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BackTable / ENT / Article
Retropharyngeal Abscess Treatment: Antibiotics, Steroids & Surgery
Iman Iqbal • Updated Nov 23, 2024 • 37 hits
Pediatric retropharyngeal abscesses are a serious infection that require prompt care. Treatment involves a careful balance between medical and surgical interventions, with antibiotic therapy playing a central role in the initial management. While some patients show rapid improvement, others may require further intervention, including adjustments to their antibiotic regimen or surgical drainage.
The complexity of retropharyngeal abscess management is heightened by its location, potential for airway obstruction, and proximity to vital structures, which can make treatment decisions particularly challenging. Clinicians must remain vigilant in monitoring patient progress and be prepared to adapt their approach to ensure the best outcomes. This article covers the current strategies for managing pediatric retropharyngeal abscesses, from initial antibiotic choices to surgical techniques, and highlights the factors that influence decision-making in these critical cases.
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
• Empiric antibiotics for pediatric retropharyngeal abscess treatment include Clindamycin, Rocephin, and Unasyn, commonly targeting Streptococcus and Staphylococcus bacteria.
• Steroids are used to reduce inflammation, but their role remains limited due to potential risks such as masking infection progression and complicating cases of severe abscess.
• A 48-hour observation period is typically recommended to assess antibiotic effectiveness before considering additional interventions like surgery.
• For abscesses near vital structures, surgical strategies focus on minimizing risks, with detailed imaging to guide decision-making.
• In severe cases, especially with abscesses extending into the chest or lateral neck, external approaches or nasal drains may be necessary for continuous drainage and management.
• Serial imaging, such as CT scans, is can be helpful to monitor changes in abscess size and proximity to critical structures like the carotid artery.
• Surgical judgment, patient status, and individualized approaches are crucial in achieving effective drainage and minimizing procedural risk.
Table of Contents
(1) Retropharyngeal Abscess Treatment with Antibiotics & Steroids
(2) When to Operate on a Pediatric Retropharyngeal Abscess
(3) Managing the Anatomically Challenging Retropharyngeal Abscess
(4) Surgical Techniques for the Severe Retropharyngeal Abscess
Retropharyngeal Abscess Treatment with Antibiotics & Steroids
Empiric antibiotics for pediatric retropharyngeal abscess treatment include Clindaymycin and Rocephin. These often target Staphylococcus and Streptococcus bacteria and have been historically preferred due to their effectiveness. Unasyn has also become a popular alternative, but some patients improve only after adding Clindamycin and Rocephin, highlighting the variability in treatment responses. This emphasizes the importance of flexible, responsive treatment within the initial 48-hour period, balancing coverage with a careful approach to avoid bacterial resistance.
Steroids reduce inflammation and may also enhance antibiotic penetration to the abscess site. However, short courses are recommended due to potential risks, especially in masking infection progression. Prolonged steroid use can complicate cases with severe abscesses near essential structures. In specific cases, steroids can be helpful for initial airway management, especially in severe inflammation scenarios, but their routine use remains cautious. While steroids are valuable for reducing acute inflammation, draining the abscess itself effectively mitigates risk by relieving pressure and allowing antibiotic access to the site of infection for more effective healing.
[Dr. Gopi Shah]
Tell me in terms of empiric antibiotics, I think of Unasyn as the main one. You'd mentioned staph, and potentially MRSA for younger kids. If you switch that up and do Clinda. Tell me your choice of antibiotics for empirics and does age matter, does size, what they've been on outpatient matter to you? How do you decide?
[Dr. John McClay]
It's interesting the Unasyn thing because that's a new thing. We always put them on Clinda because of staph and strep, right? For some reason early on in my career, probably in my training in the early '90s, I would read these articles about H flu, sometimes they would find-- I would read all the bacteriology of the abscesses. I would put them on Rocephin in addition to Clinda. I did that and I saw success with it, but then the hospitalist who were admitting the patients would say, or the infectious disease person say, "Why are you using Rocephin? Why don't you just use the Clinda? It's going to be staph or strep." I'm like, "Okay."
During that process, we then sometimes would stop and not do Rocephin, but it would be weird because-- again, I don't have any numbers, but it seemed like some of those wouldn't get-- half might get better, but the other half wouldn't. Then we'd add the Rocephin and then they would get better. Rocephin does have some activity against staph and strep and it may attack it from a different way. I came to a point in thinking, somebody gets admitted. How much is an IV antibiotic? Am I really going to create resistant bacteria?" They already did that in the '90s because they were given amoxicillin for every cold. If I've only used it on 100 kids a year or less to add an extra Rocephin, but they seem to get better faster maybe in my mind, which could be true or not true.
I came to this conclusion, why don't you just put them on both, maybe they'll get better faster. You can discharge in 48 hours. You're going to save money and they're going to not have to stay in the hospital. I think empirically it's staph or strep. Anything that covers that, certainly Unasyn covers that too. Lately, over the past probably 5 to 10 years, people are giving Unasyn. They'll ask me what do I recommend, and they'll say, "We're going to use Unasyn." I'm like, "You're admitting them. You can do whatever you want." Then we see, and some of those get better, some of them don't, they don't get better. Then I've switched to Clinda and Rocephin and they got better.
[Dr. Gopi Shah]
You'll usually do 48 hours? Do you ever add steroids? I tend to add steroids for all these because in terms of inflammation, maybe the antibiotics can get to the abscess better if I decrease inflammation and things like that. What are your thoughts on steroids?
[Dr. John McClay]
Let me ask you, how do you do the steroids? What do you give and how long do you give?
[Dr. Gopi Shah]
Yes, I know I will have them do half mg per kg, but there's max doses. [chuckles] I granted this is my own anecdotal, but I'll do half mg per kg and max of 8 mg, IVQ-8. If they're under five, if they're between two and five years old, we might max between 3 to 4 milligrams. You know what I mean? IVQ-8. Then if they're between 5 to 10, depending on how much they weigh. In that age group, I might max it between 4 and 6 milligrams IVQ-8. I'll probably do that-- my initial, I'll do at least for 24 hours and plus/minus even 48, but usually at least the first 24.
Initially, I would say 10 years ago, the hospitals didn't like that because is it masking the infection would be one reason. I can't follow their white count would be the second reason. I find that now I get less pushback. Clinically, I think it helps the kids, I don't know. What are your thoughts on steroids?
[Dr. John McClay]
Who do you give it to? Do you give it kids with cellulitis or phlegmon or abscess or there's a certain size that you do?
[Dr. Gopi Shah]
If they get admitted and there's a retropharyngeal, I kind of for all of it, frankly. Frankly, for in the retropharyngeal space, all of it.
…
[Dr. John McClay]
If you have a big abscess, I use steroids definitely for an initial dose, maybe for a 24-hour period, but usually it's on somebody that I'm not worried about at all.
Oftentimes if they're on IV antibiotics and they're not getting better, I may give a couple of doses, but I don't just routinely put everybody on it. Except maybe a dose or two initially. I think it depends on the nature of what you're seeing. If there's not an abscess that's going to erode the carotid or something like that, you're probably fine, because steroids will weaken different structures of your body, I think. Two, it depends on how long they're on them. That's a little bit of my concern, but 48 hours, you're probably fine. 24, you're for sure fine. It's just, if things linger on, you're probably not going to let them linger on that long anyway.
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When to Operate on a Pediatric Retropharyngeal Abscess
When patients remain symptomatic with persistent abscess size or elevated inflammatory markers, the decision to continue antibiotics, adjust treatment, or proceed to surgery becomes crucial. For patients with stable overall health but slow recovery, a further 24-hour antibiotic trial may be reasonable, especially since about 20% of cases improve during this period. If surgery becomes necessary, reassessment with imaging helps in planning, as changes in abscess size can impact surgical strategy.
In the OR, key surgical steps focus on minimizing risk, especially in complex anatomy involving the carotid artery or a deep lateral abscess. Precise incision techniques are used, often with long-handled tools and an 18-gauge needle to locate the abscess and obtain cultures. For challenging cases, specialized techniques like the placement of a Penrose drain through the nose can allow continuous drainage and gentle irrigation, especially when the abscess extends toward the chest. In certain cases, leaving a red rubber catheter allows controlled drainage over several days. Surgical judgment, patient status, and an individualized approach are essential to achieve effective drainage and minimize procedural risk.
[Dr. Gopi Shah]
Let's say it's the 3-year-old that came in, it's been 48 hours, there's that 1.8-centimeter retropharyngeal abscess on the right side. Let's say they've been on the Unasyn for 48 hours and the CRP hasn't really moved [chuckles] because they're going to draw that for you, and exam wise, they've been eating and drinking, but they're not really still doing much with their neck. What do you do next? Because I feel like that's the ball. That's the decision-making tree. That's where we all have to decide, sort of, do you give them more time, do you add more antibiotics, do you go to the OR?
[Dr. Gopi Shah]
Well, interestingly, I guess, going back to the study, out of the 76 that got better, 80% or 60 of them got dramatically better, or resolved almost by 48 hours. That still means 20% didn't, but that means they're still potentially going to get better. I think that 48 to 72-hour window is dealer's choice a lot of times. Depends on what the parents want, what the hospitalist is thinking, and your gut feeling. You're looking at the kid, does he look sick or is he eating like a champ? Even though his abscess is still big, even though his neck-- You're right, sometimes that neck pain and stiffness doesn't go away automatically, and that's the last kicker.
In fact, that one kid I just told you about, where they made me go drain the kid, it was the neck stiffness and the CRP, but otherwise, he looked like a champ, so I probably err on giving him one more day of antibiotics. After 72 hours, I would think they probably are due to go to the OR. I might rescan him, though, because I need to know how big that abscess really is. Is it now 1 centimeter and it was 1.8? It's going to be harder to find, and so this decreases my risk of doing something bad in the OR.
[Dr. Gopi Shah]
Yes. No, I find that that's always-- that's the struggle, like the decision part where always I'm like, "Do I want to give him more time? Is there a role to add Clindas here?" Most of the time the pediatrician is like, "No," and I'm like, "Okay, maybe that's not going to do anything," and just adding more antibiotics. I struggle sometimes with that.
[Dr. John McClay]
Tell them 20% are going to get better if you give them one more day of antibiotics.
[Dr. Gopi Shah]
I just want to-- let's say we do go to the OR, and let's say it's that standard, the typical 1.8 centimeter or 2.2, whatever, and between that 1.8 to 2.5-centimeter range, what's your approach usually, any special tips or tricks, changes that you've made over the years that have helped you with these, or anything that you always do to help you stay safe in the OR?
[Dr. John McClay]
Yes. I think staying safe for me is, again, getting the CT and making sure the depth of the pharyngeal swelling and the location of the carotid artery, because if that carotid artery is medial and abscess is lateral, you got to go lateral. There's no other choice, and especially if it's high, it's going to be a little harder, so you just have to buckle in. If it's smaller, that's going to be even harder to find. I guess I'm so recalcitrant to a small 1.5 centimeter abscess, it's not getting better, I guess you got to go do something, but it may not be that satisfying in what you're going to get out, but at least you made the effort.
I remember, too, training in the early '90s, sometimes we take these kids to the OR, and we wouldn't get much out, but then they would get better after we operated on them, we thought we were doing something. Maybe we were, or maybe they were just going to get better on it because they'd already been on antibiotics or something, I don't know. I use a long knife handle blade because I don't want to have to cram my hand in there. I usually use an 11 blade, and then make a vertical incision, but I often will stick an 18-gauge first to try to locate it, and just for cultures, and then use a clamp to widen it.
It's interesting. I trained in DC, and King Grunfest was there, and the '70s or '80s, he wrote a paper where he stuck a quarter-inch Penrose through the nose, and then he would feed it all the way down to the nasopharynx and the pharynx, and then he would put the quarter-inch Penrose in the actual wound that he made so that it would stay open for a day or two, because you can't just stick it out of the mouth if they're not intubated, so he'd put it through the nose, and I thought that was interesting.
I think a couple of times when we had some extension of a retropharyngeal abscess into the mediastinum and I was a little more concerned about it because I maybe took a red rubber and put it through the nose and then all the way down and into the actual space so you could irrigate a little bit too gently and because it was already down pretty far into the chest. Then I think I probably taken care of several of those and some of them I would just drain and not do that. I would feed a catheter at the time and suction it out and irrigate it, but I wouldn't always leave a red rubber catheter.
Managing the Anatomically Challenging Retropharyngeal Abscess
Retropharyngeal abscesses that extend high near the skull base and close to the carotid sheath present unique management challenges. These abscesses, typically smaller than 2 centimeters, often improve with IV antibiotics, but high-positioned abscesses may require extended monitoring and, occasionally, a follow-up CT scan. In clinical practice, laboratory markers are essential tools for tracking an abscess's response to antibiotics. Hospitalists often rely on CRP and white blood cell counts to assess inflammatory activity, although CRP tends to lag behind visual and clinical improvements. A 48-hour observation period is generally recommended to gauge the effect of antibiotics and determine if additional intervention is warranted.
When an abscess shows no improvement after two to three days, a second CT can clarify its position, changes in size, and proximity to critical structures like the carotid artery, helping to determine whether surgical drainage is necessary. The approach to draining a high retropharyngeal abscess is delicate and may require intraoral access if the abscess remains medial to the carotid sheath.
Careful preoperative planning based on CT dimensions minimizes risks, especially since inserting a needle too deeply can cause severe complications by puncturing the carotid artery. By carefully monitoring clinical signs and interpreting imaging findings in relation to anatomical landmarks, clinicians can make informed decisions about the timing and necessity of surgical intervention, thus maximizing patient safety and recovery.
[Dr. Gopi Shah]
Going back to retropharyngeal, talk to me about the ones that I'm like, "Ooh, I hope the antibiotics work," are the ones that are super high up at the skull base? What do you do when those don't get better? They're all going to be close to the carotid, but every once in a while-- I think I had read one result where it was like, "This carotid, of course, is medially close proximity." I'm like, "Oh gosh. I hope that one gets better too." How do things like that play a role and what do you do if one of those don't get better? Do you ever get-- what do you do in those situations?
[Dr. John McClay]
Yes, so that's a good question, but you bring up a lot of points. 1995 of my fellowship in DC and George Zalzal throws up a CT scan of a circular 1.5-centimeter abscess high in the retropharynx, and he goes, "John, what do you want to do?" I just came off of training round. I'm like, "Let's go drain it." He said, "No, no, no, no." I'm like, "Why?" He's like, "John, it will get better." Anyway, maybe that started my whole thing about IV antibiotics because that kid did get better. Really when you look at those high ones, they're usually not that big. They're usually less than 2 centimeters.
Usually those will get better, but the high ones are really tough. If they don't get better, they'll probably extend a little lower. It gives you some access to drain them, but you're right. Another thing that the CT shows me is the location of the carotid sheath, the location of the carotid to the abscess. Sometimes if a kid doesn't get better, even after two or three days, I might repeat the CT because I've seen that change because it determines are you going to go medial or lateral? Even if you're going medially and maybe it's gotten a little better, you have to determine the thickness of the soft tissue that you get to the abscess and then how big the abscess is, because you're going to drain it intraorally, most likely if the carotid sheath is lateral, but the carotid sheath is still right there.
You want to make sure of the distance, because sometimes you'll stick that 18-gauge needle in and nothing's coming out. Then you're in the OR going, "Oh oh, what's going on here? Am I in the right place?" Even though that's where the bulge is. The CT tells you-- I really look at that and think, "Well, I've got 5 millimeters, 8 millimeters," whatever, until I get to the abscess because of the swelling of the pharynx. Then the abscess may be 1 centimeter. If I stick that needle in too far, I'm going to hit the carotid. I need to know those dimensions. Some people might say, "Well, you're getting another CT. Why are you doing that?" I'm like, "Because I don't want to kill the kid. I want to make sure that I know what I'm doing."
I had this argument one time, probably late '90s with the head of pediatrics in Children's. It was a lateral abscess in the erythema, and that was actually one of the signs in our study that shows you're probably going to need to drain it. It's not going to get better on IV antibiotics if you have erythema of the skin. On a lateral abscess, that's a retropharyngeal, you're not going to have that. He's like, "Look, it's red." I said, "Yes, but I don't know the extent of it. I don't know where the carotid is. I don't know where any of the vital structures are. I don't know how deep I've got to go once I open it. Yes, it's great if you just make an incision and it pops right out, but that didn't always happen.
Because sometimes, if it's in Levels 2 through 4, it's going to oftentimes be medial to sternocleidomastoid, so you're still going to have to go digging around in there a little bit." He said, "Well, you don't need a CT." I think he even canceled the CT out of order. I'm like, "Oh, fine, if you don't need a CT, why don't you go drain it? I'm the one that's having to go to the OR and make sure this kid is going to be okay." I like information. I don't like any mistakes. Nobody does. We're in medicine, we want to make sure we do the right thing every time as much as we can.
[Dr. Gopi Shah]
There's important structures all around us in the head and neck. I should have probably asked this in the beginning, but just to clarify terminology, when you say medial and lateral, are we talking in reference to the carotid sheet? Are we talking about trans/intraoral versus external drainage, SCM, external lateral neck, or deep? Just so I'm consistent.
[Dr. John McClay]
Yes. That's probably my fault because we were doing this study, I found if it was medial to the carotid sheet is parapharyngeal, retropharangeal, and peritonsillar. Lateral to the carotid sheet is Levels 1 through 5 and parotid. I guess I found such a big difference in this study. That's how I refer to them because the medial ones usually get better on IV antibiotics, and they can be up to 2 centimeters, 2.5 centimeters, which is consistent with the literature.
If you look in the literature, there's a couple of different papers that talk about abscesses up to 2.5 centimeters getting better on IV antibiotics. Usually, we're talking retropharangeal. Lateral, it's not as successful using IV antibiotics. A lot of times, you have to drain them. It's interesting too because we broke it down by Levels 1, 2 through 4, 5, and parotid. None of the parotids got better. In the posterior chain, less than 40% got better-- No, it was 50% got better. In the semantibular, like you were talking about, about 45% got better. In Levels 2 through 5, and it could have been based on size, about 80% got better. 2 through 4, 80% got better.
It was 45 patients, so it wasn't terrible. Each group has maybe 5, or 10, or 15, when you're talking lateral. Still, it's interesting information to generally guide you about what can happen or what might happen based on how you treat them.
[Dr. Gopi Shah]
In terms of labs, do you follow, have the pediatricians draw labs, follow labs? I feel like the question I always get asked is, "Do you want a CRP or an ESR?" Probably not the next day, but then I might, maybe at 40. I don't know. What are your thoughts on labs? If so, which ones and how do you utilize them?
[Dr. John McClay]
I lean pretty heavily on my hospitalist colleagues to admit the patients. They like data like that, which is fine. They'll often get a set rate in the CRP when they get admitted. Those are good parameters. I think the white count's probably even better because I think it changes faster than the CRP, which is probably used more than the set rate now. Used to be the set rate when CRP came around, but they're using that. I have seen though, the practice now is they'll admit them to the hospitalist, we'll put them on-- depending on the CT, if it's within that range, that might get better. They'll put them on for 48 hours, they'll draw a CRP and then they'll follow that to see if they're getting better.
What I've seen is even a child that had probably 72 hours of antibiotics and the kid looked great, I would never think about draining this kid. The CRP had not come down. The hospital was just like, "Yes, but they're not improving." I'm like, "Okay, I'll take them to the OR." Well, I think I got half a CC of bloody milky nothing. I don't think I did anything. I think the CRP lags clinical response. I don't know any studies on that. That's just what I've seen clinically. I think the white count is a good indicator. Then certainly clinically, when they look good, then they're turning the corner, but I have seen people too.
Surgical Techniques for the Severe Retropharyngeal Abscess
In managing severe retropharyngeal abscesses, especially those extending into the chest or lateral neck, securing a nasal drain is critical. Taping a nasal catheter to the nose can keep it in place temporarily without a deep anchoring, although such drains are generally left for just a couple of days. If the infection spreads into lateral neck or chest areas, an external approach can provide better control, allowing the surgeon to avoid sensitive medial areas and large blood vessels. This approach also offers better access to the "danger space" posterior to the retropharyngeal space. However, surgeons may face challenges due to the inflamed tissue and proximity to vital structures, requiring precise technique and vigilance.
With infants or very young patients, more aggressive drainage strategies may be necessary due to their immature immune responses and increased infection severity. Revisiting the OR to re-drain the abscess can be part of the treatment plan in these critical cases, and it’s an accepted strategy to ensure patient safety. Prioritizing a proactive approach to surgical drainage is encouraged to avoid potential complications, as failing to operate can have severe consequences.
[Dr. Gopi Shah]
Every once in a while they're super sick. It's really big and it goes into the chest. For those do you ever do an external approach? I've had one, it was a tiny baby who had a large retropharyngeal abscess that extended laterally into the lateral neck as well as into the chest, and we approached it from the neck so that we could leave a drain. I think the pediatric surgeon kind of-- I was like, "I don't really want to stick my hands in there." [chuckles] I know it's in the neck, but I'm not trying to go that low into the baby's chest. That way she could stick a drain in. Again, those are very rare, but every once in a while.
[Dr. John McClay]
Like you said, you saw it. You got to be prepared to make a decision on it. I think that's the appropriate thing when it's lateral like that. When some of it is lateral, you got to go lateral that's going to protect your carotid and that's going to give you better extension to the danger space, what they say, posterior to the retropharynx even.
[Dr. Gopi Shah]
I find those to be difficult too. I found that to be a difficult approach because it's inflamed, it's hot, you're going medial. I'm trying really not to get [laughs] that medial, but you are, you're getting close to the big vessels and I did not enjoy it. [laughs]
[Dr. John McClay]
I remember an adult we did when I was a resident that we had to open up both sides of the neck and go from both sides and try to get posterior to the entire trachea esophagus over the spine.
[Dr. Gopi Shah]
I guess the other thing to remember is, I think that baby had to go a couple of times, like wash at least more than once. I think that's something to keep in mind that when it's that bad, it's okay that you may have to go back and it might be part of it. Because I remember there was actually maybe two or three when I was at Children's for that time period where there were these that had come in and it required a lot. [laughs]
[Dr. John McClay]
I think that's a great point because for some reason those young kids maybe it's just their immune system is not great. You have to drain them but they're not fighting it as well, so you got to drain them again potentially, especially if they're bad. Nobody's ever going to fault you for taking a kid to the OR. They're only going to fault you if you don't. Something happens. Which is the last pearl.
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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