bubble_chart Overview

Retropharyngeal abscess occurs in the retropharyngeal space, often caused by infection and suppuration of the retropharyngeal lymph nodes. It is classified into acute and chronic types. The acute type is more common in children, while the chronic type is rare and usually results from abscess formation in the cervical subcutaneous nodes, also known as cold abscess. This section discusses acute suppurative retropharyngeal abscess.

bubble_chart Etiology

The retropharyngeal space is located posterior to the pharyngeal wall, between the buccopharyngeal fascia and the prevertebral fascia. It extends superiorly to the base of the skull and inferiorly to the mediastinum, adjacent to the parapharyngeal spaces on both sides. This potential fascial space contains loose connective tissue and is divided into left and right parts by the median raphe of the pharynx. In infants and young children, the retropharyngeal space is rich in lymph nodes, which receive lymphatic drainage from the posterior nasal cavity, nasopharynx, eustachian tube, and middle ear. Acute infections in these areas can spread via the lymphatic pathway, leading to suppurative lymphadenitis and abscess formation. The retropharyngeal lymph nodes gradually disappear between the ages of 3 and 8, so this condition predominantly occurs in children under 3 years old. Some cases may result from injury and infection of the posterior pharyngeal wall or the spread of inflammation from adjacent areas. The causative bacteria are the same as those found in peritonsillar abscesses.

bubble_chart Clinical Manifestations

Sick children often have a prior upper respiratory tract infection. The onset is sudden, with fever, crying, dysphoria, and refusal to eat due to throat pain. Generally, an abscess forms within 2 to 3 days after the onset. Once the abscess forms, the posterior wall of the pharynx bulges into the pharyngeal cavity, leading to varying degrees of dysphagia and respiratory distress. Infants may exhibit a duck-like cry, and breastfeeding may result in milk regurgitating into the nasal cavity or causing choking. Older children may display slurred speech and snoring. In severe cases, inspiratory stridor and dyspnea may occur, along with cyanosis, dehydration, acidosis, and signs of systemic exhaustion. If the abscess compresses the laryngeal inlet or is complicated by laryngitis, sudden asphyxia may occur.

Examination reveals the child tilting their head slightly backward and toward the affected side to alleviate pain and breathing difficulties. Neck movement is restricted, with swelling and tenderness of the lymph nodes below the mandibular angle and along the neck. The pharyngeal mucous membrane is congested, and the posterior pharyngeal wall is swollen, often偏向一侧, feeling soft or fluctuant upon palpation. The abscess protrudes forward, approaching or displacing the ipsilateral palatopharyngeal arch and soft palate. Pus can be aspirated by puncture.

bubble_chart Diagnosis

Based on medical history, symptoms, signs, and aspiration of pus, the diagnosis of a retropharyngeal abscess is not particularly difficult. A lateral neck X-ray may reveal anterior displacement of the retropharyngeal wall and widening of the prevertebral soft tissue shadow, or show the presence of fluid levels, which aids in diagnosis.

bubble_chart Treatment Measures

1. Once acute retropharyngeal abscess is confirmed, it should be incised immediately to {|###|}expel pus{|###|}. Place the child in a supine position with the head and chest lowered and the head slightly extended. Use a direct laryngoscope, anesthesia laryngoscope, or Davis mouth gag to expose the retropharyngeal wall. Under direct vision, first aspirate the pus by puncture, then make a longitudinal incision of about 1.5 cm with a small knife, insert a hemostat to expand the abscess cavity for unobstructed drainage, and simultaneously irrigate the cavity with antibiotic solution. Ensure the suction tip is placed near the incision to promptly aspirate any discharged pus. Postoperative dyspnea usually resolves promptly. If dyspnea does not improve after {|###|}expelling pus{|###|}, a {|###|}tracheostomy{|###|} may be performed. Subsequently, the incision should be dilated daily to {|###|}expel pus{|###|} once, typically healing after 3–5 sessions.

2. Pay attention to systemic supportive therapy and the use of sufficient antibiotics to control infection, commonly high-{|###|}dose{|###|} intravenous penicillin. In children, dangerous conditions such as laryngospasm or even respiratory and cardiac arrest may occur. Emergency preparations must be made in advance to ensure smooth rescue operations, including preparations for tracheostomy, emergency medications, oxygen, and suction devices.

bubble_chart Complications

Retropharyngeal abscess in children is an acute sexually transmitted disease. Delayed or improper treatment can be life-threatening. The abscess may extend downward, causing laryngeal obstruction or mediastinal infection; lateral spread into the parapharyngeal space can erode major neck vessels, leading to fatal hemorrhage. Sudden rupture of the abscess may result in aspiration pneumonia or asphyxia. Therefore, during pharyngeal examination, gentle palpation is advised, and preparations should be made. If the abscess ruptures, immediately position the head lower, use a tongue depressor to open the mouth, allowing pus to drain or be suctioned with an aspirator.

bubble_chart Differentiation

It needs to be differentiated from subcutaneous nodular abscess: subcutaneous nodular retropharyngeal abscess, which is a "non-febrile" abscess caused by cervical vertebral subcutaneous nodules or retropharyngeal space lymphatic subcutaneous nodules. The abscess caused by cervical vertebral subcutaneous nodules is located in the prevertebral space and may rupture in the late stage [third stage], forming a cold abscess in the retropharyngeal space. This condition is more common in adults or older children, often with a history of pulmonary subcutaneous nodules. The onset is slow, accompanied by systemic symptoms such as chronic cough, afternoon low-grade fever, night sweats, and weight loss. The abscess is protuberant, mostly located in the center of the posterior pharyngeal wall, and the aspirated pus is thin, where subcutaneous nodular bacilli can be detected. Cervical spine CT or X-ray imaging can reveal cervical spondylosis changes. Additionally, the patient has no difficulty extending the tongue or opening the mouth, which helps differentiate it from peritonsillitis and suppurative submandibular adenitis; the absence of hoarseness distinguishes it from acute laryngitis and laryngeal edema.