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All that drools: Retropharyngeal and peritonsillar abscess
Case presentation
A 4-year-old child is referred from her primary care provider’s office over concerns for meningitis. The patient has had fever and decreased oral intake and has not wanted to move her neck or head for the past 3 days. She has had rhinorrhea and mild cough for the past 3 days. She was seen by her primary care physician initially, who diagnosed an upper respiratory infection. The patient returned to her primary care provider when it was noted she did not want to move her neck or head.
Her physical examination reveals an anxious child in no immediate distress. She has a temperature of 103 degrees Fahrenheit, a heart rate of 120 beats per minute, respiratory rate of 30 breaths per minute, and a blood pressure of 85/40 mm Hg. Her examination reveals a mildly erythematous oropharynx without palatal petechiae or asymmetry. She is tilting her head toward the left and has very limited range of motion of the neck. In fact, she is refusing to move her neck or head. There is scattered anterior cervical lymphadenopathy that is nontender and without fluctuance. Her tympanic membranes are clear and there is no mastoid tenderness, erythema, or fluctuance.
Imaging considerations
The retropharyngeal space is not usually well visualized on imaging without the presence of a pathologic process. , Imaging often plays a role in both the diagnosis and the management of patients with suspected deep soft tissue neck infections.
Plain radiography
This imaging modality can be useful in assessing for the presence of an infection in the deep spaces of the neck. Plain radiography is available and rapid and has minimal exposure to ionizing radiation with adherence to pediatric imaging protocols. The presence of an increase in the width of the soft tissue space anterior to the cervical spine with narrowing of the oropharyngeal airway should prompt the clinician to consider such infections. In children younger than 5 years of age, the retropharyngeal space normally measures one-half of the full width of the adjacent vertebral body; in older children, a second cervical (C2) prevertebral width of greater than 7 mm and sixth cervical (C6) width of up to 14 mm are acceptable. , Some authors propose that prevertebral space measurements greater than these measurements, with clinical findings to support a deep neck space infection, are sufficient to make the diagnosis of a retropharyngeal abscess (RPA). , , However, obtaining lateral neck radiographs can be challenging in pediatric patients, who may not cooperate behaviorally to produce a meaningful study. Flexion of the neck, crying, swallowing, and rotational artifacts can lead to difficulty interpreting these radiographs. , , Additional indications of a deep neck infection may include gas within the soft tissues of the neck, prevertebral or retropharyngeal soft tissue thickening, cervical spine straightening (loss of lordosis) on the lateral view, and torticollis on anterior-posterior projections. ,
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