Deep neck infections

Retropharyngeal abscess

• Epidemiology & Risk Factors:

  • Age: Children 6 mo – 6 yrs (atrophy of retropharyngeal LNs after age 6).
  • Triggers: URI, pharyngitis, posterior pharyngeal trauma (foreign body, endoscopy).
  • Bacteriology: Polymicrobial (GAS, S. aureus/MRSA, anaerobes).

• Clinical Features:

  • High fever, severe sore throat, dysphagia, drooling, “hot potato” voice.
  • Neck hyperextension (posturing for airway), pain w/ neck extension, bulging of posterior pharyngeal wall.

• Diagnosis:

  • Airway First: Secure if in respiratory distress.
  • Initial Imaging: Lateral neck X-ray (widened retropharyngeal soft tissue: >7 mm at C2, >14 mm at C6 in kids).
  • Confirmatory Imaging: CT neck w/ contrast (hypodense collection w/ rim enhancement).

• Key Differential Diagnostics:

  • Peritonsillar Abscess: Trismus, uvular deviation (contralateral), tonsillar swelling.
  • Epiglottitis: Thumbprint sign, tripod position, cherry-red epiglottis.
  • Croup: Barking cough, steeple sign (subglottic narrowing).
  • Ludwig Angina: Submandibular space cellulitis, elevated tongue, firm mouth floor.

• Management:

  1. Airway Protection: Emergent intubation/tracheostomy if stridor/distress.
  2. Empiric IV Abx: Ampicillin-sulbactam OR Ceftriaxone + Metronidazole (+ Vancomycin if MRSA suspected).
  3. Surgical I&D: Indicated if large (≥2 cm), airway compromise, or failed Abx therapy at 24–48 hrs.

• High-Yield Complications:

  • Acute Mediastinitis: Spread down “danger space” (posterior to retropharyngeal space) to posterior mediastinum.
  • Airway obstruction, aspiration pneumonia (rupture), IJV thrombosis, sepsis.