Dr. Terencia, Dr. Sajitha Nair, Dr. Sathyajith, Dr. Sindhu, Dr, Sreya,DrC Jayakumar
One year old child presented with high grade intermittent fever of 10 days and restricted movements of neck of 5 days duration. Small swelling on the right side of the neck was also noticed . Came to AIMS after treatment from near health care facility
Differentials-
1. Retropharyngeal abscess
2. Parapharyngeal abscess
3. Peritonsillar abscess
4. Epiglottitis/CROUP
5. Laryngopharyngeal diphtheria
6. Lymphangioma/Hemangioma
Child immunised up to date
Child was sick looking and febrile with stable vitals. On examination he was pale and Torticolis towards left side
He had multiple enlarged upper cervical lymph nodes on right side of neck involving Anterior and posterior triangle, largest measuring 2x 2cm.
Growth parameters were normal
Labs
TC-22.56K, N-59%, L-22%, HB-8.9, PLT-68
CRP of 36.08mg/L.
Peripheral smear suggestive of iron deficiency
Iv ceftriaxone,flucloxacillin and symptomatic measures were started after sending relevant samples for culture.
USG neck showed cervical adenopathy probably infective origin with early abscess in deep cervical space with retropharyngeal extension.
MDCT neck with contrast confirmed retropharyngeal abscess.
Incision and drainage of the retropharyngeal abscess was done and pus was sent for relevant tests.
Pus culture grew Streptococcus mitis.
Based on the culture report Flucloxacillin was changed to clindamycin. The child improved with treatment . AFB smear and gene Xpert MTB were negative in the pus drained.
Inj clindamycin was given for 7 days. At discharge he is afebrile and is hemodynamically stable.
RETROPHARYNGEAL ABSCESS-
Suppurative infections of the neck are uncommon but serious in children.
Suppurative cervical lymphadenitis is the most common superficial neck infection. Deep neck infections include peritonsillar abscess, retropharyngeal abscess, and lateral pharyngeal space infection (also known as pharyngomaxillary or parapharyngeal space infection).
Lateral pharyngeal space infection most often arises via contiguous spread of infection from a peritonsillar or retropharyngeal abscess.
Clinical features and diagnosis- Rapid assessment of the degree of upper airway obstruction is the initial step in the evaluation of the child with potential deep neck space infection.
Patients with signs of retropharyngeal abscess and severe airway obstruction (eg, anxious, leaning forward with head in the “sniffing position,” and marked suprasternal retractions) warrant immediate involvement of airway specialists (eg, anesthesiologist or intensivist and an otolaryngologist) to assist with securing the airway.
Retropharyngeal infection should be considered in children who present with fever, stiff neck, pain with neck extension, dysphagia, and other symptoms related to inflammation or obstruction of the upper aerodigestive tract.
Neck stiffness is an important symptom and may occur in the absence of respiratory symptoms.
Examination of the oropharynx may be limited if the child is unable to open his or her mouth widely and should be avoided in children with significant airway compromise.
Imaging – In stable patients without significant airway compromise, computed tomography (CT) of the neck with intravenous contrast is the preferred study to confirm the diagnosis of retropharyngeal infection and to differentiate retropharyngeal abscess from cellulitis.
Management
•Initial therapy – Children with suspected retropharyngeal infection should be hospitalized
Particular attention must be paid to maintenance of the airway. Initial therapy depends upon the severity of respiratory distress and likelihood of drainable fluid (based upon CT findings and clinical features, such as duration of symptoms and clinical course)
Surgical drainage – In patients with severe airway secure the airway immediately and proceed to emergency surgical drainage.
We also suggestsurgical drainage for stable patients with CT imaging showing abscesses that are large (≥2.5 cm2) and consistent with a mature abscess (complete rim enhancement and scalloping)
Antimicrobial therapy – We suggest that children with retropharyngeal abscesses and no airway compromise receive a trial of empiric intravenous antibiotic therapy for 24 to 48 hours without surgical drainage, especially if the CT findings are not consistent with a mature abscess that is ≥2.5 cm2.
Initiate empiric intravenous antibiotic therapy as soon as possible after surgical drainage or once the decision is made to treat without surgical drainage.
Empiric antibiotic therapy should include coverage for group A Streptococcus (GAS), Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA], if appropriate), and respiratory anaerobes.
Response to antimicrobial therapy is indicated improvement in symptoms.
CT with contrast should be performed if there is no clinical improvement 24 to 48 hours after initiation of antibiotic therapy.
TAKE HOME MESSAGE-
It is essential to anticipate and treat retropharyngeal abscesses early because when detected early and appropriately treated, retropharyngeal abscess seldom leads to long-term consequences like Airway obstruction, Septicemia,, Aspiration pneumonia if the abscess ruptures into the airway, Internal jugular vein thrombosis, Jugular vein suppurativethrombophlebitis (Lemierre syndrome), Carotid artery rupture, Mediastinitis (suggested widening of the mediastinum on chest radiograph), Atlantoaxial dislocation.
