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Retropharyngeal Abscess


KEY FACTS

Terminology

  • Extranodal purulent fluid collection in retropharyngeal space (RPS)

Imaging

  • Lateral radiograph: Wide prevertebral distance with loss of normal contours at hypopharynx-esophagus interface

  • CECT best tool for rapid characterization & evaluation of extent/complications

    • RPS distended by defined, ovoid, rim-enhancing low-density collection with convex anterior margin

    • Complications include airway compromise, jugular vein thrombosis/thrombophlebitis, mediastinal extension/mediastinitis, internal carotid artery pseudoaneurysm (rare, suggests methicillin-resistant Staphylococcus aureus )

Top Differential Diagnoses

  • Pseudothickening of retropharyngeal soft tissues

  • Retropharyngeal space edema

  • Necrotic/suppurative adenopathy in RPS

  • Lymphatic malformation

Clinical Issues

  • Presentation: Dysphagia, sore throat, poor oral intake, dehydration, fever, chills, ↑ WBC & ESR; toxic-appearing child with marked neck pain & limited motion, especially extension

    • Most < 6 years old; increasing incidence in adults

  • Etiology

    • Head & neck infection (pharyngitis, tonsillitis) seeds RPS lymph node → suppurative intranodal abscess → nodal rupture → RPS abscess

    • Pharyngeal penetration by foreign body

  • Treatment: Early ENT consultation, IV antibiotics, airway management, fluid resuscitation

Axial graphic illustrates the location & typical contour of a retropharyngeal space (RPS) abscess
displacing the cervical esophagus
anteriorly & flattening the prevertebral muscles.

Axial CECT in a 10 month old with a 5-day history of febrile illness reveals a large, low-density, ovoid collection distending the RPS
with anterior displacement of the pharynx & splaying of the carotid sheaths. There is minimal enhancement of the collection wall.

Lateral radiograph in a 12-month-old boy with sepsis shows significant thickening of the prevertebral soft tissues
. The normal step-off at the pharyngeal-esophageal junction has been effaced.

Sagittal reformatted CECT in the same child clearly shows the cause of the prominent soft tissues to be a convex anterior RPS abscess
with extension of fluid into the posterior mediastinum
.

TERMINOLOGY

Definitions

  • Retropharyngeal space (RPS): Midline space posterior to pharyngeal mucosa & cervical esophagus from skull base to T3 vertebral level in mediastinum

  • RPS abscess: Extranodal purulent fluid collection in RPS

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