Retropharyngeal infections in children
- Ellen R Wald, MD
Ellen R Wald, MD
- Professor of Pediatrics
- University of Wisconsin School of Medicine and Public Health
- Section Editors
- Morven S Edwards, MD
Morven S Edwards, MD
- Section Editor — Pediatric Infectious Diseases
- Professor of Pediatrics
- Baylor College of Medicine
- Glenn C Isaacson, MD, FAAP
Glenn C Isaacson, MD, FAAP
- Section Editor — Pediatric Otolaryngology
- Professor, Department of Otolaryngology, Head and Neck Surgery and Pediatrics
- Lewis Katz School of Medicine at Temple University
- Stephen J Teach, MD, MPH
Stephen J Teach, MD, MPH
- Section Editor — Pediatric Signs and Symptoms
- Professor of Pediatrics and Emergency Medicine
- George Washington University School of Medicine and Health Sciences
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Suppurative infections of the neck are uncommon in children. However, they are potentially very serious. Suppurative cervical lymphadenitis is the most common superficial neck infection. Deep neck infections include peritonsillar abscess, retropharyngeal abscess, and lateral pharyngeal space infection (also known as pharyngomaxillary or parapharyngeal space infection). Lateral pharyngeal space infection most often arises via contiguous spread of infection from a peritonsillar or retropharyngeal abscess.
The clinical features, evaluation, and management of retropharyngeal cellulitis and abscess in children will be discussed here. Cervical lymphadenitis, peritonsillar cellulitis and abscess, and other deep neck space infections are discussed separately. (See "Cervical lymphadenitis in children: Etiology and clinical manifestations" and "Peritonsillar cellulitis and abscess" and "Deep neck space infections".)
ANATOMY AND PATHOGENESIS
The retropharyngeal space extends from the base of the skull to the posterior mediastinum (figure 1). The anterior boundary is the middle layer of the deep cervical fascia (abutting the posterior esophageal wall). The posterior boundary is the deep layer of the deep cervical fascia. These fascia fuse inferiorly at the level between the first and second thoracic vertebrae. The retropharyngeal space communicates with the lateral pharyngeal space. The lateral pharyngeal space is bounded laterally by the carotid sheath, which contains the carotid artery and jugular vein .
The retropharyngeal space contains two chains of lymph nodes that are prominent in the young child, but atrophy before puberty [2-4]. These lymph nodes drain the nasopharynx, adenoids, posterior paranasal sinuses, middle ear, and eustachian tube. Infections in these areas may lead to suppurative adenitis of the retropharyngeal lymph nodes [1,2,5,6]. Retropharyngeal abscess is associated with antecedent upper respiratory tract infection in approximately one-half of cases .
In approximately one-fourth of cases (usually in older children or adults), retropharyngeal infection is secondary to pharyngeal trauma (eg, penetrating foreign body, endoscopy, intubation attempt, dental procedures) [1,5,7-11]. It also may occur in association with pharyngitis, vertebral body osteomyelitis, and petrositis.
- Tebruegge M, Curtis N. Infections related to the upper and middle airways. In: Principles and Practice of Pediatric Infectious Diseases, 3rd ed, Long SS, Pickering LK, Prober CG (Eds), Elsevier Saunders, New York 2012. p.205.
- Goldstein NA, Hammersclag MR. Peritonsillar, retropharyngeal, and parapharyngeal abscesses. In: Textbook of Pediatric Infectious Diseases, 6th, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL. (Eds), Saunders, Philadelphia 2009. p.177.
- Asmar BI. Bacteriology of retropharyngeal abscess in children. Pediatr Infect Dis J 1990; 9:595.
- McClay JE, Murray AD, Booth T. Intravenous antibiotic therapy for deep neck abscesses defined by computed tomography. Arch Otolaryngol Head Neck Surg 2003; 129:1207.
- Ungkanont K, Yellon RF, Weissman JL, et al. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995; 112:375.
- Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg 2008; 138:300.
- Philpott CM, Selvadurai D, Banerjee AR. Paediatric retropharyngeal abscess. J Laryngol Otol 2004; 118:919.
- Poluri A, Singh B, Sperling N, et al. Retropharyngeal abscess secondary to penetrating foreign bodies. J Craniomaxillofac Surg 2000; 28:243.
- Sethi DS, Chew CT. Retropharyngeal abscess--the foreign body connection. Ann Acad Med Singapore 1991; 20:581.
- Singh B, Kantu M, Har-El G, Lucente FE. Complications associated with 327 foreign bodies of the pharynx, larynx, and esophagus. Ann Otol Rhinol Laryngol 1997; 106:301.
- Morrison JE Jr, Pashley NR. Retropharyngeal abscesses in children: a 10-year review. Pediatr Emerg Care 1988; 4:9.
- Gaglani MJ, Edwards MS. Clinical indicators of childhood retropharyngeal abscess. Am J Emerg Med 1995; 13:333.
- Dawes LC, Bova R, Carter P. Retropharyngeal abscess in children. ANZ J Surg 2002; 72:417.
- Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics 2003; 111:1394.
- Coulthard M, Isaacs D. Neonatal retropharyngeal abscess. Pediatr Infect Dis J 1991; 10:547.
- Novis SJ, Pritchett CV, Thorne MC, Sun GH. Pediatric deep space neck infections in U.S. children, 2000-2009. Int J Pediatr Otorhinolaryngol 2014; 78:832.
- Yellon RF. Head and neck space infections. In: Pediatric Otalrynology, 5th ed, Bluestone CD, Simons JP, Healy GB (Eds), Saunders, Philadelphia 2014. p.1769.
- Wright CT, Stocks RM, Armstrong DL, et al. Pediatric mediastinitis as a complication of methicillin-resistant Staphylococcus aureus retropharyngeal abscess. Arch Otolaryngol Head Neck Surg 2008; 134:408.
- Brook I. Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg 2004; 62:1545.
- Inman JC, Rowe M, Ghostine M, Fleck T. Pediatric neck abscesses: changing organisms and empiric therapies. Laryngoscope 2008; 118:2111.
- Abdel-Haq N, Quezada M, Asmar BI. Retropharyngeal abscess in children: the rising incidence of methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J 2012; 31:696.
- Cheng J, Elden L. Children with deep space neck infections: our experience with 178 children. Otolaryngol Head Neck Surg 2013; 148:1037.
- Sperring JL. Neck and oral cavity infections. In: Comprehensive Pediatric Hospital Medicine, Zaoutis LB, Chiang WV. (Eds), Mosby, Philadelphia 2007. p.360.
- Cmejrek RC, Coticchia JM, Arnold JE. Presentation, diagnosis, and management of deep-neck abscesses in infants. Arch Otolaryngol Head Neck Surg 2002; 128:1361.
- Baum ED, Elden LM. Bacterial infections of the neck. In: Current Pediatric Therapy, 18th, Burg FD, Ingelfinger JR, Polin RA, Gershon AA. (Eds), Saunders, Philadelphia 2006. p.1117.
- Currarino G, Williams B. Air collection in the retropharyngeal soft tissues observed in lateral expiratory films of the neck in 9 infants. Pediatr Radiol 1993; 23:186.
- Brechtelsbauer PB, Garetz SL, Gebarski SS, Bradford CR. Retropharyngeal abscess: pitfalls of plain films and computed tomography. Am J Otolaryngol 1997; 18:258.
- Barratt GE, Koopmann CF Jr, Coulthard SW. Retropharyngeal abscess--a ten-year experience. Laryngoscope 1984; 94:455.
- Sztajnbok J, Grassi MS, Katayama DM, Troster EJ. Descending suppurative mediastinitis: nonsurgical approach to this unusual complication of retropharyngeal abscesses in childhood. Pediatr Emerg Care 1999; 15:341.
- Endicott JN, Nelson RJ, Saraceno CA. Diagnosis and management decisions in infections of the deep fascial spaces of the head and neck utilizing computerized tomography. Laryngoscope 1982; 92:630.
- Lazor JB, Cunningham MJ, Eavey RD, Weber AL. Comparison of computed tomography and surgical findings in deep neck infections. Otolaryngol Head Neck Surg 1994; 111:746.
- Thawley SE, Gado M, Fuller TR. Computerized tomography in the evaluation of head and neck lesions. Laryngoscope 1978; 88:451.
- Nagy M, Pizzuto M, Backstrom J, Brodsky L. Deep neck infections in children: a new approach to diagnosis and treatment. Laryngoscope 1997; 107:1627.
- Vural C, Gungor A, Comerci S. Accuracy of computerized tomography in deep neck infections in the pediatric population. Am J Otolaryngol 2003; 24:143.
- Kirse DJ, Roberson DW. Surgical management of retropharyngeal space infections in children. Laryngoscope 2001; 111:1413.
- Daya H, Lo S, Papsin BC, et al. Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int J Pediatr Otorhinolaryngol 2005; 69:81.
- Choi SS, Vezina LG, Grundfast KM. Relative incidence and alternative approaches for surgical drainage of different types of deep neck abscesses in children. Arch Otolaryngol Head Neck Surg 1997; 123:1271.
- Boucher C, Dorion D, Fisch C. Retropharyngeal abscesses: a clinical and radiologic correlation. J Otolaryngol 1999; 28:134.
- Martin CA, Gabrillargues J, Louvrier C, et al. Contribution of CT scan and CT-guided aspiration in the management of retropharyngeal abscess in children based on a series of 18 cases. Eur Ann Otorhinolaryngol Head Neck Dis 2014; 131:277.
- Stein MT, Trauner D. The child with a stiff neck. Clin Pediatr (Phila) 1982; 21:559.
- Shefelbine SE, Mancuso AA, Gajewski BJ, et al. Pediatric retropharyngeal lymphadenitis: differentiation from retropharyngeal abscess and treatment implications. Otolaryngol Head Neck Surg 2007; 136:182.
- Al-Sabah B, Bin Salleen H, Hagr A, et al. Retropharyngeal abscess in children: 10-year study. J Otolaryngol 2004; 33:352.
- Lalakea Ml, Messner AH. Retropharyngeal abscess management in children: current practices. Otolaryngol Head Neck Surg 1999; 121:398.
- Courtney MJ, Mahadevan M, Miteff A. Management of paediatric retropharyngeal infections: non-surgical versus surgical. ANZ J Surg 2007; 77:985.
- Sichel JY, Dano I, Hocwald E, et al. Nonsurgical management of parapharyngeal space infections: a prospective study. Laryngoscope 2002; 112:906.
- Broughton RA. Nonsurgical management of deep neck infections in children. Pediatr Infect Dis J 1992; 11:14.
- Harper MB, Fleisher GR. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 6th, Fleisher GR, Ludwig S, Henretig FM. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.887.
- Saluja S, Brietzke SE, Egan KK, et al. A prospective study of 113 deep neck infections managed using a clinical practice guideline. Laryngoscope 2013; 123:3211.
- Plaza Mayor G, Martínez-San Millán J, Martínez-Vidal A. Is conservative treatment of deep neck space infections appropriate? Head Neck 2001; 23:126.
- Pesola AK, Sihvonen R, Lindholm L, Pätäri-Sampo A. Clindamycin resistant emm33 Streptococcus pyogenes emerged among invasive infections in Helsinki metropolitan area, Finland, 2012 to 2013. Euro Surveill 2015; 20.
- Goldenberg D, Golz A, Joachims HZ. Retropharyngeal abscess: a clinical review. J Laryngol Otol 1997; 111:546.
- Goldenberg NA, Knapp-Clevenger R, Hays T, Manco-Johnson MJ. Lemierre's and Lemierre's-like syndromes in children: survival and thromboembolic outcomes. Pediatrics 2005; 116:e543.
- Waggie Z, Hatherill M, Millar A, et al. Retropharyngeal abscess complicated by carotid artery rupture. Pediatr Crit Care Med 2002; 3:303.
- Thompson JW, Cohen SR, Reddix P. Retropharyngeal abscess in children: a retrospective and historical analysis. Laryngoscope 1988; 98:589.
- Coulthard M, Isaacs D. Retropharyngeal abscess. Arch Dis Child 1991; 66:1227.
- ANATOMY AND PATHOGENESIS
- EVALUATION AND DIAGNOSIS
- Physical examination
- Laboratory evaluation
- DIFFERENTIAL DIAGNOSIS
- Overview of strategy
- Supportive care
- Antimicrobial therapy
- - Empiric therapy
- - Response to therapy
- Surgical drainage
- Discharge instructions
- SUMMARY AND RECOMMENDATIONS
- Clinical features and diagnosis