inspiration so that the retropharyngeal space is not falsely thickened. Some studies emphasize the utility of neck CT scan to diagnose this condition accurately9,14,25,26 and the potential utility of neck ultrasound.25 A survey of pediatric otolaryngologists noted that 72% preferred CT scans as the initial method of imaging,10 and in 3 case series, all patients underwent neck CT scanning.2,7,27 We also prefer CT for diagnosing RPA. Widespread availability of CT scanning and increased familiarity with the clinical presentation may obviate the need for a "screening" lateral neck radiograph.
Recent studies have attempted to correlate CT scan findings with intraoperative findings.7,27 It is clear that neck CT scanning is flawed in predicting pus at surgery; the false-negative rate (CT suggests no abscess while surgery recovers pus) and the false-positive rate (CT scan suggests abscess that exploration fails to detect) were 13% and 10%, respectively.27 The study by Kirse and Roberson7 suggests that scalloping of the abscess wall may more accurately predict pus than other findings but had a sensitivity of only 64%. Our series emphasizes the utility of CT scanning in differentiating retropharyngeal cellulitis (RPC), also referred to as a retropharyngeal phlegmon, from a well-delineated RPA. In both the Kirse and Roberson7 study and that by Lazor et al,27 only patients who underwent surgical exploration or drainage procedure were included. Our patients selectively underwent surgery, so we can draw no conclusions about the sensitivity or predictive value of specific radiographic findings.
This ability to distinguish RPC from RPA is relevant if this distinction contributes to medical decision-making, especially related surgical intervention. In a study of 14 pediatric patients with deep neck infections, 7 of 8 patients who were treated without surgery had CT evidence of cystic lesions.11 In our study, 58% did not undergo surgery. Even in the 27 patients with defined abscess, 37% were managed with antibiotics alone. Nonoperative management occurred more often (69%) when there was no clearly defined abscess. There were no treatment failures in the surgery plus antibiotics or the antibiotics-only groups. It is intriguing to speculate whether more patients could have been managed without surgery.
Surgical practice for RPA is varied. A 1997 subspecialty survey revealed that whereas 22% believed that operative drainage was always needed, 31% would routinely institute a trial of antibiotics when there was no airway compromise.10 A management flow diagram for deep neck infections in a pediatric otolaryngologic textbook also allows for an antibiotic trial before surgery.28 Our series represents the largest group of children with RPA managed with antibiotics alone. This is in contrast to recent reports of 85% to 100% surgery rates.7,12 A recent review stated that "standard treatment of retropharyngeal abscesses includes surgical drainage,"29 and an investigator noted, "What advantage treatment with IV antibiotics offers over surgical drainage is unclear."7
The necessity of surgery may vary between studies, as inclusion criteria may vary and as imaging techniques become more precise. In a recent report of 26 patients, 21 with clear abscesses on CT were treated with surgical drainage and 5 without clear abscess were treated successfully with antibiotics alone.2 In a series of 27 children from Pittsburgh Children’s Hospital, 18 had RPC and none had RPA; overall 12 (44%) were treated with antibiotics only.14 The role of nonoperative management is evolving. With the paucity of reported failures after antibiotic treatment alone, a trial of antibiotics should be considered in cases of RPC and some cases of RPA in which the abscess is small and when there is no evidence of airway compromise. The appropriate duration of intravenous antibiotic therapy could not be assessed in the study. Hospitalization and intravenous antibiotic courses were generally short (<5 days), and the decisions to discharge the patient and switch to oral antibiotic therapy were based on clinical improvement.
The other remarkable finding in our study relates to the frequency with which we see this condition. Although comparison between regions is difficult, we noted 64 nontraumatic cases of RPA in 5 years, an institutional case rate of 
13 per year. This is higher than reported at other pediatric hospitals: Boston (75 cases in 10 years, 7.5 per year),7 Pittsburgh (27 cases in 6 years, 4.5 per year),14 Denver (17 cases in 10 years, 1.7 per year),12 Los Angeles (65 cases in 36 years, 1.8 per year),13 and Sydney, Australia (31 cases in 36 years, 1 per year).3 The Boston series and our series are the most recent and could suggest an increasing frequency of disease, different-sized population bases, different incidence of disease in different regions, or different antibiotic use patterns.
Our study has several limitations. Because this is a retrospective review, there was no assurance of standardized documentation relating to the physical findings. It is likely that some physical findings were underreported. This likely affected reporting of the subtleties of the neck examination more than documenting the presence of stridor. There were no standardized criteria for documenting CT scan interpretation, and interpretation was performed by several different pediatric radiologists. However, this situation mirrors clinical practice. There was no predetermined management protocol regarding antibiotic choice or surgical intervention. We cannot comment about strict differences in the subsets managed by operative or nonoperative methods or draw conclusions about the accuracy of CT scanning when compared with surgical findings. We also cannot comment about the "appropriateness" or "success" of surgical intervention, ie, whether the surgery was necessary or whether hospitalization differed between groups. Similarly, there may be individual practice variation both in antibiotic choice and in the decision for surgery. Last, our study emphasizes the presence of limited neck mobility, especially limited neck extension, but does not attempt to evaluate the positive predictive value of these neck findings in identifying patients with RPA. Clearly, other medical conditions may limit neck motion, including pharyngitis, cervical adenitis, cervical osteomyelitis, and meningitis.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study reviews a large pediatric series of RPA. Our experience raises the question of whether the incidence of this condition is increasing or occurs at a higher frequency in our region. We emphasize the increasing importance of differentiating RPC from RPA, the utility of CT scan to aid in this distinction, and the implications of that distinction on possible nonoperative management. We suggest that most of the patients with RPC and some of these patients with RPA can be treated successfully without surgery. Furthermore, our clinical experience diminishes the importance of respiratory distress or stridor as a presenting finding. Increased attention should be placed on the typical neck examination. Heightened suspicion for RPA should occur with the child who will not fully extend his or her neck to look up. At our institution, we refer to this as "Bolte’s sign," in deference to our colleague (Robert G. Bolte, MD), who noted the importance of this finding several years ago. This may prove to be extremely useful in differentiating RPA and RPC from other conditions that may present in a similar manner. Additional studies of retropharyngeal infections should investigate the clinical utility of neck and respiratory findings in diagnosing this condition and in identifying subpopulations for nonoperative management.
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FOOTNOTES |
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Received for publication Dec 27, 2001; Accepted Dec 20, 2002.
Reprint requests to (J.E.S.) Emergency Department, Primary Children’s Medical Center, 100 N. Medical Dr, Salt Lake City, UT 84113. E-mail: jeff.schunk{at}hsc.utah.edu
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