Dr. T. Balasubramanian M.S.
Retropharyngeal abscess is a collection of pus
between the posterior pharyngeal wall and the fascia and muscles
covering the cervical vertebrae. It occurs in two forms - 1. The
acute primary retropharyngeal abscess which is common in infants,
and 2. Chronic retropharyngeal abscess which is common in adults.
These two types of abscesses differ in their etiology and
Acute primary retropharyngeal
abscess: Is the more dangerous type occurring in infants. It
is common between the age group of 3 months to 3 years. The
predisposing factors are malnutrition, gastroenteritis, poor hygeine
Etiology: Abscesses may follow general debilitating
illnesses like scarlet fever, measles etc. Infections from tonsils,
adenoid and naso pharynx may even lead to the formation of
retropharyngeal abscess. Rarely foreign bodies like bone pieces and
pins may also cause retropharyngeal abscess.
Pathology: The disease consists of suppurative
lymphadenitis of the retropharyngeal nodes of Henle, situated on
either side of midline between the psoterior pharyngeal wall and the
aponeurosis over the bodies of the second and third cervical
vertebrae. These glands receive the lymphatics of the post nasal
space, pharynx, nose, eustachean tube and middle ear. These nodes
atrophy between the 3rd and 5th year of life hence acute
retropharyngeal abscess is uncommon in children above the age of 4.
The Henle's node when infected from the lymphatics, there
is first adenitis, then periadenitis and abscess formation occur.
The suppuration is usually one sided, and most prominent in the oro
pharynx. If not evacuated in time or when it does not rupture, pus
may spread along the esophagus or burst in different directions -
towards the larynx, the angle to the jaw or even in to the external
auditory canal. The pus is generally foul smelling yellow or whitish
in color. It usually contains streptococci, and more rarely
staphylococci and pneumococci.
Chronic retropharyngeal abscess: Is commonly known to occur in adults. This is usually
caused by tuberculosis. The tuberculous foci occur in the bodies of
the cervical vertebrae( Pott's disease) which later spread into the
retropharyngeal space. Primary syphilis of the mouth and pharynx may
also cause retrophrayngeal abscess. This abscess usually is present
in midline and is free to spread to either side also.
Symptoms: These patients have excruciating
pain while swallowing (odynophagia). Young infants with
retrophryngeal abscess will refuse feed, may have extensive
drooling. In adults the head may be held straight. Torticollis is
also common in these patients. These patients may have difficulty in
breathing (stridor), in which case tracheostomy must be considered
to secure the airway in the first place. Constitutional symptoms
like fever / toxicity is very common in acute retropharyngeal
Complete blood count show leucocytosis.
Blood cultures can also be performed to ascertain the appropriate
antibiotics to be used.
C reactive proteins are also found to
increased in these patients
Xray soft tissue neck - A.P. and lateral
These pictures show prevertebral
soft tissue widening. This can be ascertained by estimating the size
of the prevertebral soft tissue which is normally half the size of
the body of the corresponding vertebra. If the widening is more than
half the body size of the corresponding vertebra then
retropharyngeal abscess must be considered. The cervical spine are
straightend with loss of the normal lordosis (Ram Rod spine). Above
the prevertebral shadow air shadow is seen in almost all cases of
retropharyngeal abscesses. This gas shadow is caused by entrapped
air which occur during breathing. Some bacteria esp. Clostridium are
known to form gases which may be entrapped in the prevertebral
showing xray soft tissue neck lateral view in a patient with
C.T. scan neck or MRI study of neck
will also help in clinching the diagnosis. This must ideally be
performed using intravenous contrast agents. It appears as a
hypodense lesion in the retropharyngeal space with ring enhancement.
Other effects that could be seen are soft tissue swelling, and
obliteration of normal fat planes.
C.T. scan is really helpful in differentiating cellulitis
CT showing retropharyngeal abscess as hypodense area
In majority of cases incision and draiuage
is done and the pus is immediatly aspirated out using suction. The
incision is made with 11 blade knife over the most prominent portion
of the swelling. The I&D is done under local anaesthesia. In the
case of infants it is preferable that the patient is held upside
down while the surgery is being performed to prevent aspiration of
pus into the lungs. When general anaesthesia is preferred a cuffed
endotracheal tube must be used to minimize the hazard of aspiration
of pus into the lungs. The patient must be put in Rose position
(tonsillectomy position) while the I&D is being done to reduce
the threat of aspiration.
When the abscess points towards the neck
then it should be opened through an incision over the neck,
preferably along the posterior border of sternomastoid muscle. The
dissection is carried out behind the great vessels of the neck and
in front of the prevertebral muscles. The surgery is followed by a
course of antibiotics mostly cephalosporin group. Clinamycin in dose
of 600-900mg intravenously 8th hourly can be administered in adults.
Injection penicillin G in doses of 24 million units per day as
continuous infusion along with metronidazole injection in doses of
500mg three times a day can also be considered. Metronidazole is
highly effective against anaerobes.
If tuberculosis is suspected to be the cause
then surgery is deferred. Anti tuberculous treatment is initiated.
2. Airway obstruction
3. Atlanto occipital
4. Jugular vein thrombosis
5. Cranial nerve deficits especially the
lower three ones
6. Haemorrhage secondary to involvement of
the carotid artery
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