Clinical presentation can be nonspecific, and not initially point to the development of infection in the retropharyngeal space. However, sore throat, fever, neck stiffness, as well as swelling, odynophagia, rhinorrhea and cough have been reported most commonly in infants and children [10], which signalizes an ongoing process in the upper respiratory tract and pharynx. Other symptoms that may be present include dysphagia and odynophagia, dysarthria and stridor (as a result of mechanical compression of the abscess on the surrounding structures), nuchal rigidity, as well as cervical lymphadenopathy.

• Pain

  OBJECTIVE: To present a case of an uncommon presentation of cellulitis of the neck as benign neck pain. CLINICAL FEATURES: A 44-year-old man had severe neck pain and headaches for 2 weeks with an unknown cause. [ncbi.nlm.nih.gov]

• Fever

  Abstract Fever is a common presenting chief complaint in the pediatric emergency department. [ncbi.nlm.nih.gov]

  Retropharyngeal vs Peritonsillar R: < 6 yo, P: Teens R: fever, sore throat, neck stiffness P: fever, sore throat, trismus R: purulence of retropharyngeal LN P: purulence in tonsillar fossa R: may need imaging P: PE diagnostic CHLA Board Review 2005, other [johnsarm.net]

  Consider RPA in young children with fever, limited neck movement, and fever. Do not rely on signs of respiratory distress to cause suspicion. [pedclerk.bsd.uchicago.edu]

  Retropharyngeal abscesses, most common among young children, can cause sore throat, fever, neck stiffness, and stridor. Diagnosis requires lateral neck x-ray or CT. Treatment is with endotracheal intubation, drainage, and antibiotics. [merckmanuals.com]

• Malaise

  RPA is a relatively uncommon illness, and therefore may not receive early diagnosis in children presenting with stiff neck, malaise, difficulty swallowing, or other symptoms listed below. [en.wikipedia.org]

  Other common symptoms include irritability, malaise, mild photophobia, and odynophagia (painful swallowing). Odynophagia causes drooling, poor oral intake, and anorexia. [online.epocrates.com]

  […] the mouth Trismus: difficulty in opening the mouth Respiratory problems, such as stridor (abnormal breathing sound that is very high-pitched) High-grade fever Airways obstruction Cough Agitation Neck pain, stiff neck, presence of swelling in the neck Malaise [dovemed.com]

  It is usually seen in an infant or young child with high fever, agitation, neck pain, malaise, fever, dysphagia, drooling, cough, respiratory distress, and stridor. [ 3 ] There is a stiff neck with the head tilted to one side. [patient.info]

• Weakness

  Tenderness over the involved vertebrae, weakness of the related muscles, and paraesthesia are the usual symptoms. [ncbi.nlm.nih.gov]

  A 36-year-old Nigerian woman presented with a month history of neck pain and neck stiffness and 6 day history of weakness in the upper and lower limbs worse on the left. [atmph.org]

• Streptococcal Pharyngitis

  The patient presented to an emergency department with symptoms suggesting meningitis but was subsequently diagnosed with streptococcal pharyngitis. He was discharged home on oral antibiotics after a short hospitalization. [ncbi.nlm.nih.gov]

• Aspiration

  USG (Ultrasonography) guided aspirate of abscess sent for microscopy and culture showed acid fast bacilli. Multiple USG guided aspirations under antibiotic and antitubercular cover (Category I) were done. [ncbi.nlm.nih.gov]

• Stridor

  Children may have odynophagia, dysphagia, fever, cervical lymphadenopathy, nuchal rigidity, stridor, dyspnea, snoring or noisy breathing, and torticollis. Adults may have severe neck pain but less often have stridor. [merckmanuals.com]

  The symptoms are sore throat, fever, neck stiffness and stridor. [apicareonline.com]

  Stridor and hoarseness of voice decreased immediately. Within two-and-a-half hours, the patient improved neurologically. [ncbi.nlm.nih.gov]

• Dysphagia

  Abstract Retropharyngeal tubercular abscess is an uncommon cause of neck pain and dysphagia in the developed world. [ncbi.nlm.nih.gov]

  May differ between adults and children Most common: Sore throat Neck pain/stiffness Odynophagia Dysphagia Fever Additional presenting symptoms: Stridor, dyspnea Muffled voic... [5minuteconsult.com]

• Dysphagia

  Abstract Retropharyngeal tubercular abscess is an uncommon cause of neck pain and dysphagia in the developed world. [ncbi.nlm.nih.gov]

  May differ between adults and children Most common: Sore throat Neck pain/stiffness Odynophagia Dysphagia Fever Additional presenting symptoms: Stridor, dyspnea Muffled voic... [5minuteconsult.com]

• Odynophagia

  A case of tuberculous retropharyngeal abscess is described here presenting with odynophagia and Horner's syndrome. Horner's syndrome as a presenting feature of tuberculous retropharyngeal abscess has never been reported in Pakistan. [ncbi.nlm.nih.gov]

  Other symptoms that may be present include dysphagia and odynophagia, dysarthria and stridor (as a result of mechanical compression of the abscess on the surrounding structures), nuchal rigidity, as well as cervical lymphadenopathy. [symptoma.com]

• Trismus

  […] dysphonia - like a duck ( cri du canard ) appears ill, supine, next extended, (tripod) respiratory difficulty, stridor ET intubation is difficult, hazardous PE: posterior pharynx edema, erythema tender cervical LAD tender cervical musculature high fever trismus [johnsarm.net]

  The presenting symptoms, for all patients, were fever, odynophagia, torticollis, and trismus, and the clinical examination showed bulging of the posterior wall of the oropharynx. [ncbi.nlm.nih.gov]

  Trismus is minimal. Posterior abscesses may involve structures within the carotid sheath, possibly causing rigors, high fever, bacteremia, neurologic deficits, and massive hemorrhage caused by carotid artery rupture. [merckmanuals.com]

  Upper airway obstruction [PDF] grade fever Neck pain and swelling Greyish adherent pseudo membrane Retropharyngeal abscess Neck pain and swelling, dysphagia, trismus... [evidence.nhs.uk]

  […] affects children 6 months to 6 years Causitive organisms Group A strep S. aureus Bacteroides Presentation Symptoms fever neck pain patients prefer not moving the neck (it is painful to do so) drooling Differential Ludwig angina dysphonia, dysphagia, trismus [medbullets.com]

• Neck Pain

  OBJECTIVE: To present a case of an uncommon presentation of cellulitis of the neck as benign neck pain. CLINICAL FEATURES: A 44-year-old man had severe neck pain and headaches for 2 weeks with an unknown cause. [ncbi.nlm.nih.gov]

• Torticollis

  We also discussed the relationship between acute torticollis and retropharyngeal abscess. [ncbi.nlm.nih.gov]

  Children may have odynophagia, dysphagia, fever, cervical lymphadenopathy, nuchal rigidity, stridor, dyspnea, snoring or noisy breathing, and torticollis. Adults may have severe neck pain but less often have stridor. [merckmanuals.com]

  In children, presentation may be vague and depends on the stage of disease, but characteristic symptoms include spiking fever, neck pain (especially on movement) or torticollis, and dysphagia. [online.epocrates.com]

• Photophobia

  Other common symptoms include irritability, malaise, mild photophobia, and odynophagia (painful swallowing). Odynophagia causes drooling, poor oral intake, and anorexia. [online.epocrates.com]

• Neck Swelling

  (a) Operative view of the posterior neck swelling. (b) Operative view of the oral cavity, showing swelling of the left posterior pharyngeal wall. (c) Operative view of the posterior neck swelling. [bmcresnotes.biomedcentral.com]

  CASE PRESENTATION: A 2-year-old Japanese boy recently presented to our department with a chief complaint of neck swelling. Physical examination revealed bilateral tonsillitis and swelling of the left posterior pharyngeal wall. [ncbi.nlm.nih.gov]

  On general examination she was irritable, febrile, bilateral neck swelling with restricted neck mobility. Mouth opening was 2.5cm with grade III Mallampati score. [apicareonline.com]

  […] to look for tonsillar swelling, oropharyngeal swelling, and lymphadenopathy. [online.epocrates.com]

• Neck Stiffness

  Retropharyngeal abscesses, most common among young children, can cause sore throat, fever, neck stiffness, and stridor. Diagnosis requires lateral neck x-ray or CT. Treatment is with endotracheal intubation, drainage, and antibiotics. [merckmanuals.com]

  In addition, symptoms such as neck stiffness and swelling, and general discomfort in the neck region may occur. [symptoma.com]

  Retropharyngeal abscess can cause pain, difficulty swallowing, drooling, neck stiffness, and breathing difficulties. Keep in Mind Retropharyngeal abscess is a serious infection that may be life threatening if left untreated. [m.kidshealth.org]

• Headache

  CLINICAL FEATURES: A 44-year-old man had severe neck pain and headaches for 2 weeks with an unknown cause. Minimal response to chiropractic treatment leads to coordination of treatment with the patient's primary care physician. [ncbi.nlm.nih.gov]

  Medically treated deep neck abscess presenting with occipital headache and meningism. J Headache Pain [online] 2008 Feb, 9(1):47-50 [viewed 22 August 2014] Available from: doi:10.1007/s10194-008-0005-2 Result ONG YK, GOH YH, LEE YL. [explainmedicine.com]

  The patient complained of headache that worsened with lying down. A lumbar puncture was performed proving mild increased intracranial pressure (55 mmHg) which was treated well with Diamonx. [omicsgroup.org]

  Four days prior to this ED referral, he had come home from school complaining of a bad headache, nausea, sore throat and "neck pain." He denied any history of neck or oropharyngeal trauma. [hawaii.edu]

• Paresthesia

  During the evening, she started to feel neurological symptoms (left-hand paresthesia), and surgery was performed to clear out the abscess. [em-consulte.com]

In patients with symptoms that can present as signs of infection, a detailed workup should be performed, in order to try and identify the cause, as well as the localization of the infection. Testing should start by obtaining a complete blood count (CBC), which may show leukocytosis. However, patients may present with leukopenia as well, depending on the stage of the disease, and leukocyte count is not a specific sign, and should, therefore, be interpreted with caution. In patients with signs of systemic infection, hemoglobin count may be low and should be considered together with platelet count.

In addition to CBC, inflammatory markers should be obtained. C-reactive protein (CRP) levels are usually low. However, the levels may be high in the severe forms of the disease. Procalcitonin may be particularly high in the early stages of infection.

Blood cultures should be performed as soon as possible, and prior to starting antibiotic therapy, to try and identify the causative agent. However, more than 80% of blood cultures are negative in this form of infection, which may present a diagnostic difficulty, particularly if a pathogen resistant to recommended antibiotics is the causative agent.

During surgical drainage, however, pus cultures reveal one (or sometimes more) bacterial pathogens in the majority of cases, and aid in determining optimal antibiotic therapy.

In addition to blood tests, imaging studies should be performed and computed tomography (CT) of the neck is the method of choice for establishing the presence of the abscess in the retropharyngeal space. Other methods, such as lateral neck radiography [11], ultrasound of the neck, as well as magnetic resonance imaging (MRI) with gadolinium enhancement, are proposed as alternatives but are secondary to CT in terms of efficacy.

It is important to perform a chest X-ray in every patient in whom a retropharyngeal abscess is suspected, to exclude mediastinitis, as well as aspiration pneumonia, which may rapidly progress to acute respiratory distress syndrome (ARDS), which may be life-threatening, and require intensive care.

• Neutrophilia

  Laboratory investigations CBC with differential should be ordered initially to confirm neutrophilia. An ESR can also be performed to establish the degree of inflammatory disease in the absence of a significant neutrophilia. [online.epocrates.com]

• Pseudomonas

  Pseudomonas aeruginosa was cultured from the ear and the osteomyelitis specimen. [ncbi.nlm.nih.gov]

  Following is the list of organisms responsible for retropharyngeal abscess in adults: Staphylococcus epidermidis Beta-hemolytic streptococci Klebsiellapneumoniae Pseudomonas aeruginosa Cryptococcus neoformans Streptococcus viridans Peptostreptococcus [epainassist.com]

• Leukocytosis

  Testing should start by obtaining a complete blood count (CBC), which may show leukocytosis. [symptoma.com]

  The abscess remained limited and with little systemic manifestations, such as fever and leukocytosis, which is another important aspect of the case reported. [arquivosdeorl.org.br]

  There was significant leukocytosis (28.1) with increased neutrophils (25.8). [omicsgroup.org]

Patients with retropharyngeal abscesses should be treated as a medical emergency if the airway is compromised, which can be indicated by symptoms such as tachypnea, cyanosis, decreased oxygen saturation, and stridor, and immediate hospital admission is necessary to start treatment. As soon as the patient is admitted, empiric antibiotic therapy is initiated (blood cultures obtained prior to starting therapy), such as ceftriaxone 50-75 mg/kg q24h, while other choices include clindamycin, ampicillin/sulbactam, cefuroxime and metronidazole (to cover anaerobic causative agents), and they may be sometimes used as a combination [12]. Corticosteroids are recommended in the initial therapeutic regimen for patients with this infection [13]. In patients in whom vital signs are stable, and breathing is not compromised, intravenous antibiotic therapy is usually sufficient.

However, patients who are vitally compromised, endotracheal intubation, and surgical incision and drainage of the abscess is performed, usually under general anesthesia [14]. In adults, tracheostomy may be required, in order to establish normal ventilation, and prevent complications such as respiratory insufficiency and development of aspiration pneumonia and sepsis open link [15], although they may be potential complications of tracheostomy. Endotracheal intubation should be conducted as long as it is necessary, to facilitate stabilization of the upper airways and gas exchange.

Prognosis of this form of infection is good if treatment is initiated on time. However, if left untreated, or if therapy is delayed, mortality rates reach up to 40-50% if serious complications (such as meningitis, sepsis, and septic shock) develop [8]. Recurrence may occur, and it is observed in 1-5% of patients. Because treatment can sometimes include aggressive procedures, such as surgical drainage which necessitates endotracheal intubation, or tracheostomy in adults, the hospital stay can be significantly prolonged, thus increasing chances of developing intrahospital infections, depending on the accompanying comorbidities, as well as the choice of treatment. Some studies demonstrated a prolonged duration of stay at the hospital, as well as increased risk for complications if inflammatory markers were severely high on admission [9].

Formation of abscess in the retropharyngeal space occurs as a result of bacterial colonization and infection, which may be preceded by pharyngitis, upper respiratory tract infection, or tonsillitis [4]. Other predisposing causes include aspiration of foreign bodies, or after instrumentation. Organisms that have been identified as causative agents include [5]:

• Beta-hemolytic streptococci
• Staphylococcus aureus (which may be methicillin-resistant, or MRSA)
• Bacteroides spp.
• Haemophilus parainfluenzae (usually causes abscess formation in unvaccinated children)
• Proteus sp.
• Fusobacterium
• Mycobacterium tuberculosis (chronic abscess formation may occur as a result of tuberculous infection of the spine)

Retropharyngeal abscess is not commonly encountered in clinical practice, but it should nevertheless be considered in patient with signs and symptoms suggestive of it, as it may be life-threatening. These abscesses are most commonly observed in young children between the ages of 3 to 5 years, and they comprise more than 20% of all deep space infections in the neck [6]. However, this infection may be encountered in adults as well, and an increasing incidence has been observed. There is a slight gender predilection, with slightly more cases occurring in male patients [7], while racial predilection varies from study to study, but is most prevalent among Caucasian and African-American individuals.

The retropharyngeal space contains loose connective tissue and retropharyngeal lymph nodes up to 5 years of age and primarily serves to allow movement of the esophagus on swallowing, as well as lymphatic drainage, as it is connected to the parapharyngeal space and the infratemporal fossa. It is located posteriorly to the pharynx and esophagus, and is anteriorly covered by the cervical fascia, and posteriorly by the alar fascia. Usually, this space remains tightly closed, but when retropharyngeal lymph nodes recede by the age of 5, children with recurrent upper respiratory infections, or those with a chronic sore throat are at risk of developing the infection in the retropharyngeal space, and consequent abscess formation. From the retropharyngeal space, which is directly connected with the superior and posterior mediastinum, the infection may spread to other locations in the chest cavity, and cause systemic infection accompanied with shock, aspiration pneumonia, mediastinitis, although it is rarely encountered in practice if timely treated.

Prevention of retropharyngeal abscess may be performed through timely treatment of preceding infections, such as a sore throat (which may be chronic in patients who eventually develop the infection of the retropharyngeal space), and upper respiratory tract infections, since they may predispose patients, especially young children, to developing a retropharyngeal abscess. In addition, a good oral hygiene is recommended, in order to prevent accumulation of pathogenic bacteria in the oral cavity. However, bacteria belonging to the normal flora of the oral cavity and the mouth may sometimes be responsible for the formation of the retropharyngeal abscess.

Retropharyngeal abscess can be a life-threatening infection, which is most commonly seen in young children up to 5 years of age, but can be observed in patients of all ages [1]. Although this disorder is not commonly encountered, the rates of its occurrence have increased in the past years, which could be explained by better diagnostic techniques. Causative agents include fusobacterium, bacteroides species, Staphylococcus species (potentially methicillin-resistant, which may cause severe and possibly life-threatening infections)[2], Streptococcus species, and Klebsiella species, while some other pathogens, such as Proteus species and Citrobacter are rarely isolated. Abscess formation in the retropharyngeal space during early childhood is facilitated because the retropharyngeal lymph nodes disappear during this age period, thus creating a favorable site for infection. Certain studies implicate a slightly more common occurrence among males, and patients can present with various, and sometimes nonspecific symptoms, such as fever, sore throat, fatigue, cough, and stridor, but also neck stiffness, odynophagia and dysphagia, and cervical lymphadenopathy may be observed. Because retropharyngeal abscess may be life-threatening if not treated promptly, the diagnosis should be confirmed early, most effectively through radiographic procedures, primarily computed tomography (CT), especially if the blood results indicate the presence of infection, such as elevated inflammatory markers, including C-reactive protein (CRP), elevated sedimentation rate (ESR), leukocytosis, and other accompanying results. Treatment implies immediate systemic antibiotic therapy, and if necessary, surgical drainage with endotracheal intubation, and possibly ventilation therapy [3].

Retropharyngeal abscess is a localized bacterial infection of the space located in the back of the throat and can be caused by a range of bacteria, some of them belonging to the normal flora of the mouth. Although this type of infection is rare, it is sometimes considered as a medical emergency, as it may obstruct the airways and cause breathing difficulties. It is most commonly seen in young children between 3 to 5 years of age, presumably because the lymph nodes in that space slowly disappear during the maturation of the immune system, and thus create a vulnerable place for bacteria to establish an infection. It may occur in adults as well, and it is slightly more prevalent among male patients. This infection may be localized, or it may spread to other sites, and cause potentially fatal pneumonia, meningitis, or sepsis, which is why prompt diagnosis and treatment are vital in managing this infection.

This infection is characterized by the presence of fever, sore throat (that may be chronic, and may precede the formation of retropharyngeal abscess), enlarged lymph nodes of the neck, and respiratory difficulties, such as stridor (high-pitched breathing sound that occurs as a result of airway occlusion by indirect pressure of the abscess), and increased rate of breathing, as a result of decreased oxygen delivery. In addition, symptoms such as neck stiffness and swelling, and general discomfort in the neck region may occur.

The diagnosis is obtained through findings of blood test, which may show the presence of an infection through elevated white blood cell count (but not always), and elevated markers of inflammation, such as sedimentation rate, C-reactive protein, and fibrinogen. In addition to blood tests, imaging studies should be performed and computed tomography (CT scan) of the neck is the method of choice for establishing the presence of a retropharyngeal abscess while excluding other causes of symptoms in that area.

Treatment comprises rapid intravenous administration of antibiotics, while patients who are vitally compromised, surgical drainage of the abscess with intubation and appropriate breathing support may be necessary, in order to save the life of the patient. If therapy is initiated rapidly, the prognosis is good, but for patient with signs of systemic infection, as well as breathing compromise, and in those in whom treatment is delayed, there is a significant risk for complications, including fatal outcomes.

Since infection such as a sore throat and upper respiratory tract infection may be precipitating factors in the development of retropharyngeal abscesses, proper management of this infection is vital in preventing potential complications. Also, it is imperative to maintain good oral hygiene as a preventive measure.

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