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RETROPHARYNGEAL

and stridor. .Retropharyngeal abscess (RPA) produces the symptoms of sore throat. fever.BACKGROUND . neck stiffness.  Retropharyngeal abscess poses a diagnostic challenge for the emergency physician because of its infrequent occurrence and variable presentation Early recognition and aggressive management of retropharyngeal abscess are essential because it still carries significant morbidity and mortality.

such as beta-hemolytic streptococci and Staphylococcus aureus  Anaerobic organisms. jugular venous thrombosis. the prevertebral fascia posteriorly. mediastinitis. such as Haemophilus parainfluenzae and Bartonella henselae The high mortality rate of retropharyngeal abscess is owing to its association with airway obstruction. bound by the buccopharyngeal fascia anteriorly. necrotizing fasciitis. and erosion into the carotid artery .The retropharyngeal space is posterior to the pharynx. sepsis. such as species of Bacteroides and Veillonella  Gram-negative organisms. and the carotid sheaths laterally Abscesses in this space can be caused by the following organisms:  Aerobic organisms. aspiration pneumonia. epidural abscess.

EPIDEMIOLOGY  Retropharyngeal abscess is more common in males than in females. retropharyngeal abscess was thought to be a disease limited to children. but now it is being encountered with increasing frequency in adults.  Initially. . with generally reported male preponderance of 53-55%.

children.HISTORY  History is variable. Symptoms of retropharyngeal abscess are different for adults. and infants. depending on the age group. Symptoms in adults *Sore throat  Fever  Dysphagia  Odynophagia  Neck pain  Dyspnea Symptoms in children older than 1 year Symptoms in infants Fever (85%) Sore throat (84%)  Neck swelling (97%)  Fever (64%)[15]  Poor oral intake  Neck stiffness (64%) [15]  Odynophagia (55%) [15]  Cough (55%)  Rhinorrhea (55%)  Lethargy (38%)  Cough (33%) .

but often they do not. Physical signs in adults Physical signs in infants and children  Posterior pharyngeal edema (37%)  Cervical adenopathy (36%)[15]  Nuchal rigidity  Retropharyngeal bulge (55%. Individuals who do not exhibit signs of airway obstruction initially may progress to airway obstruction.PHYSICAL  Patients with retropharyngeal abscess may present with signs of airway obstruction. do not palpate in children)[15]  Cervical adenopathy  Fever (64%)[15]  Fever  Torticollis (18%)  Drooling  Neck stiffness (64%)[15]  Stridor  Drooling (22%)  Torticollis[17]  Agitation (43%)  Trismus[17]  Neck mass (55%)[15] . The most common presenting signs may be different for adult and pediatric patients.

22. 27]  Peptostreptococcus species [21]  Haemophilus species  Fusobacterium species [21]  Beta-hemolytic streptococcus  S aureus  Methicillin-resistant Staphylococcus aureus ( MRSA)  [22] ( Streptococcus pyogenes) [12 Bacteroides species  Staphylococcus coagulase negative  Klebsiella pneumoniae Blood cultures are indicated before administration of intravenous antibiotics.CAUSE ADULTS CHILDREN AND INFANTS  Beta-hemolytic streptococci  S aureus [12]  Streptococcus viridans  MRSA [3. 26. but culture results may be negative in as many as 82% of retropharyngeal abscess cases. .

 Occasionally. . endotracheal intubation or cricothyrotomy may be required if the patient exhibits signs of upper airway obstruction. the sniffing position may be beneficial.PREHOSPITAL-CARE  Supplemental oxygen and attention to upper airway patency are the essential components of prehospital care in patients with suspected retropharyngeal abscess.  If a child exhibits respiratory distress.

MEDICATION  The goals of pharmacotherapy are to eradicate the infection. to reduce morbidity. and to prevent complications. Metro) . Intravenous broad-spectrum antibiotic coverage is indicated in the treatment of retropharyngeal abscess.  Ampicillin and sulbactam (Unasyn)  Clindamycin (Cleocin)  Penicillin G (Pfizerpen-G)  Piperacillin and tazobactam (Zosyn)  Metronidazole (Flagyl.

retropharyngeal cellulitis).  The ENT physician decides whether to incise and drain the abscess in the operating room or whether a trial of medical therapy is indicated first (eg. admit the patient to the intensive care unit. initiate intravenous antibiotics and admit the patient to the hospital.  If any signs of respiratory distress are present. Once the diagnosis of retropharyngeal abscess is established. .

PROGNOSIS  Prognosis generally is good if retropharyngeal abscess is identified early.  The mortality rate may be as high as 40-50% in patients in whom serious complications develop . managed aggressively. and complications do not occur.

COMPLICATION  Airway obstruction  Mediastinitis  Epidural abscess  Sepsis  Acute respiratory distress syndrome (ARDS)  Erosion of the second and third cervical vertebrae  Cranial nerve deficits (cranial nerves IX-XII are contained in the cervical fascia)  Septic thrombosis of jugular vein or hemorrhage secondary to erosion into carotid artery[39]  Compression of carotid artery and internal jugular vein [39]  Facial nerve palsy .

H I S A K A M I R  E T .

. causing bactericidal activity against susceptible organisms. It is an alternative to amoxicillin in patients who are unable to take medication orally. This drug combination of beta-lactamase inhibitor with ampicillin interferes with bacterial cell wall synthesis during active replication. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.  Clindamycin is a semisynthetic antibiotic produced by 7(S)-chloro- substitution of 7(R)-hydroxyl group of parent compound lincomycin. possibly by blocking dissociation of peptidyl tRNA from ribosomes. Inhibits bacterial growth. causing RNA-dependent protein synthesis to arrest.

resulting in bactericidal activity against susceptible microorganisms. Inhibits the biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication  Metronidazole is active against various anaerobic bacteria and protozoa. penicillin G interferes with the synthesis of cell wall mucopeptide during active multiplication. causing cell death. Unstable intermediate compounds are then formed that bind DNA and inhibit synthesis. Second DOC. .  Antipseudomonal penicillin plus beta-lactamase inhibitor. Cells of microorganisms that contain nitroreductase absorb metronidazole.