Retropharyngeal Abscess

Retropharyngeal Abscess is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • Deep tissue infection of the retropharyngeal space:
    • Potential space bound anteriorly by buccopharyngeal fascia, posteriorly by alar fascia, superiorly by skull base, inferiorly by fusion of fascial layers at T2
    • Space fused by raphe at midline with chains of lymph nodes extending down each side
    • Alar fascia is poor barrier and allows retropharyngeal infections to spread into “danger” space and posterior mediastinum
  • Primarily a disease of children, but increasing frequency in adults:
    • Peak incidence at 3–5 yr when retropharyngeal nodes most prominent
  • Prognosis is good when promptly diagnosed and aggressively managed with IV antibiotics and/or surgical drainage
  • Complications due to mass effect, rupture, or spread are the major source of morbidity and include:
    • Airway compromise (most common)
    • Aspiration pneumonia due to rupture
    • Sepsis
    • Spontaneous perforation
    • Necrotizing soft tissue infection
    • Mediastinitis
    • Thrombosis of the internal jugular vein
    • Jugular vein suppurative thrombophlebitis (Lemierre syndrome)
    • Erosion into carotid artery (primarily adults)
    • Atlantoaxial dislocation from erosion of ligaments
    • Cranial nerve palsies (typically IX–XII)
    • Epidural abscess
    • Recurrent abscess formation (1–5%)

Etiology

  • Causes:
    • Most often arises from infection of nasopharynx, paranasal sinuses, or middle ear
    • Infection then spreads to lymph nodes between posterior pharyngeal wall and alar fascia
    • Trauma, foreign bodies, and iatrogenic introduction of infection from instrumentation also common cause, especially in adults
    • Diabetes and other immunosuppressed states may predispose to this infection
  • Bacteriology: Predominately polymicrobial with anaerobes and aerobes
  • Most common organisms are:
    • Streptococcus pyogenes and Streptococcus viridans
    • Staphylococcus aureus (including MRSA)
    • Respiratory anaerobes (including Prevotella, Fusobacterium, and Veillonella)
  • Less common organisms are:
    • Haemophilus species
    • Acid-fast bacilli
    • Klebsiella pneumoniae
    • Escherichia coli
    • Eikenella corrodens
    • Mycobacterium tuberculosis
    • Aspergillus and Candida species

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Basics

Description

  • Deep tissue infection of the retropharyngeal space:
    • Potential space bound anteriorly by buccopharyngeal fascia, posteriorly by alar fascia, superiorly by skull base, inferiorly by fusion of fascial layers at T2
    • Space fused by raphe at midline with chains of lymph nodes extending down each side
    • Alar fascia is poor barrier and allows retropharyngeal infections to spread into “danger” space and posterior mediastinum
  • Primarily a disease of children, but increasing frequency in adults:
    • Peak incidence at 3–5 yr when retropharyngeal nodes most prominent
  • Prognosis is good when promptly diagnosed and aggressively managed with IV antibiotics and/or surgical drainage
  • Complications due to mass effect, rupture, or spread are the major source of morbidity and include:
    • Airway compromise (most common)
    • Aspiration pneumonia due to rupture
    • Sepsis
    • Spontaneous perforation
    • Necrotizing soft tissue infection
    • Mediastinitis
    • Thrombosis of the internal jugular vein
    • Jugular vein suppurative thrombophlebitis (Lemierre syndrome)
    • Erosion into carotid artery (primarily adults)
    • Atlantoaxial dislocation from erosion of ligaments
    • Cranial nerve palsies (typically IX–XII)
    • Epidural abscess
    • Recurrent abscess formation (1–5%)

Etiology

  • Causes:
    • Most often arises from infection of nasopharynx, paranasal sinuses, or middle ear
    • Infection then spreads to lymph nodes between posterior pharyngeal wall and alar fascia
    • Trauma, foreign bodies, and iatrogenic introduction of infection from instrumentation also common cause, especially in adults
    • Diabetes and other immunosuppressed states may predispose to this infection
  • Bacteriology: Predominately polymicrobial with anaerobes and aerobes
  • Most common organisms are:
    • Streptococcus pyogenes and Streptococcus viridans
    • Staphylococcus aureus (including MRSA)
    • Respiratory anaerobes (including Prevotella, Fusobacterium, and Veillonella)
  • Less common organisms are:
    • Haemophilus species
    • Acid-fast bacilli
    • Klebsiella pneumoniae
    • Escherichia coli
    • Eikenella corrodens
    • Mycobacterium tuberculosis
    • Aspergillus and Candida species

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