BackTable / ENT / Podcast / Transcript #190

Podcast Transcript: Managing Retropharyngeal Abscesses in Children

with Dr. John McClay

Nothing is more satisfying than draining an abscess, right? But when is medical management sufficient or even better? In this episode of the BackTable ENT Podcast, pediatric otolaryngologist Dr. John McClay joins host Dr. Gopi Shah to educate listeners on the diagnosis and management of pediatric retropharyngeal abscess (RPA). You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Retropharyngeal Abscess Presentation & Risk Factors in Children

(2) Assessing Retropharyngeal Abscesses

(3) The Use of CT & Ultrasound in Retropharyngeal Abscess Diagnosis

(4) Managing Complex Retropharyngeal Abscesses

(5) Empiric Treatment Approaches for Retropharyngeal Abscesses

(6) Empiric Therapy vs. Surgical Intervention

(7) Exploring Surgical Options for Complicated Neck Abscesses

(8) Balancing Costs & Outcomes of Pediatric Neck Abscess Intervention

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Ep 190 Managing Retropharyngeal Abscesses in Children with Dr. John McClay

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[Dr. Gopi Shah]
Hello, everyone, and welcome to The BackTable ENT Podcast, where we discuss all things ENT. We bring you the best and brightest in our field with a hope that you can take something from our show to your practice. My name is Gopi Shah. I'm a pediatric ENT, and I have an awesome guest today who is also a fellow pediatric ENT. I have Dr. John McClay. He's a pediatric ENT practicing at Cook Children's ENT in Frisco and Prosper, Texas, and he's here to talk to us about retropharyngeal abscess in children. Welcome to the show, John. How are you?

[Dr. John McClay]
I'm doing great. It's great to see you, Gopi. It's been a while.

[Dr. Gopi Shah]
It has. I was going to say my first, I think, memory of working with you was actually when I was a fellow at UT, and it was like early on, month one, and I think on a Monday we had a pretty extensive allergic fungal sinusitis in a 10-year-old, and then that Wednesday there was an open airway reconstruction with you 3 days later. I'm like, "Man, he's got range." [laughs]

[Dr. John McClay]
That's a good week.

[Dr. Gopi Shah]
It was a good week.

[Dr. John McClay]
Especially when you came through 2013, 2014, because the airway was drying up a little bit. We've done a ton before, but people were taking care of them in a better way. They were using smaller tubes in the ICU, and so it was just better. I love airway surgery and sinus surgery. Those are two big things for me versus the ears. I didn't do as much ear surgery. When that started decreasing I was a little bit of a bummer, but happy for the kids, but I like the procedures. That was good. I remember those cases, and I actually was happy when you decided to stay at UT because I was leaving, and I did a lot of the sinus stuff there.

[Dr. Gopi Shah]
No, I learned a ton. Because I remember being like, "What? No, I need somebody to teach me."

[Dr. John McClay]
Yes, but you were already pretty good. I was happy with your surgical skill set.

[Dr. Gopi Shah]
Oh, thank you.

[Dr. John McClay]
I thought, "This is good that she's staying." Then you did take over a lot of the airway, the cystic fibrosis kids. Because we had operated on about 60 of them, and then we were finding out whether or not that was beneficial. I was glad that you took the reins because you were good.

[Dr. Gopi Shah]
Ye. No, it was fun to build a sinus school-based practice at Children's and at UT and have people like Dr. Brad Marple, Dr. Matt Ryan to work with. I would reach out to you. The surgical skill's great, but the hard part eventually is the decision-making, when to go back, revise. I think things are better definitely in our CF modulators now with the sinus disease, as well as with the biologics and things like that. Anyways, it was a fun time. I'm so glad you're here. Before we get into retropharyngeal abscesses, can you tell us a little bit about yourself and your practice?

[Dr. John McClay]
Yes. We were talking about-- that was 10, 12 years ago. Then I did leave the med school. I was there for 17 years. Then I decided to open up a practice in Frisco, but I still took care of a lot of sinus kids and some airway kids too. I did some airway surgeries at other hospitals and they were freaking out a little bit about that. When I left, there was a clinically integrated network that was getting formed through Children's. I got involved with that. I was on the board and then I was the chairman of the quality committee actually. We thought, "Well, gosh, value-based medicine's coming in. Let's figure out what we can do to save costs but also increase the quality."

Really, that fizzled out after five or six years because insurance companies cared about quality, but they really cared about cost. [chuckles] We were doing all these things about measuring different quality, had different quality measurements, but it didn't really matter much to them if we didn't save money. Anyway, I also was getting involved with American Academy of Pediatrics. I was on the executive committee for a while and then became the chairman of the education committee. Then actually I'm still doing that. We're coming up with different and educational materials for pediatricians.

(1) Retropharyngeal Abscess Presentation & Risk Factors in Children

[Dr. Gopi Shah]
That's awesome. I love that. 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.

(2) Assessing Retropharyngeal Abscesses

[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 do find head rotation for retropharyngeal can be-- I just have a hard time. That's something that helps me, because a lot of times some kids will come in looking toxic, but a lot of kids they're there because the scan showed maybe a centimeter abscess, so we're doing IV antibiotics, and granted, we'll get into that, because that size is still not 1.8.

[Dr. John McClay]
That's huge.

[Dr. Gopi Shah]
Yes, like 1.8, then I'm like, "ooh, maybe, but maybe not." Sometimes I've even tried passively, gently trying to turn their head, using light, using toys, using music, and sometimes it can be tough. You have to figure out how to make that next clinical decision. You're right though, if they're gone to the playroom, [laughs] and they're eating and drinking and happy, then maybe they're getting better, and I don't need to force things that don't always contribute to the overall clinical picture.

[Dr. John McClay]
Yes, I think it's, again, being smart because you get trained to like, "Oh, you got to do all these things," and, "Oh, if you don't do it, you're not really completing what you were supposed to do." I don't think it's always the case. I just think you have to be smart about what you do. You have to get the information you need to make a decision about what you want to do, whether or not you want to treat them with antibiotics for a while, whether you want to go to the OR. A lot of that is based on how they look and some of the other parameters. They're going to have blood work that you can look at, hopefully a CT, but that can be a little tricky too on a sick kid.

Forcing a kid to do something, I don't always do it. I have to tell you, the parents don't like it. They look at you like, "What are you doing to my kid?" It's shared decision-making, but you're the doctor, so you have to make a decision about what's best for the child and let them know that or talk to them about it.

[Dr. Gopi Shah]
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.

[Dr. John McClay]
When I first started practice, for some reason, sensorineural hearing loss was a big deal. I needed to find craniofacial syndromes and I needed to make sure every kid, if they had hearing loss, I could diagnose something. I'm looking at this baby and they have sensorineural hearing loss and the eyes are a little wide, I think. I'm talking to the mom, "Yes, your child looks like they have some hypertelorism and the face looks a little funny." She just looked at me like, "Who are you? You're telling me my beautiful baby looks weird." I never saw her again.

Some of it is just being smart about what you're doing. You can get information in different ways that aren't offensive or difficult for the patient or family. Anyway, sorry.

(3) The Use of CT & Ultrasound in Retropharyngeal Abscess Diagnosis

[Dr. Gopi Shah]
No, no. It's helpful. 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. Other things on our differential, I think you'd mentioned other head-neck abscesses, like parapharyngeal potentially, depending on how big and deep. Although for that, I'd probably still, if we're going to go the OR want to scan, I think the retropharyngeal scan's definitely helpful, but other parotid, buccal, submandibular, which aren't as common. [laughs] It can be helpful.

Even sometimes for those, especially the submandibular space, sometimes I find if we're not moving the right direction, I might still want something anatomical like a CT if we're not moving the right direction for a submandibular space infection, just given the location and some of the submandibular gland and other things that can be there. It's not always a lymph node, it could be an infected lymphatic malformation, ranula, all those kinds of things that change up your management etiology and if they're going to need further things down the line. In terms of CT findings for retropharyngeal abscess, you discussed size, you went through it. Talk to me a little bit more [laughs] about size. What are you looking for? Size, location, other things on your scan that might be red flags or help you decide OR, not OR?

[Dr. John McClay]
Yes. I'm going to take you through a study we did from 1999 to 2004, basically. There were 291 children with neck abscesses over that period of time-- with neck infections, sorry, not all abscesses, but 195 abscesses and 96 phlegmon cellulitis cases. During that period of time, we then were starting to give IV antibiotics because we had seen that it was helping even in kids who had greater than a centimeter in diameter abscesses and we wrote a paper on that like in 2003. We had 100 kids that were stable and we did a trial of IV antibiotics on.

We looked at if they were successful or failed, and actually 76% improved and 24 of those 100 failed. Then we looked at what are the parameters to show whether they improved or not. It was interesting because there were 55 medial abscesses. I think of those similarly, retropharyngeal, parapharyngeal, paratonsillar, because 90% of those got better in IV antibiotics. When you looked at the size of the ones that improved, it was like 2 by 2.2 by maybe 1.5. Pretty decent size abscess. That was the average, which means some were smaller, some were bigger, that got better. The ones that failed were bigger than that.

Then for the lateral abscesses, we actually had 45 lateral abscesses, and on what you described, but only 60% got better. They were smaller when they got better. They were 1.2 by 1.5. Here you get this information. A CT will tell you the location of the abscess and the size of the abscess. It gives you an idea about potentially who's going to get better. That way, if you have a 3-centimeter abscess and the posterior chain are level five, it's not going to get better. You might as well just take that kid to the OR. If you have a 3 or 4-centimeter abscess, even if the child's stable in the retropharyngeal area, probably not going to get better. You may want to go drain it.

In fact, I just had a kid come in who had about a 3.5 to 4-centimeter retropharyngeal abscess. He was totally stable. I think he was like seven. I'm like, "I just give him some IV antibiotics." We did it for 72 hours, didn't get better, and so I drained him. It held up. I've been using the data in my head for about 20 years, and it seems to hold up because of the medial abscesses. We only had three peritonsillar, which was weird, but it might've been that 95 of the abscesses, people just took straight to the OR, so there was no trial of IV antibiotics. I think the lean would be if it's peritonsillar, just go drain it. Maybe we didn't have a lot of those, but all of those got better and they were all big.

Over the past 10 years, I have not drained a peritonsillar abscess.

[Dr. Gopi Shah]
[chuckles] They get better, 100%. I think it was Dr. Romaine Johnson, his trio thesis was about PTAs.

[Dr. John McClay]
Was it?

[Dr. Gopi Shah]
Yes. Because he did a lot of big data and lots of different--

[Dr. John McClay]
He likes big data.

(4) Managing Complex Retropharyngeal Abscesses

[Dr. Gopi Shah]
Yes. The data is using lots of different databases. It's statistical-like some results, really. I think it was that he found that 50% will get better, and so 100% with PTAs, I don't-- definitely. 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 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.

It's interesting because you talk about how long they need to stay in the hospital where they'll be looking good 24 to 36 hours and they're letting them go. Some of those kids bounce back. I think 48 hours was just generally something we saw, but if you read the literature, that's pretty consistent over the last two or three decades is that's the benchmark people use because I think clinically they're seeing them. It's like the studies on chronic tonsillitis. Bluestone and Paradise came up with those numbers, three, five, and seven, infections per year or two years or three years. That wasn't what their data showed. They just said, "Oh, this seems right." Sometimes that's okay. Perfect.

[Dr. Gopi Shah]
Yes, to start from somewhere. [laughs]

[Dr. John McClay]
Right, exactly.

(5) Empiric Treatment Approaches for Retropharyngeal Abscesses

[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]
I love steroids, I love them. I think they're great. I think they work wonders for lots of things. I'd tell you. Let me tell you another story. 1996, I'm a professor at the med school, just started. We would cover the adult hospital as well because we weren't that big faculty, was like seven or eight, and they needed help. I got this call one time I'm in my office, and I'm not even supposed to be covering Parkland, which is the adult hospital, the indigent hospital.

Dr. McClay, the secretary, said, "They need you in OR2 over Parkland." I'm like, "I'm not even supposed to be covering." "They can't find the other guy." I'm like, "Okay." I walk into this room, there's 17 people in this OR, and everybody's flustered around. There's this 32-year-old guy on the table, awake, getting versed, and the residents are over the neck trying to do an awake local trach on a guy who had been treated with IV steroids and IV antibiotics for a week in an ICU somewhere. It was a difficult airway. We couldn't get it. They finally got the wake-- we did the wake local trach, and then we opened up the neck and had a huge pseudoaneurysm that was about to rupture in the neck, and we had 1-inch space next to the skull base.

We clamped the carotid off before this pseudoaneurysm blew and tied it off and thought, "I don't know, is this guy going to stroke here?" There's no time for a circle of Willis test or anything. The guy lived. I always think about that with an abscess and steroids. However, two caveats, he's an adult, and adults are different, and it was a week of steroids. I'll never forget when I presented that one study, it was 2001, about neck abscesses and IV antibiotics, and 10 of the 11 got better, and this guy in the audience who'd just written a paper from Boston on draining 80 of them.

He said, "You know some of those are abscesses?" I'm like, "Yes." He said, "You know what's going to happen is somebody's going to sit on some kid in nowhere, Ohio, and something bad's going to happen to that kid." I'm like, "Look, I'm not here to tell you what to do, I'm just here to tell you what we found. Information is information." Saying all that, steroids and sitting on kids, it's two different things. 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.

[Dr. Gopi Shah]
No, no. It's helpful because you're right, I think the point of sitting on something versus giving them an empiric trial are two different things. I think that's really important. Two, I do think, in terms of what's it getting you, and you bring up like, well, if it's pretty big and you're probably going to have to treat it, still having that dose may be helpful in terms of airway protection and things like that, if it's middle of the night type of stuff. It's a tool, but I agree, it's not it's not something that necessarily is a reflex always. [laughs]

[Dr. John McClay]
Once you drain the abscess, all bets are off. You're fine. When we drained them when we were residents, we were doing the peritonsillar, and once the abscess was gone, we didn't worry about it. We gave them some steroids because now you're taking that risk away of the-- because it's the pressure along with what the steroids can do, so the pressure's off. We saw in our study too, we looked at-- like you were talking about different parameters of size and location, but we also thought, "Well, gosh, what about if there's pus in the carotid sheath? Because there's some studies that show that may be something concerning.

What about if the carotid artery is narrowed? What about if jugular vein is obstructed?" We looked at all that data, actually, and found that none of it was really inconsequential. Although of the six retropharyngeal abscesses that did not improve, five had pus in the carotid sheath. We thought, "Well, maybe that's something because it approached statistical significance," but when you look at the positive predictive value, 40% that got better on IV antibiotics still had pus in the carotid sheath. It didn't really help you determine whether or not you should intervene because a lot of those got better.

I think we didn't really see anything else necessarily, but you do have to be concerned about a neck abscess. These are potentially deadly things, and so treating them in the non-traditional approach, and now it's become more traditional, but when we were doing initially, you're putting yourself out there a little bit.

(6) Empiric Therapy vs. Surgical Intervention

[Dr. Gopi Shah]
Yes, that's true. In terms of, let's say you are now-- 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]
[laughs] Maybe that's the better, yes.

[Dr. John McClay]
Then if they don't get better, you're like, "Okay." You call them up.

[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.

I don't know if that's necessary or not. I guess it just depends on how you feel about it, how sick the kid is, how worried you are. Art of medicine.

(7) Exploring Surgical Options for Complicated Neck Abscesses

[Dr. Gopi Shah]
Yes, I know. I've never left anything in the nose down into the retropharyngeal space. Would you sew it?

[Dr. John McClay]
You could tape it at the nose.

[Dr. Gopi Shah]
Then how is it going to stay in that retropharyngeal space?

[Dr. John McClay]
Well, you don't. If it's taped, even if it comes out, you're not going to swallow it.

[Dr. Gopi Shah]
That's true.

[Dr. John McClay]
You know what I mean? You check on it I guess. You don't leave it for a day or two. A lot of drains you leave for a day or two and take out anyway. I think I stopped doing that. I think there was just one really sick kid that we got concerned about.

[Dr. Gopi Shah]
You're right, 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.

(8) Balancing Costs & Outcomes of Pediatric Neck Abscess Intervention

[Dr. Gopi Shah]
[laughs] No, it's a good pearl. Before we start rounding it out, I wanted to talk to you a little bit about data on cost or length of hospital stay when it comes to draining or doing IV antibiotics. What have you found? What are your thoughts?

[Dr. John McClay]
It's interesting because I did look at some of the data and it's different all around the world because hospital costs are different all around the world. When people quote these numbers, it's based on what's happening in their arena. Even Dallas-Fort Worth probably is more expensive than other places to have health care according to what I read in the past. I think the key, for me, is knowing the appropriate intervention, whether that's IV antibiotics or surgery as soon as possible and then that's going to get them out of the hospital as soon as possible. It goes back to getting that CT and is it medial lateral?

If it's a big lateral, 2 centimeters or greater, take them to the OR. Put a drain in. You can send them home with a drain and see them back in your clinic. You don't have to keep them in the hospital with a drain in these days like we used to. If it's a medial, 1.5 centimeter and abscess, they may get better 48 hours, they could go home. You're optimizing the care and the timing of care by increasing your fountain of knowledge of what that abscess actually is. If they're sick, you're going to take them to the OR immediately and you're just going to treat them for sickness.

I think you just do the right thing for the patient, but using some of the data to determine the optimum timing of care helps decrease the cost in general and it improves the quality of care.

[Dr. Gopi Shah]
No, that's a great pearl, having good clinical decision-making early on, like an initial presentation. That's super helpful. John, as we start to round this out, any final pearls or pitfalls whether it's specific to deep neck, retropharyngeal abscess in kids, any other practice pearls or wisdom that you want to leave us with?

[Dr. John McClay]
When in doubt, just take them to the OR, if you're vacillating about what to do. Like I said, nobody's ever going to fault you for taking them to the OR, just have a good fountain of knowledge of how these respond and based on their location and size and other factors and then you treat them optimally. If somebody's pushing you a little bit to go and you think you're not quite sure or they look sick, just do it. I'm the guy who treats everything with IV antibiotics, [chuckles] so if I'm saying that, you probably ought to think about it. [chuckles] Because even nontuberculous mycobacterium, we wrote a study that was medical therapy when standard of care is surgical excision.

[Dr. Gopi Shah]
Thank you so much, John. Any of our listeners want to reach out to you, are you on any social media? If you're not, they can also reach out to us and we can get them in touch with you.

[Dr. John McClay]
I do have a website, johnmcclaymd. I don't know if there's-- I think there's access to make an appointment. I don't really have social media for healthcare or whatever.

[Dr. Gopi Shah]
Thank you so much. I learned a ton.

[Dr. John McClay]
Hey, it was great seeing you. It's been so long.

[Dr. Gopi Shah]
Good to see you too.

[Dr. John McClay]
All right. Thanks, Gopi.

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.