A ppt document on Retropharyngeal Abscess and its management.

1. Afolabi Boluwatife
BDS Group A 2015

2.  Introduction
 Relevant anatomic considerations
 Definitions
 Epidemiology
 Aetiology
 Pathophysiology
 Clinical features
 Investigations
 Treatment
 Complications
 Prognosis
 References
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3. Retropharyngeal abscess and other deep neck space
infections are potentially life threatening conditions and
can often present with diagnostic and therapeutic dilemmas
to the physician.
 The incidence and morbidity of deep neck space infections
has been significantly reduced with the introduction of
antibiotic therapy.
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7. 7

8. Abscess- A localized collection of pus surrounded by
inflamed tissue.
Retropharyngeal Abscess- This is the presence of an
abscess cavity within the retropharyngeal space.
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9. It is almost exclusively a paediatric diagnosis although it is
now being observed with increasing frequency in adults.
50% occur in patients 6-12 months of age.
96% occur before 6 years of age.
Peak age incidence is between 3-4 years.
Although no gender predilection has described but there is
higher incidence of as high as 60% in male children than
females.
There is however no racial predilection.
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10. Pediatrics
Pharyngitis, tonsillitis, otitis, adenitis, adenoiditis,
sinusitis, and nasal, salivary, and dental infections.
Congenital abnormalities: Branchial cyst, branchial
fistula
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11.  Adults
 Dental infections
 Salivary gland infections.
 Pharyngeal trauma from endotracheal intubation, endoscopy,
foreign body ingestion.
 Extension from adjoining deep neck space.
 Immunocompromised or chronically ill, diabetics, alcoholics,
cancers etc
 IV drug abusers.
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12. In children, retropharyngeal abscess is usually caused by
infections that spreads to the retropharyngeal lymph nodes
from surrounding structures with subsequent cellulitis and
formation of abscess.
The retropharyngeal lymph nodes usually regress and even
atrophy with increasing age hence its reducing frequency.
In older patients, infection of the retropharyngeal space
usually occurs from penetrating trauma or direct spread
from adjacent neck spaces.
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14. Symptoms in infants: fever, neck swelling, anorexia,
decreased appetite, irritability.
Symptoms in older children: fever, sore throat, malaise,
chills, odynophagia, decreased appetite, neck stiffness.
Symptoms in adults: fever, chills, malaise, sore throat,
odynophagia, dysphagia, sensation of lump in the throat,
muffled voice, neck pain, jaw stiffness.
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15. In children
-pyrexia.
- stridor.
- drooling of saliva.
- tender cervical lymphadenopathy.
- posterior pharyngeal bulge.
-Associated signs like tonsillar enlargment and hyperemia, otitis
media.
- ‘tracheal rock sign’ in which there is pain on rocking the trachea and
larynx from side to side.
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16. In adults
-pyrexia.
-drooling of saliva.
-stridor.
- posterior pharyngeal edema and hyperemia.
- tender cervical lymphadenopathy.
- nuchal rigidity.
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17.  Laboratory studies
- Electrolyte, Urea and Creatinine
- Full blood count- May show leukocytosis but normal WBC count does not
rule out the diagnosis of a retropharyngeal abscess.
- Blood culture
- Retroviral screening
- Random blood sugar
- Abscess aspirate for m/c/s
 Radiological
- Lateral neck X-ray- May show widening of the retropharyngeal space, gas-
fluid levels or gas in tissues, or even a foreign body in the retropharyngeal
space.
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19. CT scan of the neck with
contrast
- Very useful in the
diagnosis and management
of RPA. RPA appears as a
hypodense lesion in the
retropharyngeal space
with peripheral ring
enhancement.
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20.  MRI can also be done
 A chest x-ray is indicated to look for aspiration pneumonia and
mediastinitis.
 Ultrasound is an imaging modality that is gaining popularity. It is safer
than CT scan, since it is portable and does not use radiation.
Ultrasound is also less traumatic to children, requiring less frequent
use of sedation.
 In experienced hands, ultrasound can help determine the presence
and location of an abscess and can allow the clinician to distinguish
an abscess from cellulitis with some accuracy.
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21. The three keys to successful management of deep neck
infections are:
- Protection and control of the airway.
- Antibiotic therapy.
- Surgical drainage.
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22.  Initial Care
 Includes attention to the airway, fluid resuscitation if necessary, antibiotic
treatment, and preparation for an emergency operation. Frequent vital sign
checks and continuous oxygen saturation monitoring are essential.
 Airway management
 Apply supplemental oxygen. In young children, this can be done in a
nonthreatening way by letting the parent direct blow-by oxygen at the
child's face.
 Endotracheal intubation may be required if the patient has signs of upper
airway obstruction. It may be difficult because of upper airway swelling.
 Cricothyrotomy may be required in the patient with upper airway
obstruction who cannot be intubated.
 Tracheostomy may be required for definitive airway management.
 Intravenous fluids are required if the patient is dehydrated because of fever
and difficulty swallowing. 22

23.  Consultation of an ENT specialist is necessary as soon as the diagnosis
of RPA is established or as soon as the diagnosis is suspected if the
patient is exhibiting signs of upper airway obstruction.
 If it confirmed to be cellulitis rather than an abscess, IV antibiotics
should be commenced.
- Augmentin (Co- amoxiclav) or Ampicillin/sulbactam (unasyn)
-Metronidazole to improve anaerobe coverage.
-3rd generation cephalosporins and clindamycin are alternatives.
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24. The approach of drainage is dependent on the location of
the abscess and its relationship with other structures.
Image guided aspiration for small, uniloculated abscesses
Transoral surgical drainage
Preoperative CT – precisely locate the carotid sheath and
its content.
External surgical drainage.
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25. External surgical drainage
 The anterior approach involves an incision paralleling the anterior
border of the sternocleidomastoid, dissection along the anterior
border of the muscle, lateral retraction of the carotid sheath,
medial retraction of the larynx, trachea and thyroid and exposure
of the abscess cavity at the hypopharynx.
 The posterior approach utilizes an incision behind the
sternocleidomastoid, medial and anterior retraction of the muscle
and carotid sheath, opening into the abscess from posterior to the
great vessels.
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27.  Airway obstruction
 Ludwig’s angina
 Mediastinitis
 Pleural effusion
 Ruptured abscess can lead to Pneumonia or lung abscess
 Sepsis
 Skin defect
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28.  IJV thrombosis
 Carotid artery rupture (20 - 80% mortality)
 Multiple space involvement
 Cervical osteomyelitis
 Epidural abscess
 Pericarditis
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29. Prognosis generally is good if they are identified early,
managed aggressively, and complications do not occur.
Once mediastinitis occurs, mortality approaches up to 50%
even with antibiotic therapy.
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30. Retropharyngeal abscess must be identified early in order to
prevent life-threatening complications.
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31.  Acta Otorhinolaryngol Belg 2000; 54 (3) : 237 -41. Department of
Otorhinlaryngology, Head and neck surgery, University Hospitals leuven, Belgium
 Medscape
 Atlas of Human anatomy – Netters 2006.
 Journal of urban health – R.J Ruben and N.Weg. N Y acad. Med 1976
 Basic Otorhinolaryngology by Rudolf Probst, Gerhard Grevers, Heinrich Iro. Page 108
 Abstract of paper presented at 11th annual and scientific conference of association
of Pediatric surgeons of Portharcourt between 22 – 24 th September, 2011.
Department of Otolaryngology, University of Portharcourt Teaching Hospital.
 Wikipedia
 Slideshare.com
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32. THANK YOU FOR YOUR TIME 
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