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BackTable / ENT / Article
Retropharyngeal Abscess in Children: Symptoms, Physical Exam & Diagnostic Imaging
Iman Iqbal • Updated Oct 31, 2024 • 43 hits
Pediatric retropharyngeal abscesses are potentially serious infections that can rapidly progress. In some severe cases, symptoms of airway obstruction may emerge, necessitating urgent intervention. These abscesses, typically secondary to an upper respiratory tract infection, pose a particular risk in young children due to their immune immaturity and smaller airway size, both of which can complicate infection management.
Although retropharyngeal abscesses are generally identified in emergency settings, some cases may present in outpatient clinics, highlighting the need for timely diagnosis and swift referral to specialized care. This article explores key considerations in evaluating and diagnosing these infections, emphasizing the role of imaging modalities such as CT and, to a lesser extent, ultrasound, in guiding treatment plans.
This article features excerpts from the BackTable ENT Podcast with otolaryngologist Dr. John McClay. You can listen to the full podcast below.
The BackTable ENT Brief
• Symptoms of retropharyngeal abscesses include fever, neck stiffness, and dysphagia, with potential airway compromise in more severe cases.
• Young children, particularly those under six, are at increased risk due to frequent respiratory infections, while older children may develop abscesses from dental or recurrent infections.
• Physical examination of young children can be challenging due to their distress, and imaging may be preferred for definitive assessment.
• CT scans provide valuable information on abscess size and location, aiding in decision-making for antibiotic versus surgical management.
• Although sometimes used for lateral neck abscesses, ultrasound is generally less reliable than CT for retropharyngeal abscesses.
• Engaging parents as part of the clinical assessment is key to enhancing diagnostic accuracy and ensuring compliance with treatment plans.
• When a CT scan is unavailable, clinicians may admit and observe with IV antibiotics, assessing response before deciding on surgical intervention.
Table of Contents
(1) Clinical Presentation of Retropharyngeal Abscess: Symptoms, Causes & Complications
(2) Physical Exam Techniques for Assessing Retropharyngeal Abscess
(3) Imaging in Retropharyngeal Abscess: CT & Ultrasound
Clinical Presentation of Retropharyngeal Abscess: Symptoms, Causes & Complications
Pediatric retropharyngeal abscesses often present with common symptoms like neck stiffness, fever, difficulty swallowing, and pain with swallowing. More severe cases may show signs of airway obstruction, such as stridor or noisy breathing (stertor), which can be particularly concerning. While these abscesses are often diagnosed in emergency or inpatient settings due to the severity of symptoms, they can occasionally be identified in outpatient settings, though young children generally cannot tolerate drainage procedures in a clinic and are referred to the hospital.
The primary cause of a retropharyngeal abscess in children is an upper respiratory tract infection, which can lead to lymphadenitis and subsequently, an abscess if the infection progresses. Younger children, especially between 1 to 6 years of age, are most vulnerable due to their frequent exposure to colds and viruses. In older children, abscesses may be related to dental issues or recurrent infections like strep throat. While trauma-induced abscesses are rare in younger children, cases involving foreign bodies, such as fishbones, have been observed.
Infants under 18 months present a unique challenge. Their immune systems are not fully developed, making them more susceptible to infections like staph and MRSA, which can complicate abscesses. In these younger children, even minor swelling can quickly compromise their smaller airways, leading to faster deterioration. Consequently, clinicians tend to be more cautious in managing neck abscesses in infants and toddlers, with closer monitoring and quicker intervention, whether surgical or antibiotic-based, to prevent complications.
[Dr. Gopi Shah]
Let's get into our topic today, a retropharyngeal abscess in children. How do these kids usually present to you?
[Dr. John McClay]
Really like any neck abscess, whether it's retropharyngeal or lateral, whatever, they have neck stiffness, fever, sometimes neck swelling depending on where the abscess is. They'll have adonophagia, dysphagia, and fever oftentimes, but if they start having issues with their airway or stridor or stertor, you get a little bit more concerned. It's pretty typical with neck infections all over the place in the head and neck area. They present very similarly.
[Dr. Gopi Shah]
In terms of retropharyngeal abscess, I feel like it's usually in the ER or the inpatient setting where they've been admitted. Have you ever diagnosed or had a kid sent over to you in the outpatient setting with a concern for retropharyngeal abscess?
[Dr. John McClay]
We usually get the phone call and we say maybe she'd go to the ER. Sometimes somebody-- yes, I've seen a couple of kids, especially peritonsillar, probably, more than a retropharyngeal, and they'll come in and it's a teenage kid. When I was training, we would drain those in the emergency room if they were 14 to 18 or something because they could tolerate it, but younger kids really don't. I'll see them in the clinic, but I won't do anything. Actually, I think when I first started, I probably tried to drain a couple and it wasn't very fun. We just sent them to the ER and get a better diagnosis and then go from there.
[Dr. Gopi Shah]
In terms of risk factors, do you feel like there's any specific risk factors? The reason I ask is, sometimes families when they come in and their kid does have, whether it's a peritonsillar, more so though, I never know how to answer when it's a retropharyngeal abscess of why this happened, what they could have prevented or avoided. How do you explain that to families, and are there risk factors that maybe I'm just not thinking about?
[Dr. John McClay]
Well, really it's a cold. Kids, when they get exposure, they get 10 or 12 colds in the first couple of years of life, especially if they're in daycare, but anytime you get exposure. It starts with upper respiratory tract infection, then leads to lymphadenitis and then it leads to an abscess if it progresses. Those are usually kids from less than six, one to six years of age. Now, older kids, if they've had dental problems or teeth that are hurting, but a lot of them too, it's an upper respiratory tract infection, or maybe for a peritonsillar, it's recurrent strep throat.
When you look at different kinds of infections in different areas, now for retropharyngeal, it's pretty much an upper respiratory tract infection, but for older kids in lateral infections, it can be a dental issue.
[Dr. Gopi Shah]
That's a good point. I guess another thing to sometimes think about, which I don't think is common, is maybe like trauma or have you ever had a kid with a history of trauma or even potential foreign body like a fishbone or something, even though that's going to be very rare, usually there's going to be a history associated.
[Dr. John McClay]
I think I've seen one fishbone that caused a neck abscess. Trauma, you see that more in older kids that lead to an infection. A lot of young kids will have trauma like from a toothbrush or something. You always worry because the palate has a laceration. If it's lateral, you got to get a CT scan, make sure their carotid's fine. I don't know if I've ever seen a neck infection from trauma in a young kid. I've seen a lot of trauma in the palate.
[Dr. Gopi Shah]
No, that's a good point. In terms of the younger kids, when I think of retropharyngeal abscess, I think of like two to six. Then there are those handful of babies that will come in that are infants, like under 15 months, that are under a year. Do you think about that group a little bit differently in terms of presentation, exam, or risk factors?
[Dr. John McClay]
Yes. I treat all neck abscesses the same in the sense that I look and see how sick they are. If they don't seem very sick, I don't get as concerned and sometimes I will treat non-surgically. However, you're right, those 18 months, less than 1, it's more often going to be like staph versus strep in those young kids. With MRSA too-- even though we did a study, but that was probably about 15 years ago, that showed there wasn't increased complications with MRSA. You still worry about that a little bit.
I probably am more hypervigilant with the young kids, just because too little swelling and their airway's smaller, they're going to lead to a problem quicker. You don't know what their immune system's like. Your immune system doesn't get to where it should be in 2 to 6 or 7, and by 2.5 or 3, it's about 85% of what it should be. A 1-year-old or 18-month-old, their immune system's not great.
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Physical Exam Techniques for Assessing Retropharyngeal Abscess
When conducting a physical exam for pediatric retropharyngeal abscess, several key steps are involved. The physician first assesses the child’s overall appearance, looking for signs of lethargy or fever. Neck palpation and inspection of the throat can reveal swelling or bulging, particularly in the tonsils or retropharyngeal area. A lateral neck infection might present differently, with potential neck stiffness or swelling. In rare cases, an infection might indicate an underlying condition like a fourth branchial cleft or nontuberculous mycobacterium, which may warrant further investigation.
For younger children, performing a physical exam can be particularly challenging due to their discomfort and reluctance to cooperate. Clinicians must carefully balance the need for an accurate assessment with the risk of causing additional distress. While a full examination is ideal, it is not always necessary to force it, especially if the child is stable. In many cases, a CT scan can provide crucial information without escalating the child’s stress or aggravating potential airway issues. However, transporting a child with airway concerns to the scanner requires careful planning and coordination to ensure their safety. Timing is also important; an exam conducted later in the day, when the child is more awake and comfortable, may offer a clearer clinical picture than a rushed early-morning assessment.
Additionally, the relationship with the parents is key to making the best decisions for the child’s care. Parents can offer valuable observations, which, along with the clinician’s examination and imaging, contribute to an overall assessment. Establishing trust with the family ensures smoother communication and better outcomes, as parents are more likely to cooperate and feel confident in the proposed treatment plan.
[Dr. Gopi Shah]
Tell me about your exam. How do you go through your physical exam? When is a scope indicated?
[Dr. John McClay]
Fiscal exams, certainly, you're going to palpate the neck. You're going to look at them first and see how sick they look. A young kid may look lethargic. You're going to see if they have a fever. I guess you could feel them. You could tell if they have fever, usually it's documented. Then you can look in the pharynx to see if there's swelling of the tonsils or if there's a bulge in the retropharynx and palpate their neck.
Now, it's interesting because for retropharyngeal, it's going to be a little bit different in the sense that you could get lateral extension, but probably not. You'd have neck stiffness, but the swelling's probably less. If a child does have significant left neck swelling and they've had it a couple of times, I have scoped, I remember this eight-year-old, scoped her and saw pus coming from the left pyriform sinus. In your differential of like a lateral neck infection, you have to think about a fourth brachial cleft. For some reason, we saw 20 of them. Over a 10-year period, we wrote a couple of papers on it.
When I did the literature search, only France had another paper that had 20, but everybody else just had a few. I don't know why we got a bevy of them for a while, but you have to think about that. In a young kid, you got to think about a typical mycobacterium too, if it's a lateral abscess, because their immune system's not very good. If they're playing in the dirt, they're going to get the nontuberculous mycobacterium. I've rarely scoped them. If they look sick, you're just going to tip them over the edge. Now, in my training, we had epiglottitis. We didn't ever scope those either because you tip them over the edge and cause airway obstruction, but you get a lateral neck. I think people still get lateral necks, and I don't think that's a bad thing. It's not that much radiation.
[Dr. Gopi Shah]
No, I ask, but to be honest with you, when I think about it, I don't think I've ever scoped either for that reason. I always ask because we always think of potential airway compromise, stertor as a potential presentation, or if they have a URI, maybe they have a little stridor type of sounds. Sometimes it's hard to tell what the sound is.
[Dr. John McClay]
Oh, for sure.
[Dr. Gopi Shah]
Sometimes that can kind of, "Do I need to do that or not?" I think the biggest thing for me, in terms of what's difficult, especially with a retropharyngeal abscess, is getting a good exam on like a three or four-year-old. They're sick, they're mad, their neck hurts. I need them to do something for me so I can see if the empiric antibiotics are helping or not. Do you have any, with all of your experience, John, I need you to tell me what is the best way to get a good exam that following morning? Because usually we round it before the OR at 7:00, they're barely awake, and they hurt, and now it's at 48 hours or whatever, and I need to know, does this need to be drained or not? I need an exam. What's your process?
[Dr. John McClay]
Interesting, because you have to think about the consequences of what you do. If you have a kid who's stable, you can have the parents hold them on their lap and hold their arms ahead, and you stick a tongue blade in there and just gag them with a light. If you have an unstable kid, you really don't want to stir them up. There's no reason to. I think it depends if they've had a CT or not, and that'll be a discussion. I think the CT's going to tell you what you need to know. Number one, if they look sick, you probably just need to intervene. I think a CT's important, and I would get a CT that gives you a lot of information without you having to stress them out.
Now, just going to the scanner can be potentially dangerous in a kid who's got airway issues, so everybody has to be on board with that. I don't think you have to push everybody all the time to get this complete exam. You got to go be smart.
[Dr. Gopi Shah]
Yes. No, I think that's a great point. I think in terms of timing of the exam is important. It doesn't have to be at 7:30 in the morning or 7:00 AM when the lights are out and the hallway's still, just because-- I might have to go back between cases at 9:00, 8:30, before, depending on how long I've kept them, only on clears or whatever we decided the night before. With mouth opening and gagging for PTAs, if they're feeling better, and I find that if I don't have to use a tongue depressor, even if I could see their mouth is opening more, compared to the-- Yes, I'm okay with that. I don't always have to "Jjam it in" either.
…
I don't think I appreciated the importance of the relationship you have with the parents and the family and how much of the history and observations that the parents make when they're with their kid and how important that information is and talking. It wasn't until probably, not only just at the start of my fellowship, but really when I started my practice, a couple of first few years. Even now it's like there is a certain way in which you have to dance with the parent and the family to help assess this kid and get them through what they're going through.
Imaging in Retropharyngeal Abscess: CT & Ultrasound
When faced with potential retropharyngeal abscess cases, managing a patient without a CT scan can be challenging. Often, emergency room or inpatient teams may call after a scan is completed, providing clear information on the abscess size and characteristics. However, situations can arise when a child presents with concerning symptoms such as fever, stiff neck, and signs of distress, but without a scan. In these cases, the decision to admit the child and begin treatment, including IV antibiotics, is based on their overall stability and the urgency of their condition. While there is a tendency to treat with antibiotics first, a CT scan can clarify the diagnosis and determine the need for surgical intervention, ultimately guiding the management plan effectively.
The role of ultrasound in these scenarios has been debated, with some evidence suggesting its utility, although historical studies may not accurately reflect current practices or advancements. While ultrasound can be beneficial for certain conditions, such as evaluating lateral neck abscesses, it is often not as effective as CT for diagnosing retropharyngeal issues.
[Dr. Gopi Shah]
Talk to me a little bit about CTs. I feel like most of the time when you get the call from the ER or from the inpatient team, the scan's been done and you know at this point, "I know there's a retropharyngeal abscess, I know how big, et cetera." There are a handful of times where I'll get a call and let's say the child just ate, they have a stiff neck, they have high white count, they just got fever, there's some fullness. To get a CT would require station and it's 2:00 in the morning. Can we just admit them? At that point, when you don't have a CT and you have a quit-working diagnosis, how do you manage those kids?
[Dr. John McClay]
I think everything's within reason too. If they get admitted to 2:00, it doesn't mean the CT has to be done there. Again, it determines how sick they are. If you have a kid that looks sick and the emergency room physician is worried about them, then that's a different story. If the child looked great, but there are some symptoms, fever, stiff neck, some other concerns, but they're stable, yes, admit them and get the CT in five hours or whatever. We just had a discussion in our group about whether you get a CT at all, because so many of these kids respond to IV antibiotics. Do you put them on IV antibiotics for 48 hours and if they do great, then send them home?
The only problem with that is I just got called when I was on call last week and somebody was looking in the throat and they said the tonsils look really big, but they'd already got the scan. When they looked in there, they thought, "Oh, surely this kid's got an abscess." If we would have determined, oh yes, they probably got an abscess, let's just put them on IV antibiotics because they're stable and swallowing, even though they have a fever and a white count, then that kid would have got admitted to the hospital. The CT showed no abscess and it was just tonsillitis, so then the kid can go home.
A CT really shows you how you treat them. If there's no abscess, the child's swallowing, give them a dose of IV antibiotics and give them oral antibiotics and let them go home. If they have a small abscess, less than 2 to 2.5 centimeters in the medial compartments, medial to the carotid sheath, then they'll probably respond to IV antibiotics. If they're bigger than that, then they probably won't. You can make determinations with the CT, even though CT is radiation and that's the argument. You don't want to do it because of radiation, but it's really a good test to guide what you're going to do because you don't have to admit them. You're saving a ton of money there for the healthcare system and plus the child didn't have to get admitted.
[Dr. Gopi Shah]
Yes, those are interesting points because sometimes I would lean towards giving them a trial of antibiotics and we're assuming that's what we're treating and sometimes that can be difficult in terms of counseling and expectations for all the reasons that you just mentioned. Is there ever a role for ultrasound?
[Dr. John McClay]
I was never a fan. I did a little literature search just to see, and it was interesting. I found some article from 1992. It was in a radiology journal that looked at CT versus ultrasound for retropharyngeal. I guess they went lateral to do the ultrasound and they thought that ultrasound was better than CT because CT, if you read all the studies, it's about 75% accurate for whether it's the abscess or phlegm line or cellulitis or whatever. I've never seen anything else like that and that's over 30 years ago. For retropharyngeal, I think it's difficult.
Now, if you got some evidence that there's something there and you did an ultrasound and you wanted to treat them with IV antibiotics, that's probably reasonable to do, especially even for a lateral. If I'm going to have to take a child to the OR, they're going to need a CT because I need to know the size of the abscess, the location of the carotid sheath, all those kinds of things. Again, if a child's relatively stable, even if you have a medial or lateral abscess, I guess you could go off ultrasound. It's interesting because the accuracy is not really mentioned. Of course, I might've missed those studies. It's more of like, "Oh, we got an ultrasound or a CT and they stay in the hospital the same length of time, and so ultrasound is fine." I'm like, "Okay, but you don't really tell me if it's accurate or not."
[Dr. Gopi Shah]
I think they're helpful maybe to evaluate for some of the other things on our differential, PTA potentially, depending on who's doing the ultrasound and if your hospital uses that consistently, lateral neck abscess, most places are pretty consistent and able to help use an ultrasound for that kind of management.
Podcast Contributors
Dr. John McClay
Dr. John McClay is a pediatric otolaryngologist at Cook Children's in Frisco, Texas.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2024, September 10). Ep. 190 – Managing Retropharyngeal Abscesses in Children [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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