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Atypical locations of retropharyngeal abscess: Beware of the normal lateral soft tissue neck X-ray
International Journal of Pediatric Otorhinolaryngology 74 (2010) 1445–1448
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Case report
Atypical locations of retropharyngeal abscess: Beware of the normal lateral soft tissue neck X-ray Vincent Uzomefuna *, Fergal Glynn, Tara Mackle, John Russell Otolaryngology Dept., Our Ladys Children Hospital Crumlin, Dublin 12, Ireland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 August 2010 Received in revised form 2 September 2010 Accepted 3 September 2010 Available online 15 October 2010
Retropharyngeal abscesses (RPA) are uncommon but potentially lethal deep neck space infections, over 95% of which occur in children under six years of age [1,2]. Without a high index of suspicion, early recognition and prompt intervention, catastrophic consequences can ensue, and mortality can be as high as 60% if jugular vein thrombosis or mediastinitis occurs [3]. While older children may have specific complaints referable to the pharynx, infants and young children may present with vague symptoms [4]. To date, a lot of emphasis continues to be placed on the importance of lateral soft tissue neck X-ray in the diagnosis and management of patients with suspected retropharyngeal abscesses; and lateral neck X-ray has been cited as the most useful radiological view of the laryngopharynx [5]. While we recognise the role of lateral neck X-rays in retropharyngeal and other upper airway pathologies, we present three case series in which lateral neck X-rays were normal and diagnosis was made only after CT scanning. These three cases were unusual as the abscesses were located high in the naso-pharynx making them impossible to detect on the lateral soft tissue neck X-rays and this underscores the need for high index of suspicion and prompt CT or MRI scanning, in any child with symptoms or signs suggestive of a possible retropharyngeal abscess. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Retropharyngeal Abscess Airway X-ray CT scan Diagnosis Incision and drainage
1. Case reports 1.1. Case 1 A five year old boy who was admitted to hospital by our medical colleagues with a five day history of flu-like symptoms, fever and a three day history of restrictive neck movement. He had loss of appetite and one episode of vomiting. There was no neck swelling, rash, sore-throat or otalgia and no signs of meningeal irritation. He had right sided neck tenderness but no palpable cervical lymphadenopathy. Chest was clear on auscultation and abdomen was normal. Bloods: white cell count – 22 units, CRP – 233, U+E – normal, monospot and mumps serology – negative. A lateral soft tissue neck X-ray was normal. He was admitted for rehydration, IV benzylpenicillin and flucloxacilin. One day after admission, he developed left sided torticollis. An ultrasound neck- was obtained which showed multiple left cervical chain lymphadenopathy, but no collection.
* Corresponding author at: 26 Captains Avenue Crumlin, Dublin 12, Ireland. Tel.: +353 863934774. E-mail addresses: [email protected], [email protected] (V. Uzomefuna). 0165-5876/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2010.09.008
An otolaryngology opinion was sought- and the child was noted to have trismus, slightly muffled voice and torticollis. A CT skull base and neck was obtained and this demonstrated a 2.1 cm 1.4 cm 1.4 cm collection high up in the nasopharynx at the level of the skull base. The patient was taken to the operating theatre where he had incision and drainage of left sided retropharyngeal abscess. Procedure was done trans-orally using 1208 telescope and sickle knife. The abscess was located high in the nasopharynx adjacent to the fossa of rosemuller. There was dramatic clinical improvement following this and the patient was discharged home on the 5th post operative day (Fig. 1). 1.2. Case 2 A five year old male was admitted with a three day history of sore throat, feeling unwell and a one day history of fever and decreased oral intake. Clinically, he was alert, pale, and febrile. He had no drooling, stridor or respiratory distress. Ear, nose and throat exam showed inflamed tonsils with a tender cervical adenopathy but no peritonsillar swelling or exudate. He had limited neck movement due to pain. Lateral neck X-ray was normal. Haemogram: white cell count – 26.5, neutrophils – 21.7, Plt – 379, Hb – 10.6, CRP – 304, U+E – normal, Monospot – negative.
[()TD$FIG]
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V. Uzomefuna et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 1445–1448
Fig. 1.
He was admitted under the medical team with a diagnosis of acute tonsillitis and commenced on IV benzylpenicillin and IV fluids. Following 48 h of persistent neck stiffness, restriction of neck movement and decreased oral intake despite antibiotics, he had a CT scan which demonstrated a 0.9 cm 1.0 cm 1.5 cm low attenuation collection in the retropharyngeal space predominantly in the midline and to the right, causing a displacement of jugular and carotid vessels on the right side but no occlusion. The abscess was high in the nasopharynx extending from skull base inferiorly. He was taken to the operating theatre where frank pus mixed with altered blood was drained high up in the naso-pharynx using 1208 telescope and sickle knife trans-orally.
His clinical condition improved rapidly thereafter and he was discharged home on the 3rd post operative day (Fig. 2). 1.3. Case 3 A five year old male presented with a 24 h history of headache, neck pain and decreased oral intake. Clinically, he had left sided torticollis, mild drooling of saliva, offensive breath, enlarged and inflamed tonsils but no peritonsillar abscess. He had left sided tender submandibular/jugulo-digastric lymphadenopathy and restriction of neck movement, but kernig’s sign was negative. Haemogram: white cell count – 24.2, Hb – 11.8, CRP – 48, Plateletes – 333, U+E – normal.
[()TD$FIG]
Fig. 2.
[()TD$FIG]
V. Uzomefuna et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 1445–1448
1447
Fig. 3.
USS neck showed left sided adenopathy with no necrosis or abscess formation. A provisional diagnosis of acute tonsillitis was made and he was admitted under the medical team for IV augmentin and analgesia. Despite 48 h of antibiotic therapy, he continued to have torticollis, fever and malaise, so an otolaryngology opinion was sought. Lateral neck X-ray showed normal airway, however because of persistent signs which were clinically suggestive of retropharyngeal abscess, a CT neck was carried out which showed presence of 2 cm 3 cm 2 cm left sided retropharyngeal abscess within the left longus coli muscle, immediately anterior and slightly cephalad to the anterior arch of C1 vertebra. The abscess was displacing the carotid space laterally with effacement of the left internal carotid artery and left internal jugular vein reducing their lumina to approximately 1 mm and 2 mm, respectively (Fig. 3). He was taken to theatre for incision and drainage. Clinical improvement followed this and he was discharged home on the 3rd post operative day.
2. Discussion Retropharyngeal abscess (RPA) is usually a disease of children which develop most frequently as a contiguous spread of upper respiratory tract infection including viral upper respiratory tract infection, pharyngitis and otitis media which cause retropharyngeal lymphadenopathy [6,7]; suppuration of these nodes leads to RPA. It is uncommon in adults. The retropharyngeal space is a potential space bounded anteriorly by the constrictor muscles of the neck and its investing fascia, posteriorly by the alar layer of the prevertebral fascia, superiorly by the skull base, laterally by the carotid sheath and inferiorly by the fusion of the anterior and posterior layers of fascia at the level of C7 vertebra. The space contains no vital structures except for lymph nodes in children, which normally regress around the age of six years possibly explaining the reason for rarity of RPA in adults [8]. Instrumentations of the oropharyngeal cavity and penetrating oropharyngeal trauma can however lead to development of RPA in adults [9,10]. The retropharyngeal space is in close approximation with the
prevertebral space with the potential for suppurative spread of infection into the posterior mediastinum [11]. Clinical features of possible RPA include high fever, dysphagia, odynophagia, drooling, neck/cervical rigidity and swelling, anorexia and a muffled voice or ‘‘hot potato voice’’. There may be a bulging of the posterior pharyngeal wall on clinical examination. Although high fever and toxicity is consistently emphasised in literature, cases of RPA in afebrile children and neonates have been reported [12,13]. Common causative organisms are groupA b-haemolytic streptococci, Staphylococcus aureus, Haemophilus influenza, bacteroides, peptostreptococus, and fusobacterium. In the management of patients with suspected RPA, security of the airway is paramount and safety of the airway must be guaranteed before sending patients for any radiologic investigation. Where there is significant risk, appropriate interventions including oro-pharyngeal airway, laryngeal mask airway or intubation must be undertaken. This is particularly important in paediatric patients where investigations like CT or MRI often require sedation. Presence of normal looking neck X-ray can help discount a massive RPA that may have the potential of imminent airway obstruction. All patients with suspected RPA require hospitalisation, prompt intravenous antibiotic therapy and investigation to determine the presence, site and extent of the abscess and if appropriate, timely drainage. Patients are almost always referred for lateral soft tissue neck X-ray and a normal appearing lateral radiograph quite often may influence the decision to discount a RPA. This could lead to delay in intervention, increasing the chances of life-threatening complications such as extension of the abscess against pharynx or trachea, rupture and aspiration of abscess, lateral extension causing jugular vein thrombosis or carotid rupture, inferior extension resulting in mediastinitis, purulent pericarditis and cardiac tamponade. The classic clinical features RPA often looked for are more likely to be noticeable in older children and adults, but younger children tend to have non-specific manifestations such as irritability and poor feeding; dyspnoea may be a late sign [14] making waiting and observation for this age group potentially hazardous. Furthermore, while the interpretation of lateral neck X-ray is based on the
1448
V. Uzomefuna et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 1445–1448
retropharyngeal width; CT scan or MRI of the neck, unlike the lateral neck X-ray, can differentiate abscesses from simple cellulitis and other causes of retropharyngeal swelling [15]. Though lateral neck X-ray still remains a cheap, straightforward and certainly useful investigation in the diagnoses of many upper airway pathologies including RPA, subglottic stenosis, epiglottitis, impacted foreign body in upper aerodigestive tract, etc., the clinician should develop lower threshold towards CT scanning now that these are more readily accessible, considering that not only will it aid in resolving difficult diagnoses, it may also help in preventing unnecessary surgery by demonstrating that an apparent retropharyngeal swelling on lateral neck X-ray is an oedema and not an abscess. Many reports in the literature exist which tends to overemphasise the usefulness and sensitivity of lateral neck X-ray in the diagnosis of retropharyngeal abscess with some authors reporting that lateral neck X-rays have a 100% diagnostic sensitivity for RPA [7]. The three case series presented on this paper are to highlight the fact that a fatal error could be made by placing too much emphasis on the lateral neck X-ray. Accurate and timely treatment and intervention for presumed retropharyngeal abscess is crucial to prevent untoward sequelae and to achieve this, we recommend prompt CT or MRI scanning in cases of suspected RPA despite normal lateral neck X-ray. In conclusion, the presence a retropharyngeal abscess in an unusual location can significantly reduce the sensitivity of lateral neck X-ray in diagnosing this condition, therefore in any unwell child with
signs or symptoms suspicious of retropharyngeal abscess, further imaging in the form of a CT or MRI scan is recommended if the lateral neck X-ray is normal. References [1] D. Goldenberg, A. Golz, H.Z. Joachims, Retropharyngeal abscess: a clinical review, J. Laryngol. Otol. 111 (June) (1997) 546–550. [2] F.K.C. Chu, Retropharyngeal abscess, Hong Kong J. Emerg. Med. 9 (2002) 165–167. [3] J.L. Acevedo, R.K. Shah, http://emedicine.medscape.com/article/995851-overview. March 16 2009. [4] I.K. Blomquist, A.S. Bayer, Life-threatening deep fascial space infections of head and neck, Infect Dis. Clin. N. Am. 2 (1966) 237–264. [5] R.C. Herdman, S.R. Saeed, E.A. Hinton, The lateral soft tissue neck X-ray in accident and emergency medicine, Arch. Emerg. Med. 8 (1991) 149–156. [6] J.W. Thompson, S.R. Cohen, P. Redix, Retropharyngeal abscess in children: a retrospective and historical analysis, Laryngoscope 98 (1988) 589–592. [7] J.E. Morrison, N.R.T. Pashley, Retropharyngeal abscesses in children: a 10 year review, Paediatr. Emerg. Care 4 (1988) 9–11. [8] J. Echevarria, Deep neck infections, in: D. Schlossberg (Ed.), Infections of the Head and Neck, Springer-Verlag, New York, 1987, pp. 172–174. [9] J.A. Oritz, C. Hudkins, A. Kornblut, Adenitis, adenopathy and abscesses of the head and neck, Emerg. Med. Clin. N. Am. 5 (1987) 359–378. [10] R.A. Broughton, Nonsurgical management of deep neck infections, Paediatr. Inf. Dis. J. 11 (1992) 14–18. [11] G.W. Levitt, Cervical fascia and deep neck infections, Otolaryngol. Clin. N. Am. 9 (1976) 703–716. [12] R.A. De Lorenzo, J.I. Singer, W.M. Matre, Repropharyngeal abscess in an afebrile child, Am. J. Emerg. Med. 11 (1993) 151–154. [13] Y.T. Chuan, Acute stridor in childhood: retropharyngeal abscess, Med. J. Malaysia 43 (1988) 65–73. [14] G.E. Barratt, C.F. Koopmann, S.W. Coulthard, Retropharyngeal abscess – a ten year experience, Laryngoscope 94 (1984) 455–463. [15] G.R. Holt, K. McManus, R.K. Newman, et al., Computed tomography in the diagnosis of deep neck infections, Arch. Otolaryngol. 108 (1982) 693–696.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Case report
Atypical locations of retropharyngeal abscess: Beware of the normal lateral soft tissue neck X-ray Vincent Uzomefuna *, Fergal Glynn, Tara Mackle, John Russell Otolaryngology Dept., Our Ladys Children Hospital Crumlin, Dublin 12, Ireland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 August 2010 Received in revised form 2 September 2010 Accepted 3 September 2010 Available online 15 October 2010
Retropharyngeal abscesses (RPA) are uncommon but potentially lethal deep neck space infections, over 95% of which occur in children under six years of age [1,2]. Without a high index of suspicion, early recognition and prompt intervention, catastrophic consequences can ensue, and mortality can be as high as 60% if jugular vein thrombosis or mediastinitis occurs [3]. While older children may have specific complaints referable to the pharynx, infants and young children may present with vague symptoms [4]. To date, a lot of emphasis continues to be placed on the importance of lateral soft tissue neck X-ray in the diagnosis and management of patients with suspected retropharyngeal abscesses; and lateral neck X-ray has been cited as the most useful radiological view of the laryngopharynx [5]. While we recognise the role of lateral neck X-rays in retropharyngeal and other upper airway pathologies, we present three case series in which lateral neck X-rays were normal and diagnosis was made only after CT scanning. These three cases were unusual as the abscesses were located high in the naso-pharynx making them impossible to detect on the lateral soft tissue neck X-rays and this underscores the need for high index of suspicion and prompt CT or MRI scanning, in any child with symptoms or signs suggestive of a possible retropharyngeal abscess. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Retropharyngeal Abscess Airway X-ray CT scan Diagnosis Incision and drainage
1. Case reports 1.1. Case 1 A five year old boy who was admitted to hospital by our medical colleagues with a five day history of flu-like symptoms, fever and a three day history of restrictive neck movement. He had loss of appetite and one episode of vomiting. There was no neck swelling, rash, sore-throat or otalgia and no signs of meningeal irritation. He had right sided neck tenderness but no palpable cervical lymphadenopathy. Chest was clear on auscultation and abdomen was normal. Bloods: white cell count – 22 units, CRP – 233, U+E – normal, monospot and mumps serology – negative. A lateral soft tissue neck X-ray was normal. He was admitted for rehydration, IV benzylpenicillin and flucloxacilin. One day after admission, he developed left sided torticollis. An ultrasound neck- was obtained which showed multiple left cervical chain lymphadenopathy, but no collection.
* Corresponding author at: 26 Captains Avenue Crumlin, Dublin 12, Ireland. Tel.: +353 863934774. E-mail addresses: [email protected], [email protected] (V. Uzomefuna). 0165-5876/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2010.09.008
An otolaryngology opinion was sought- and the child was noted to have trismus, slightly muffled voice and torticollis. A CT skull base and neck was obtained and this demonstrated a 2.1 cm 1.4 cm 1.4 cm collection high up in the nasopharynx at the level of the skull base. The patient was taken to the operating theatre where he had incision and drainage of left sided retropharyngeal abscess. Procedure was done trans-orally using 1208 telescope and sickle knife. The abscess was located high in the nasopharynx adjacent to the fossa of rosemuller. There was dramatic clinical improvement following this and the patient was discharged home on the 5th post operative day (Fig. 1). 1.2. Case 2 A five year old male was admitted with a three day history of sore throat, feeling unwell and a one day history of fever and decreased oral intake. Clinically, he was alert, pale, and febrile. He had no drooling, stridor or respiratory distress. Ear, nose and throat exam showed inflamed tonsils with a tender cervical adenopathy but no peritonsillar swelling or exudate. He had limited neck movement due to pain. Lateral neck X-ray was normal. Haemogram: white cell count – 26.5, neutrophils – 21.7, Plt – 379, Hb – 10.6, CRP – 304, U+E – normal, Monospot – negative.
[()TD$FIG]
1446
V. Uzomefuna et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 1445–1448
Fig. 1.
He was admitted under the medical team with a diagnosis of acute tonsillitis and commenced on IV benzylpenicillin and IV fluids. Following 48 h of persistent neck stiffness, restriction of neck movement and decreased oral intake despite antibiotics, he had a CT scan which demonstrated a 0.9 cm 1.0 cm 1.5 cm low attenuation collection in the retropharyngeal space predominantly in the midline and to the right, causing a displacement of jugular and carotid vessels on the right side but no occlusion. The abscess was high in the nasopharynx extending from skull base inferiorly. He was taken to the operating theatre where frank pus mixed with altered blood was drained high up in the naso-pharynx using 1208 telescope and sickle knife trans-orally.
His clinical condition improved rapidly thereafter and he was discharged home on the 3rd post operative day (Fig. 2). 1.3. Case 3 A five year old male presented with a 24 h history of headache, neck pain and decreased oral intake. Clinically, he had left sided torticollis, mild drooling of saliva, offensive breath, enlarged and inflamed tonsils but no peritonsillar abscess. He had left sided tender submandibular/jugulo-digastric lymphadenopathy and restriction of neck movement, but kernig’s sign was negative. Haemogram: white cell count – 24.2, Hb – 11.8, CRP – 48, Plateletes – 333, U+E – normal.
[()TD$FIG]
Fig. 2.
[()TD$FIG]
V. Uzomefuna et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 1445–1448
1447
Fig. 3.
USS neck showed left sided adenopathy with no necrosis or abscess formation. A provisional diagnosis of acute tonsillitis was made and he was admitted under the medical team for IV augmentin and analgesia. Despite 48 h of antibiotic therapy, he continued to have torticollis, fever and malaise, so an otolaryngology opinion was sought. Lateral neck X-ray showed normal airway, however because of persistent signs which were clinically suggestive of retropharyngeal abscess, a CT neck was carried out which showed presence of 2 cm 3 cm 2 cm left sided retropharyngeal abscess within the left longus coli muscle, immediately anterior and slightly cephalad to the anterior arch of C1 vertebra. The abscess was displacing the carotid space laterally with effacement of the left internal carotid artery and left internal jugular vein reducing their lumina to approximately 1 mm and 2 mm, respectively (Fig. 3). He was taken to theatre for incision and drainage. Clinical improvement followed this and he was discharged home on the 3rd post operative day.
2. Discussion Retropharyngeal abscess (RPA) is usually a disease of children which develop most frequently as a contiguous spread of upper respiratory tract infection including viral upper respiratory tract infection, pharyngitis and otitis media which cause retropharyngeal lymphadenopathy [6,7]; suppuration of these nodes leads to RPA. It is uncommon in adults. The retropharyngeal space is a potential space bounded anteriorly by the constrictor muscles of the neck and its investing fascia, posteriorly by the alar layer of the prevertebral fascia, superiorly by the skull base, laterally by the carotid sheath and inferiorly by the fusion of the anterior and posterior layers of fascia at the level of C7 vertebra. The space contains no vital structures except for lymph nodes in children, which normally regress around the age of six years possibly explaining the reason for rarity of RPA in adults [8]. Instrumentations of the oropharyngeal cavity and penetrating oropharyngeal trauma can however lead to development of RPA in adults [9,10]. The retropharyngeal space is in close approximation with the
prevertebral space with the potential for suppurative spread of infection into the posterior mediastinum [11]. Clinical features of possible RPA include high fever, dysphagia, odynophagia, drooling, neck/cervical rigidity and swelling, anorexia and a muffled voice or ‘‘hot potato voice’’. There may be a bulging of the posterior pharyngeal wall on clinical examination. Although high fever and toxicity is consistently emphasised in literature, cases of RPA in afebrile children and neonates have been reported [12,13]. Common causative organisms are groupA b-haemolytic streptococci, Staphylococcus aureus, Haemophilus influenza, bacteroides, peptostreptococus, and fusobacterium. In the management of patients with suspected RPA, security of the airway is paramount and safety of the airway must be guaranteed before sending patients for any radiologic investigation. Where there is significant risk, appropriate interventions including oro-pharyngeal airway, laryngeal mask airway or intubation must be undertaken. This is particularly important in paediatric patients where investigations like CT or MRI often require sedation. Presence of normal looking neck X-ray can help discount a massive RPA that may have the potential of imminent airway obstruction. All patients with suspected RPA require hospitalisation, prompt intravenous antibiotic therapy and investigation to determine the presence, site and extent of the abscess and if appropriate, timely drainage. Patients are almost always referred for lateral soft tissue neck X-ray and a normal appearing lateral radiograph quite often may influence the decision to discount a RPA. This could lead to delay in intervention, increasing the chances of life-threatening complications such as extension of the abscess against pharynx or trachea, rupture and aspiration of abscess, lateral extension causing jugular vein thrombosis or carotid rupture, inferior extension resulting in mediastinitis, purulent pericarditis and cardiac tamponade. The classic clinical features RPA often looked for are more likely to be noticeable in older children and adults, but younger children tend to have non-specific manifestations such as irritability and poor feeding; dyspnoea may be a late sign [14] making waiting and observation for this age group potentially hazardous. Furthermore, while the interpretation of lateral neck X-ray is based on the
1448
V. Uzomefuna et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 1445–1448
retropharyngeal width; CT scan or MRI of the neck, unlike the lateral neck X-ray, can differentiate abscesses from simple cellulitis and other causes of retropharyngeal swelling [15]. Though lateral neck X-ray still remains a cheap, straightforward and certainly useful investigation in the diagnoses of many upper airway pathologies including RPA, subglottic stenosis, epiglottitis, impacted foreign body in upper aerodigestive tract, etc., the clinician should develop lower threshold towards CT scanning now that these are more readily accessible, considering that not only will it aid in resolving difficult diagnoses, it may also help in preventing unnecessary surgery by demonstrating that an apparent retropharyngeal swelling on lateral neck X-ray is an oedema and not an abscess. Many reports in the literature exist which tends to overemphasise the usefulness and sensitivity of lateral neck X-ray in the diagnosis of retropharyngeal abscess with some authors reporting that lateral neck X-rays have a 100% diagnostic sensitivity for RPA [7]. The three case series presented on this paper are to highlight the fact that a fatal error could be made by placing too much emphasis on the lateral neck X-ray. Accurate and timely treatment and intervention for presumed retropharyngeal abscess is crucial to prevent untoward sequelae and to achieve this, we recommend prompt CT or MRI scanning in cases of suspected RPA despite normal lateral neck X-ray. In conclusion, the presence a retropharyngeal abscess in an unusual location can significantly reduce the sensitivity of lateral neck X-ray in diagnosing this condition, therefore in any unwell child with
signs or symptoms suspicious of retropharyngeal abscess, further imaging in the form of a CT or MRI scan is recommended if the lateral neck X-ray is normal. References [1] D. Goldenberg, A. Golz, H.Z. Joachims, Retropharyngeal abscess: a clinical review, J. Laryngol. Otol. 111 (June) (1997) 546–550. [2] F.K.C. Chu, Retropharyngeal abscess, Hong Kong J. Emerg. Med. 9 (2002) 165–167. [3] J.L. Acevedo, R.K. Shah, http://emedicine.medscape.com/article/995851-overview. March 16 2009. [4] I.K. Blomquist, A.S. Bayer, Life-threatening deep fascial space infections of head and neck, Infect Dis. Clin. N. Am. 2 (1966) 237–264. [5] R.C. Herdman, S.R. Saeed, E.A. Hinton, The lateral soft tissue neck X-ray in accident and emergency medicine, Arch. Emerg. Med. 8 (1991) 149–156. [6] J.W. Thompson, S.R. Cohen, P. Redix, Retropharyngeal abscess in children: a retrospective and historical analysis, Laryngoscope 98 (1988) 589–592. [7] J.E. Morrison, N.R.T. Pashley, Retropharyngeal abscesses in children: a 10 year review, Paediatr. Emerg. Care 4 (1988) 9–11. [8] J. Echevarria, Deep neck infections, in: D. Schlossberg (Ed.), Infections of the Head and Neck, Springer-Verlag, New York, 1987, pp. 172–174. [9] J.A. Oritz, C. Hudkins, A. Kornblut, Adenitis, adenopathy and abscesses of the head and neck, Emerg. Med. Clin. N. Am. 5 (1987) 359–378. [10] R.A. Broughton, Nonsurgical management of deep neck infections, Paediatr. Inf. Dis. J. 11 (1992) 14–18. [11] G.W. Levitt, Cervical fascia and deep neck infections, Otolaryngol. Clin. N. Am. 9 (1976) 703–716. [12] R.A. De Lorenzo, J.I. Singer, W.M. Matre, Repropharyngeal abscess in an afebrile child, Am. J. Emerg. Med. 11 (1993) 151–154. [13] Y.T. Chuan, Acute stridor in childhood: retropharyngeal abscess, Med. J. Malaysia 43 (1988) 65–73. [14] G.E. Barratt, C.F. Koopmann, S.W. Coulthard, Retropharyngeal abscess – a ten year experience, Laryngoscope 94 (1984) 455–463. [15] G.R. Holt, K. McManus, R.K. Newman, et al., Computed tomography in the diagnosis of deep neck infections, Arch. Otolaryngol. 108 (1982) 693–696.