Hong Kong Journal of Emergency Medicine

Retropharyngeal abscess
FKC Chu

Retropharyngeal abscess is a condition commonly seen in children but not so common in adult. In this case
report, we describe an adult case of retropharyngeal abscess who presented to us with symptoms of sore
throat and dysphagia for 1 month. (Hong Kong j.emerg.med. 2002;9:165-167)

Keywords: Dysphagia, retropharyngeal abscess, sore throat

Introduction Lateral X-ray neck (Figure 1) and chest X-ray were

A 58-year-old gentleman came to our emergency
department complaining of a one month history of
sore throat. The symptom did not respond to the
medications prescribed by the private doctor. He
experienced increasing dysphagia and vomiting. He
had no fever and had no subjective weight loss. His
appetite was fair.
He enjoyed good past medical health except for a
hernia operation done 2 years earlier. There was no
history of ingestion of foreign body, nor any intra-
oral or extra-oral trauma.
ordered and chest X-ray was normal while lateral neck
X-ray showed retropharyngeal swelling at C5 level and
the retropharyngeal diameter measured 33 mm at that
level.
He was admitted to surgical unit for fur ther
management.
Blood tests performed in ward were essentially
unremarkable. Hb 15.1 g/dL and WBC slightly

Physical examination revealed satisfactory general

condition. He remained comfortable in supine
position and did not appear ill looking. He did not
have drooling of saliva. There was no stridor. Chest
was clear on auscultation and throat was mildly
congested over the posterior pharyngeal wall without
obvious swelling. There was no obvious swelling over
his neck on palpation. His blood pressure and pulse
was stable with BP 149/80 mm Hg and pulse is 106
beat per minute.

Correspondence to:
Chu Kin Chiu, Francis, MBBS, MRCP(UK)
Queen Elizabeth Hospital , Accident and Emergency
Department, 30 Gascoigne Road, Kowloon, Hong Kong Figure 1. Lateral X-ray neck showing retro-
Email: FrancisChu@my.netvigator.com pharyngeal swelling.
166
increase 11.8x10 9/L. Liver and renal function tests
were unremarkable.
Urgent CT neck was performed which showed a rim-
enhancing mass with hypodense centre in the
retropharyngeal space, just posterior to the trachea.
It was extended from lower end of C5 to the posterior
mediastinum around the upper aortic arch level. The
swelling measures 8x4.3x2.5 cm (HxWxAP), and no
definite foreign body was detected. It was suggestive
of retropharyngeal abscess at C5 level down to
posterior mediastinum. (Figure 2)
Progress
The patient was febrile after hospitalization and
emergency incision and drainage of the abscess was
performed the next day under general anaesthesia. The
operation was performed with a right oblique cervical
incision. Retropharyngeal abscess with multiple
enlarged lymph nodes was found and abscess cavity
was drained. Pathology report showed chronic
inflammation, no acid-fast bacilli and no malignant
change. Pus aspirate grew haemolytic Streptococcus,
Bacteroides, Peptostreptococcus.
He was managed post operatively in Intensive Care Unit
(ICU) with intravenous antibiotics, and was put on
nasogastric tube feeding till day 5. His progress was
uneventful, patient was transferred out of ICU on day 2
Figure 2. CT neck showing the retropharyngeal abscess.
Hong Kong j. emerg. med. ! Vol. 9(3) ! Jul 2002
post-operation and able to tolerate oral diet on day 6.
He was discharged on the thirteen post-operative day.
Discussion
Retropharyngeal abscess (RPA) is usually described as
a disease of children. Over 95% of the cases occurred
in children under the age of 6. However, it is rather
uncommon in adult. One study reported 51 cases of
this condition in adults from 1970-1995.1
The retrophar yngeal space is a potential space
bounded anteriorly by pharyngeal muscle and its
investing fascia, posteriorly by the alar layer of
prevetebral fascia, superiorly by the skull base and
inferiorly by the fusion of the anterior and posterior
layers of fascia at the level of C7. Laterally, the space
is bounded by the carotid sheaths. This potential space
contains no important structures except lymph nodes
which normally regress by the age of 6.
In children, RPA is most frequently associated with
viral upper respiratory infection, pharyngitis, otitis
media, which cause adenopathy and RPA is developed
from suppuration of RP nodes. It also explains why
RPA is rare in adult because the nodes have regressed
since childhood.2
In young children, clinical presentation of RPA
include (1) feeding problem, (2) fever, (3) upper
airway obstruction with stridor. Common organisms
grown from these abscesses are Group A Beta-
haemolytic streptococcus, Staphylococcus
aureus, Haemophilius influenza, Bacteroides,
Peptostreptococcus and Fusobacterium. 3
For adult cases of RPA, the most common presenting
symptoms are sore throat, dysphagia, and neck pain,
while a small number of patients present with airway
obstructive symptoms. Majority of the patients have
history of intra-oral procedure, such as endotracheal
intubation and endoscopy, trauma, hypopharyngeal
foreign body. Diseases like diabetes mellitus,
malignancy, chronic alcoholism and AIDS are
reported causes of RPA in adults.1
Chu/Retropharyngeal abscess
Only few cases of RPA have visible swelling of
posterior pharynx on physical examination and thus
negative physical findings cannot rule out RPA.
X-ray examination is useful in the diagnosis of RPA.
Wholey et al. concluded that measurement greater
than 7 mm at C2 and 22 mm and 14 mm at C6 in
adult and children respectively are considered
abnormal and strongly support the diagnosis of
RPA. 4
In adult RPA, the most serious and life-threatening
complication is airway obstruction. Mediastinal and
pleural involvement are frequent, resulting in
suppurative mediastinitis and pyropneumothorax and
pericarditis. Other complications are epidural abscess
and sepsis.
Although Group A beta-haemolytic streptococcus and
Staphylococcus aureus were the predominent
pathogens in adult, culture for anaerobic organisms
and tuberculosis bacilli should also be included.
In summary, adult RPA usually occurs with underlying
disease, after procedure or secondary to trauma, with
167
common presenting symptoms such as sore throat,
dysphagia and neck pain. Absence of posterior
pharyngeal swelling on clinical examination cannot
reliably rule out RPA and lateral X-ray of neck play
an utmost importance role in diagnosing RPA.
Therefore, patient with symptoms of sore throat out
of proportion to the oropharyngeal examination
should alert physician to think of RPA and consider
the need to perform a lateral neck X-ray.
References
1. Tannebaum RD. Adult retropharyngeal abscess: a case
report and review of the literature. J Emerg Med 1996;
14(2):147-58.
2. Echevarria J. Deep neck infections. In: Schlossberg D,
ed. Infections ofthe head and neck. New York: Springer-
Verlag 1987:172-4.
3. Brook I. Microbiology of retropharyngeal abscesses in
children. Am J Dis Child 1987;141(2):202-4
4. Wholey MH, Bruwer AJ, Baker HL. The lateral
roenenogram of the neck. Radiology 1958;71:
350-6.