Retropharyngeal and parapharyngeal abscess - Clinicals, Diagnosis, and Management

Otorhinolaryngology

Clinicals - History

Fact Explanation
Fever Refers to the infection and accumulation of purulent discharge within the retropharyngeal and parapharyngeal spaces. These usually develop as a complication of a primary infection elsewhere in the head and neck region, mainly nasopharynx, oropharynx, paranasal sinuses or middle ear. Other causes includes pharyngeal trauma and foreign body ingestion. Causative agents of these are usally polymicrobial with a mixture of aerobes and anaerobes. (Most commonly encountered are group A beta-haemolytic Streptococcus (GABHS) and Staphylococcus aureus.)

Note that Retropharyngeal abscess is encountered more frequently in children than adults. Due to the abundance of retropharyngeal lymph nodes that may regress with age.

Patient will be febrile due to the systemic response to infection.
Fever
Refers to the infection and accumulation of purulent discharge within the retropharyngeal and parapharyngeal spaces. These usually develop as a complication of a primary infection elsewhere in the head and neck region, mainly nasopharynx, oropharynx, paranasal sinuses or middle ear. Other causes includes pharyngeal trauma and foreign body ingestion. Causative agents of these are usally polymicrobial with a mixture of aerobes and anaerobes. (Most commonly encountered are group A beta-haemolytic Streptococcus (GABHS) and Staphylococcus aureus.)

Note that Retropharyngeal abscess is encountered more frequently in children than adults. Due to the abundance of retropharyngeal lymph nodes that may regress with age.

Patient will be febrile due to the systemic response to infection.
Odynophagia Due to external compression of the esophagus from the abscess causing diffused muscle spasms. Odynophagia
Due to external compression of the esophagus from the abscess causing diffused muscle spasms.
Dysphagia Due to external compression of the esophagus from the abscess causing partial or complete obstruction of the esophageal lumen. Dysphagia
Due to external compression of the esophagus from the abscess causing partial or complete obstruction of the esophageal lumen.
Dyspnea Narrowing of airway lumen due to swelling of the abscess towards the posterior pharyngeal wall. Dyspnea
Narrowing of airway lumen due to swelling of the abscess towards the posterior pharyngeal wall.
Loss of appetite / Refusal to feed Due to discomfort in swallowing caused by the bulging oropharyngeal mass. Loss of appetite / Refusal to feed
Due to discomfort in swallowing caused by the bulging oropharyngeal mass.
Sore throat Due to the presence of concomitant pharyngitis. Sore throat
Due to the presence of concomitant pharyngitis.

Clinicals - Examination

Fact Explanation
Cervical Lymphadenopathy Draining of infected material to these glands from the affected sites. Cervical Lymphadenopathy
Draining of infected material to these glands from the affected sites.
Torticolis Retropharyngeal edema and swollen lymph nodes causing the laxity of the ligaments and structures at the atlantoaxial level resulting asymmetrical head or neck position. Torticolis
Retropharyngeal edema and swollen lymph nodes causing the laxity of the ligaments and structures at the atlantoaxial level resulting asymmetrical head or neck position.
Oropharyngeal swelling Posterior pharyngeal edema caused by the swollen abscess. Oropharyngeal swelling
Posterior pharyngeal edema caused by the swollen abscess.
Trismus Anterior parapharyngeal abscesses can cause spasm of jaw muscles resulting difficulty in opening of the mouth. Trismus
Anterior parapharyngeal abscesses can cause spasm of jaw muscles resulting difficulty in opening of the mouth.
Stridor Commonly seen in infants. occurs due to the narrowing of the airway lumen. Stridor
Commonly seen in infants. occurs due to the narrowing of the airway lumen.
Drooling Commonly encountered among the pediatric population.

Note that stridor and drooling are signs which indicate potential airway compromise.
Drooling
Commonly encountered among the pediatric population.

Note that stridor and drooling are signs which indicate potential airway compromise.
Neck pain and stiffness Compression of the adjacent group of neck muscles and soft tissues by the abscess causing inflammatory response. Neck pain and stiffness
Compression of the adjacent group of neck muscles and soft tissues by the abscess causing inflammatory response.

Investigations - Diagnosis

Fact Explanation
Lateral neck radiography Widening of the retropharyngeal space with prevertebral soft tissue thickening and straightening of cervical spine resulting from muscle spasm can be noted.,

Note that care must be taken to ensure patient's neck is in extended position and the image should be taken at the point of complete inspiration. (due to widening of the retropharyngeal space while the neck is flexed.)
Lateral neck radiography
Widening of the retropharyngeal space with prevertebral soft tissue thickening and straightening of cervical spine resulting from muscle spasm can be noted.,

Note that care must be taken to ensure patient's neck is in extended position and the image should be taken at the point of complete inspiration. (due to widening of the retropharyngeal space while the neck is flexed.)
Contrast enhanced computer tomography Contributes greatly towards diagnosis and to determine the extent of the abscess. May help differentiating cellulitis from an abscess. Contrast enhanced computer tomography
Contributes greatly towards diagnosis and to determine the extent of the abscess. May help differentiating cellulitis from an abscess.
Magnetic Resonance Imaging Useful in evaluation of potential adjacent vascular complications. Magnetic Resonance Imaging
Useful in evaluation of potential adjacent vascular complications.
Ultrasound Useful in differentiating retropharyngeal cellulitis from an abscess. Ultrasound
Useful in differentiating retropharyngeal cellulitis from an abscess.
Chest X Ray Useful if mediastinal involvement is suspected. Chest X Ray
Useful if mediastinal involvement is suspected.
Complete Blood Count May show neutrophil leucocytosis and raised ESR count as a response to the ongoing infection. Complete Blood Count
May show neutrophil leucocytosis and raised ESR count as a response to the ongoing infection.

Management - Supportive

Fact Explanation
Airway management Is of utmost importance in a patient with compromised airway. Endotracheal intubation may be required to secure and maintain the patency. However it may be difficult because of the upper airway swelling. In such instances cricothyrotomy or tracheostomy will be required. Airway management
Is of utmost importance in a patient with compromised airway. Endotracheal intubation may be required to secure and maintain the patency. However it may be difficult because of the upper airway swelling. In such instances cricothyrotomy or tracheostomy will be required.
Intravenous fluids Due to the dehydrated status of the patient with electrolyte imbalances and metabolic derangements as a result of poor oral intake. Intravenous fluids
Due to the dehydrated status of the patient with electrolyte imbalances and metabolic derangements as a result of poor oral intake.

Management - Specific

Fact Explanation
Intravenous broad spectrum antibiotics The cornerstone of management consists in antimicrobial therapy, which aids in eradicating the infection,reducing morbidity, and prevention of complications. Empiric antibiotic therapy should be commenced as soon as possible.Mainly targeted at gram positive cocci, with pencillin or clindamycin and anaerobes with metronidazole. However choice of empirical antibiotic therapy may depend on the local sensitivity pattern. Intravenous broad spectrum antibiotics
The cornerstone of management consists in antimicrobial therapy, which aids in eradicating the infection,reducing morbidity, and prevention of complications. Empiric antibiotic therapy should be commenced as soon as possible.Mainly targeted at gram positive cocci, with pencillin or clindamycin and anaerobes with metronidazole. However choice of empirical antibiotic therapy may depend on the local sensitivity pattern.
Surgical drainage. Is indicated when the patient presents with airway compromise or unsatisfactory improvement following administration of antibiotics. Aids in prevention of severe complications such as carotid artery erosion, internal jugular venous thrombosis.
Note - External approach is used when the infection involves the parapharyngeal space.
Surgical drainage.
Is indicated when the patient presents with airway compromise or unsatisfactory improvement following administration of antibiotics. Aids in prevention of severe complications such as carotid artery erosion, internal jugular venous thrombosis.
Note - External approach is used when the infection involves the parapharyngeal space.

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