Retropharyngeal abscesses are rare in adults. They occur mostly in immunocompromised patients or as a foreign body complication. We report 5 cases of retropharyngeal abscess collected in the ENT Department of CHU Mohammed VI of Marrakech, during a two-year period (December 2008 to December 2009). Local trauma by foreign body ingestion was the aetiology in four patients. The presenting symptoms, for all patients, were fever, odynophagia, torticollis, and trismus, and the clinical examination showed bulging of the posterior wall of the oropharynx. The radiography of cervical spine showed prevertebral thickening in all cases, this thickening was associated with an aspect of vertebral lysis of the fourth cervical vertebra in one case. A CT scan was performed in all our cases and showed features of retropharyngeal abscess which was associated, in one case, with spondylodiscitis. The biological assessment found one case of diabetes. The intradermal reaction to the tuberculin was clearly positive in one case. Endobuccal abscess puncture was practiced in 4 cases; only one organism was identified by culture:
A retropharyngeal abscess is an infection in one of the deep spaces of the neck. In adults, retropharyngeal abscesses are rare in adults and can occur as a result of local trauma, such as foreign body ingestion (fishbone), or instrumental procedures (laryngoscopy, endotracheal intubation, feeding tube placement, etc.), or in the particular context of an associated disease [
The clinical records of five consecutive cases admitted at the ENT Department of the University Hospital of Marrakech with a diagnosis of retropharyngeal abscesses between December 2007 and December 2010 were retrospectively reviewed.
Peritonsillar abscesses were excluded. Factors such as sex, age, suspected aetiology, clinical symptoms, physical findings, blood tests, findings on imaging studies, treatment, clinical outcomes, and complications were analyzed.
The age range of the five cases was between 18 months and 72 years (3 males and 2 females). Foreign body ingestion was identified in four cases; 3 cases of fishbone and one case of chicken bone (Table
Summary of epidemiological data and suspected etiologies.
Patients | Age | Sex | Etiology | Morbidity |
---|---|---|---|---|
Case 1 | 18 | Male | Chicken bone | |
Case 2 | 34 | Male | Fishbone | |
Case 3 | 72 | Female | Fishbone | |
Case 4 | 46 | Female | Fishbone | Diabetes |
Case 5 | 38 | Male | Tuberculosis |
Bulging of the posterior wall of the oropharynx.
Prevertebral thickening in the radiography of cervical spine.
CT (sagittal view) showing retropharyngeal collection.
CT (transversal view) showing retropharyngeal collection.
Aspect of spondylodiscitis of the fourth cervical vertebra.
Intraoral puncture, under local anesthesia, was practiced in 3 cases. In the two remaining cases surgical drainage, under general anesthesia, was performed via oral route (Table
Established treatment.
Cases | Antibiotics | Anti-Koch’s therapy | Puncture | Surgical drainage |
---|---|---|---|---|
Case 1 | ||||
Case 2 | ||||
Case 3 | ||||
Case 4 | ||||
Case 5 |
Upon admission we commenced, in the four cases of foreign body trauma, intravenous antibiotic therapy: Co-amoxiclav, Gentamicin, and Metronidazole, switching to oral administration after 48 hours of apyrexia (after 8 days on average). The total duration of antibiotics was 14 days on average (apart from the case of tubercular origin).
No patient needed the airway securing as a result of respiratory distress. In the case with diagnosis of a retropharyngeal abscess complicating Pott’s disease antibiotics were withheld and anti-Koch’s therapy was commenced (2 months of Rifampicin, Isoniazid, and Pyrazinamide followed by 7 months of Rifampicin and Isoniazid) after surgical drainage.
The Surgical drainage under general anesthesia was also performed in the case of the diabetic patient who required also the correction of hyperglycemia in intensive care unit.
The length of hospital stay varied between 6 and 15 days with an average of 9 days. Every patient was followed for six months, without evidence of recurrence. Cervical CT (after six months) showed resolution of the retropharyngeal collection (Figure
Disappearance of the retropharyngeal collection after treatment.
Persisting images of bone remodeling after treatment.
Retropharyngeal abscesses are deep neck space infections that can pose an immediate life-threatening emergency, with potential for airway compromise and other catastrophic complications [
Abscesses in this space can be caused by many organisms such as aerobic organisms (beta-hemolytic
The high mortality rate associated with retropharyngeal abscesses is due to its association with airway obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, necrotizing fasciitis, sepsis, and erosion into the carotid artery [
Retropharyngeal abscess is more common in males than in females, with generally reported male preponderance of 53–55%. The principal symptoms in adults are sore throat, fever, dysphagia, odynophagia, neck pain and dyspnoea. Patients with retropharyngeal abscesses may present signs of airway obstruction, but often they do not. The most common physical presentation is posterior pharyngeal oedema (37%), nuchal rigidity, cervical adenopathy, drooling, and stridor [
The clinical diagnosis of retropharyngeal abscess can be difficult; the clinical symptoms are variable and nonspecific. The signs of infection may be lacking in certain situations of immune suppression such as diabetes [
CT contributes greatly to the diagnosis, but it has limitations in differentiating abscess from cellulitis of the retropharyngeal space. The plain radiograph in lateral view is very specific when it shows air in the retropharyngeal space. Carrying out radiological examinations should not delay care [
Cases of tuberculous retropharyngeal abscess have been reported previously [
According to Lübben et al. [
In cases of tuberculous retropharyngeal abscesses with neurologic complications, recovery does occur in nearly all the patients following prompt drainage and antituberculous therapy. The treatment of a tuberculous retropharyngeal abscess by drugs alone is hazardous even in the absence of myelopathy [
In nonspecific retropharyngeal abscess, antibiotic therapy (generally triple intravenous antibiotics: Co-amoxiclav, Aminoglycoside, and Imidazole) alone may be insufficient, and most authors recommend combining it with a surgical drainage of the collection [
The ideal time to make the drainage is in dispute. Some suggest local antibiotic injection at the same time as surgical drainage. In our study the use of surgical drainage was required in only two cases (cases of diabetes and tuberculosis); in other cases, the puncture of the abscess and the antibiotics were respectively sufficient to control the collection and to obtain a favorable outcome. The treatment of comorbidity is crucial, which in our study necessitated insulin therapy within intensive care unit support in the case of the diabetic patient.
Retropharyngeal abscess are rare in adults and constitute a serious emergency. The diagnosis is based on the clinical and radiological pictures, and comorbidities should be appreciated. The management of these situations is based on antibiotics and surgical drainage.