You are on page 1of 52

Acute Retropharyngeal abscess

in adult
Inderdeep Singh*, Vikas Gupta, Sunil Goyal, Manoj Kumar, Lakshmi Ranjit, Salil
Gupta

Oleh : Willie Hardyson (01073170144)

Pembimbing : dr. Christian Harry S., Sp. THT-KL


Retropharhyeal abscess definition

A collection of pus in
the tissues in the
back of the throat

2
Introduction
Acute retropharyngeal
abscesses are generally
described as a disease in
children

Uncommon in adult but


potentially lethal infection
involving deep neck spaces

3
Introduction
Secondary to trauma,
foreign bodies, or as a
complication of dental
infection

4
EPIDEMIOLOGY
5
• Typically occurs in children less than 6 years old
but can occur at any of age

• Half of retropharyngeal abscesses started from


upper respiratory tract infectionretropharingeal
suppurative lymphadenitis abscess formation

• One-fourth of retropharyngeal abscesses from


trauma leading to infection in retropharingeal
space abscess formation 6
ANATOMY
7
Patophysiology
8
Retrophageal space infection

Suppurative adenitis of retropharyngeal lymph nodes

Leads to phlegmon and abscess formation


(Group A Streptococcus, Streptococcus pyrogens, Staphylococcus aureus, Fusobacterium,
Haemophilus species, and other respiratory anaerobic organisms)
9
Retroph Gradual
aringeal upper Asphyxiat SEPSIS
abscess airway ion if left can DEATH
grows in obstructi untreated occur
size on

10
Case 1
11
• 46 years old male
• Come with complaints of sore throat of 10 days
duration
• progressive dysphagia and odynophagia of 6 days
duration
• Progressive neck swelling for last 5 days
• No history of difficulty in breathing or noisy
breathing, dyspnea, trismus, previous trauma/
foreign body ingestion or dental problems

12
Examination:

• Afebrile and normal vital paramater


• Diffuse neck swelling in both sides of neck and
extending superiorly from level of mandible to
inferiorly up to clavicle.
• Posteriorly it extended up to trapezius which was
more on left side then right side

13
• Ultrasound of neck done 2 days prior: showed
subcutaneus edema and features suggestive of cellulitis

• The patient was started on oral antibiotics

• An urgent CECT (contrast enchanced computed


tomography) of neck and chest  revealed an ill-defined
necrotic peripherally enhancing collection epicentered in
the retropharyngeal space extending to prevertebral and
danger spaces posteriorly, laterally to bilateral para-
pharyngeal spaces with involvement of carotid space and
displacement internal jugular vein laterally
14
• There was also involvement of the anterior visceral on the
left side and thrombosis of the left internal jugular vein.

• Inferiorly it extended into the posterior mediastinum with


indentation of the left atrium and anterior displacement of
the cardiac structures

15
• Axial cuts of suprahyoid and infrahyoid region
showing collection in the retropharyngeal and
retrovisceral spaces respectively 16
• C: Axial cut showing collection in the posterior
mediastinum with indentation on the left atrium
• D: Sagittal cut showing the collection in danger space
extending from the skull base up to the diaphragm with
involvement of the posterior mediastinum 17
• Patient started injectable broad spectrum antibiotics

• Planned to do an urgent incision and drainage through the


cervical (in nassal intubation for general anesthesia)

18
• A : Showing the planning of the cervical incision
• B : Elevation of skin flaps
• C : Opening of the anterior visceral space with pus pockets
(dark green colour pus)
• D: Showing pus in right parapharyngeal space with lateral
displacement of internal jugular vein (White arrow) 19
• E : Green arrow pointing towards thrombosed left internal
jugular vein
• F : Blue arrow pointing towards retropharyngeal space
• G : Showing 2 drains in situ secured with temporary
tracheostomy through a separate incision.
20
• Pus sent for culture E-coli

• Antibiotics were changed based on sensitivity report

• Patient was decannulated after 2 weeks and at the same


time the drain was also removed

• The staples were removed the next day following which


the patient was discharged

• He was kept on follow up till the closure of the


tracheostoma.
21
• Showing the surgical site with drain in situ on left side and
healing tracheostoma. The neck swelling has completely
resolved.
22
Case 2
23
• 72 years old female was reffered to hospital (with
endotracheal tube intubation)
• Complaints of progressive odynophagia, dysphagia
and diffuse neck swelling since 5 days
• Trismus for the past 2 days.
• There was no history of noisy breathing or
dyspnoea.
• She gave history of a fish bone ingestion 5 days
back prior to onset of the symptoms.

24
Examination:
• Afebrile with normal vital parameters
• Diffuse right sided neck swelling from hyoid to
clavicle
• Oral cavity and oropharynx revealed trismus with
mouth opening limited to 2cm
• Hopkins rod examination revealed a reduced glottis
chink due to edema of aretenoids and epiglottis.

25
Urgent CECT neck and chest:
• Heterogeneously enhancing collection extending
from skull base to the level of C6 vertebral body
involving the retropharyngeal space
• Extending into the right parapharyngeal space and
tracking along the carotid sheath and right lobe of
thyroid medially

26
• Showing collection of pus in retropharyngeal space and
right parapharyngeal spaces
27
• Patient was started on broad spectrum injectable
antibiotics
• An urgent incision and drainage of the abscess
was done through the cervical approach under
general anaesthesia.
• Tracheostomy was performed for securing the
airway.
• Dark yellowish pus was drained from the
retropharyngeal, right parapharyngeal and carotid
spaces.
28
• Aggressive broad spectrum antibiotics were
continued
• Culture report did not show any growth
• Drain was removed after 7 days postoperatively
• Patient was decannulated and discharged on 14th
day postoperative

29
Case 3
30
• 74 year old male
• Complaints of progressive odynophagia, dysphagia
and progressive neck swelling for 5 days
• Restricted mouth opening for 2 days.
• No history of dyspnea or respiratory distress.
• No history of dental problems or trauma or foreign
body ingestion.

31
Examination:
• Patient was afebrile with normal vital parameters.
• Examination revealed swelling in midline of neck
extending from the mandible to the clavicle
• Examination of oral cavity and oropharynx revealed
trismus with mouth opening limited to 1 cm.
• Rigid Hopkins examination could not be performed
because of the severe trismus

32
• Showing midline neck swelling in a patient with
retropharyngeal abscess
33
• CT scan revealed heterogeneously enhancing
collection involving the retropharyngeal space
extending from skull base to superior mediastinum.
• There was evidence of collection in the left
parapharyngeal space, muscular space and anterior
visceral space.

34
• B: Axial CT scan showing involvement of retropharyngeal
space in suprahyoid neck.
• C: Axial CT scan showing involvement of retrovisceral
space, left parapharyngeal space, muscular space and
anterior visceral space in infrahyoid neck. 35
• Patient was started on broad spectrum injectable
antibiotics
• An urgent incision and drainage of the abscess was
done with tracheostomy under general
anaesthesia.
• Intraoperatively pus was drained from the
retropharyngeal, left parapharyngeal spaces,
muscular space and anterior visceral space

36
• Pus culture was positive was Staphlococcus aureus
• Antibiotics was changed to culture directed
sensitivity report.
• Drain was removed after 7 days post operatively.
• Patient was decannulated and discharged on 14th
postoperative day

37
Discussion
38
• The retropharyngeal space is a potential space
between buccopharyngeal fascia covering the
posterior pharynx, esophagus and the alar fascia
• It extends from the base of the skull into the
superior mediastinum.

39
• Acute retropharyngeal abscess is
usually unilateral
• Primarily seen early in childhood
because these lymph nodes tend
to regress with age
• Upper respiratory infections
cause most retropharyngeal
disease in children because
these lymph nodes receive
drainage from the nose, sinuses,
and pharynx.
• Trauma to the posterior pharynx ,
secondary infection and foreign
body will cause abscess both
adult or children.
40
de Clercq LD et al in its paper on retropharyngeal abscess in
adults have stated that patients usually present with:
• fever
• odynophagia
• dysphagia
• dyspnoea
• drooling
• cervical rigidity (torticollis)
• 'hot potato' or hyponasal voice,
• sepsis

41
• On inspection: might see a bulging of the pharyngeal wall.
• The mucosa may be swollen and inflamed
• Causative organism: both aerobes and anaerobes
• In this case series the organism are: E-coli, and
Staphloccoccus aureus
• Culture report, guides the choice of antibiotics.

42
• CECT is the radiological investigation of choice to confirm
the diagnosis and evaluate for spread of infection into
adjacent deep neck spaces
• Plain radiography, USG, and MRI can be use too
• USG usefull because: easy, bedside procedure, guided
aspiration of pus, and no radiation.

43
Complications:
• Airway compromise taken to operating room for securing
the airway (nasotracheal intubation/ tracheostomy)
• Abscess rupture aspiration pneumonia
• Surgical intervention will be done if there are more
complicated or severe cases

44
Surgical indication:
• airway compromise
• critical condition
• septicemia
• complications,
• descending infection
• diabetes mellitus
• no clinical improvement within 48 hours of the initiation of
parenteral antibiotics.

45
• Abscesses >3 cm in diameter that involve the prevertebral,
anterior visceral, or carotid spaces, or involve more than two
spaces, should be surgically drained.
• Superficial abscesses  simple intraoral or extraoral incision
• Deeper and more complicated infections more extensive
external cervical approach for drainage
• Large and multilocular abscesses  incision and drainage

46
• Lemierre syndrome: suppurative thrombophlebitis of the
internal jugular vein, as a result of extension of infection into
carotid space
• Pathognomonic findings  swelling and tenderness at the
jaw angle and along the sternocleidomastoid muscle, with
signs of sepsis (spiking fevers, chills) and evidence of
pulmonary emboli
• Downward infection will cause mediastinitis  transthoracic
drainage is needed.

47
Conclusion
48
• The aim of discussion  to highlight the mode of
presentation of a retropharyngeal abscess
• Successful outcomes depend on early
identification and urgent aggressive management
• Highlight treatmentsecure the airway surgical
drainage and antibiotics (based on culture)

49
50
51
52