- Email: [email protected]
Retropharyngeal abscess: Epiglottitis of the new millennium
Retropharyngeal abscess: Epiglottitis of the new millennium Sandy S. Lee, MD, Richard H. Schwartz, MD, and Robert S. Bahadori, MD
RESULTS From 1993 through 1999, 26 children with retropharyngeal abscess and 2 children with acute epiglottitis were cared for by pediatric otolaryngologists in northern Virginia. Fever, sore throat, dysphagia, refusal to swallow, dysphonia, drooling, and neck extension are common presenting signs and symptoms in acute epiglottitis and in retropharyngeal abscess. Contrastenhanced computed tomography of the oropharynx was performed in all cases and was the most helpful diagnostic test. (J Pediatr 2001;138:435-7)
Retropharyngeal abscess is a relatively uncommon infection of the space anterior to the prevertebral layer of the deep cervical fascia. This infection is most common in children younger than 3 or 4 years, because of the rich concentration of lymph nodes in this space.1-3 The symptoms of RPA can be similar to those of acute epiglottitis; however, children with acute epiglottitis usually appear more toxic and progress to respiratory distress much more rapidly than those with RPA. The unique abnormal physical finding in older children and adults with RPA, which is an asymmetric bulge of the posterior pharyngeal wall when inflammation has progressed to phlegmon or frank abscess, may be difficult to appreciate in infants or toddlers. With the success of the conjugate vaccine against Haemophilus influenzae
type b, acute epiglottitis is now a rare disease in children. The purpose of this study is to summarize our experience with 26 children with RPA who were treated in our hospital during a 7-year period ending in December 1999. Only 2 cases of epiglottitis were observed during this period.
METHODS We performed a retrospective review of the records of all pediatric patients discharged from our institution with a diagnosis of RPA or acute epiglottitis from 1993 to 1999. The diagnosis was cross-checked with the office records of the 2 pediatric otolaryngologists in northern Virginia. We excluded cases of RPA resulting from penetrating injuries to the pharynx.
From the Department of Pediatrics, Inova Fairfax Hospital for Children, Falls Church, Virginia; and Section of Otolaryngology, Department of Surgery, Inova Fairfax Hospital, Falls Church, Virginia. Presented at the 27th annual meeting of SENTAC (Society for Ear, Nose, and Throat Advances in Children), Williamsburg, Va, Dec 3, 1999.
Submitted for publication Jan 28, 2000; revision received July 10, 2000; accepted Aug 23, 2000. Reprint requests: Richard H. Schwartz, MD, 115 Park St SE, Suite 103, Vienna, VA 22180. Copyright © 2001 by Mosby, Inc. 0022-3476/2001/$35.00 + 0 9/22/111275 doi:10.1067/mpd.2001.111275
During the 7-year period reviewed, 26 children had acute nontraumatic RPAs; 13 (50%) had RPAs alone; and the remainder had both retropharyngeal and parapharyngeal abscesses. Patient ages ranged from 5 months to 11 years, with a median age of 3.5 years. Fifteen (58%) were <4 years of age. There were 17 boys and 9 girls. All patients were previously healthy. Sixteen patients (62%) had received oral antibiotics before admission.
CT RPA
Computed tomography Retropharyngeal abscess
Symptoms and signs noted are listed in the Table. The most frequent symptoms were fever, decreased oral intake, and sore throat. On physical examination, the most common signs were a visible or palpable neck mass (lymphadenopathy or parapharyngeal abscess) and asymmetric pharyngeal bulge. The mean leukocyte count was 22,500 (range, 8900-38,000). Imaging studies included computed tomography in all patients and lateral neck view roentgenograms in 13 patients. All the CT scans showed hypodensity, suggestive of inflammation, or ring-enhancing abscess in the retropharyngeal space. Treatment included antibiotic therapy with or without surgical incision and drainage. Five children (19%) without complete ring enhancement of the inflammatory mass were treated exclusively with antibiotics given parenterally. The remaining 21 children (81%) had surgical drainage in addi435
LEE, SCHWARTZ, AND BAHADORI
THE JOURNAL OF PEDIATRICS MARCH 2001
Table. Symptoms and signs of retropharyngeal abscess in 26 children
Number (%) Symptoms Fever Decreased oral intake Sore throat Pain on swallowing Neck pain Neck posturing or stiffness Signs Neck mass (large lymphadenopathy/parapharyngeal abscess) Asymmetrical bulge of oropharynx Drooling Torticollis Trismus
tion to antibiotic therapy; 16 patients had drainage performed with an intraoral approach only. The 5 children who had abscess cavities lateral to the great vessels of the neck had surgical drainage with combined intraoral and transcutaneous lateral neck incisions. Antibiotics used included nafcillin, cefuroxime, ceftriaxone, clindamycin, and ampicillin/sulbactam. Streptococcus pyogenes was recovered from 5 (24%) specimens of aspirate, Staphylococcus aureus from 2 (10%), anaerobic bacteria from 4 (19%), and Mycobacterium avium-intracellulare from one specimen. Prior antibiotic therapy negatively influenced isolation of the causative bacteria. A significant preoperative complication occurred in only one patient. A 5-month-old infant had significant upper airway obstruction that required emergent intubation and a prolonged stay in the pediatric intensive care unit. There were no major postoperative complications. Between 1993 and 1999, only 2 children with acute epiglottitis were admitted to our children’s hospital. In contrast, in 1998 and 1999, 12 children with RPA were admitted, which was a significantly greater number than the mean of the previous 5-year period (P = .06). 436
20 (77) 18 (69) 12 (46) 9 (35) 9 (35) 11 (42)
15 (58) 12 (46) 9 (35) 9 (35) 5 (19)
DISCUSSION Retropharyngeal lymph node infection in children classically results from extension of oropharyngeal infections including pharyngitis, tonsillitis, and adenitis. The infection progresses through 3 stages: cellulitis, phlegmon, and abscess. Probably only the last stage requires surgical drainage. Contrast-enhanced CT is invaluable in delineating the stage of inflammation, but boundaries (incomplete vs complete ring enhancement) between phlegmon and abscess stages may be blurred. In one study, the positive predictive value of CT was 84% and the negative predictive value was 44%.4 Trauma, often caused by a fall while holding a pencil or stick in the mouth, and dental infections are the usual underlying causes of RPA in older children and adults. Most symptoms and signs of RPA are identical to those of acute epiglottitis. They include fever, irritability, oropharyngeal pain, unusual positioning of the head and neck, and odynophagia. As the infection progresses, there may be refusal to swallow solids or liquids including saliva, which leads to pooling in the oropharynx and overflow drooling. The most suggestive physical signs of both diseases are hyperextension of the neck,
torticollis, muffled voice, stertor, and other signs of upper airway obstruction. Swelling of the side of the neck can be present with a mixed RPAparapharyngeal abscess. In several case series of patients with RPA, the classic physical sign of RPA, which is bulging of the posterior pharynx, was noted; however, this was present in <50% of infants.1,2 The major causative organisms are Streptococcus pyogenes, Staphylococcus aureus, and oropharyngeal anaerobic bacteria.5,6 The differential diagnosis includes acute epiglottitis, foreign body aspiration, vertebral osteomyelitis, hematoma (particularly in boys with hemophilia), and lymphoma.4 Diagnostic studies commonly include roentgenograms of the cervical area and CT scans.8 In order to minimize false-positive results, a lateral view roentgenogram may be helpful when obtained with the patient in the sitting position with the neck hyperextended and during inspiration, if possible.2 Normal buckling of upper cervical prevertebral soft tissues that occurs during flexion or expiration can simulate a retropharyngeal mass. A retropharyngeal space measured from the most anterior aspect of C2 to the soft tissues of the posterior pharyngeal wall >7 mm (normal, 3-6 mm) or a retrotracheal space >14 mm in a child suggests a mass caused by phlegmon, pus, or blood. Color flow Doppler ultrasonography is a new technique that may improve the diagnostic accuracy in differentiating phlegmon from abscess.7 Management of RPA depends on the maturity of the infection and the degree of airway compromise. Cellulitis or a phlegmon requires only targeted antibiotics active against common oral facultative and anaerobic bacteria. Historically, the treatment of an abscess has been surgical drainage. However, several recent studies have shown that medical management alone can be curative for >50% of children with RPA (usually defined by CT).9,10 Security of the airway is of paramount
LEE, SCHWARTZ, AND BAHADORI
THE JOURNAL OF PEDIATRICS VOLUME 138, NUMBER 3 importance. In our approach to management, if airway obstruction is severe, an endotracheal tube is placed and the child is admitted to the pediatric intensive care unit. All patients have a secure intravenous catheter placed and are given nothing by mouth. If a patient is stable and the benefit of avoiding a surgery outweighs the risk of complications from RPA, we have given a trial of intravenous antibiotics for 24 to 48 hours. If there is no improvement, either clinically or as determined by imaging, then the decision may be made to perform surgical drainage. Suppurative complications of RPA include rupture of the abscess with aspiration, asphyxiation, or pneumonia; empyema; and mediastinitis. Vascular complications include thrombophlebitis
of the internal jugular vein and erosion through the carotid artery sheath.
REFERENCES 1. Thompson JW, Cohen SR, Reddix P. Retropharyngeal abscess in children: a retrospective and historical analysis. Laryngoscope 1988;98:589-92. 2. Seid AB, Dunbar JS, Cotton RT. Retropharyngeal abscesses in children revisited. Laryngoscope 1979;84:171724. 3. Goldenberg D, Golz A, Joachims HZ. Retropharyngeal abscess: a clinical review. J Laryngol Otol 1997;511:546-50. 4. Barratt GE, Koopman CF, Coulthard SW. Retropharyngeal abscess—a tenyear experience. Laryngoscope 1984; 94:455-63. 5. Asmar BL. Bacteriology of retropharyngeal abscess in children. Pediatr Infect Dis J 1990;9:595-6.
6. Brook I. Microbiology of retropharyngeal abscess in children. Am J Dis Child 1987;141:202-4. 7. Glasier CM, Stark JE, Jacobs RF, Mancias P, Leithiser RE Jr, Seibert RW, et al. CT and ultrasound imaging of retropharyngeal abscesses in children. Am J Neuroradiol 1992;13:1191-5. 8. Stone ME, Walner DL, Koch BL, Egelhoff JC, Myer CM. Correlation between computed tomography and surgical findings in retropharyngeal inflammatory processes in children. Int J Pediatr Otorhinolaryngol 1999;49:121-5. 9. Broughton RA. Nonsurgical management of deep neck infections in children. Pediatr Infect Dis J 1992;11: 14-8. 10. Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, Gonzalez-Valdepena H, Bluestone CD. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995;112:375-82.
AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of The Journal of Pediatrics for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one third off on quantities of 24 or more. Please write to Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call 800-654-2452 or 407-345-4000 for information on availability of particular issues and prices. If unavailable from the publisher, photocopies of complete issues may be purchased from Bell & Howell Information and Learning, 300 N Zeeb Rd, Ann Arbor, MI 48106-1346, (734) 761-4700 or (800) 521-0600.
437
RESULTS From 1993 through 1999, 26 children with retropharyngeal abscess and 2 children with acute epiglottitis were cared for by pediatric otolaryngologists in northern Virginia. Fever, sore throat, dysphagia, refusal to swallow, dysphonia, drooling, and neck extension are common presenting signs and symptoms in acute epiglottitis and in retropharyngeal abscess. Contrastenhanced computed tomography of the oropharynx was performed in all cases and was the most helpful diagnostic test. (J Pediatr 2001;138:435-7)
Retropharyngeal abscess is a relatively uncommon infection of the space anterior to the prevertebral layer of the deep cervical fascia. This infection is most common in children younger than 3 or 4 years, because of the rich concentration of lymph nodes in this space.1-3 The symptoms of RPA can be similar to those of acute epiglottitis; however, children with acute epiglottitis usually appear more toxic and progress to respiratory distress much more rapidly than those with RPA. The unique abnormal physical finding in older children and adults with RPA, which is an asymmetric bulge of the posterior pharyngeal wall when inflammation has progressed to phlegmon or frank abscess, may be difficult to appreciate in infants or toddlers. With the success of the conjugate vaccine against Haemophilus influenzae
type b, acute epiglottitis is now a rare disease in children. The purpose of this study is to summarize our experience with 26 children with RPA who were treated in our hospital during a 7-year period ending in December 1999. Only 2 cases of epiglottitis were observed during this period.
METHODS We performed a retrospective review of the records of all pediatric patients discharged from our institution with a diagnosis of RPA or acute epiglottitis from 1993 to 1999. The diagnosis was cross-checked with the office records of the 2 pediatric otolaryngologists in northern Virginia. We excluded cases of RPA resulting from penetrating injuries to the pharynx.
From the Department of Pediatrics, Inova Fairfax Hospital for Children, Falls Church, Virginia; and Section of Otolaryngology, Department of Surgery, Inova Fairfax Hospital, Falls Church, Virginia. Presented at the 27th annual meeting of SENTAC (Society for Ear, Nose, and Throat Advances in Children), Williamsburg, Va, Dec 3, 1999.
Submitted for publication Jan 28, 2000; revision received July 10, 2000; accepted Aug 23, 2000. Reprint requests: Richard H. Schwartz, MD, 115 Park St SE, Suite 103, Vienna, VA 22180. Copyright © 2001 by Mosby, Inc. 0022-3476/2001/$35.00 + 0 9/22/111275 doi:10.1067/mpd.2001.111275
During the 7-year period reviewed, 26 children had acute nontraumatic RPAs; 13 (50%) had RPAs alone; and the remainder had both retropharyngeal and parapharyngeal abscesses. Patient ages ranged from 5 months to 11 years, with a median age of 3.5 years. Fifteen (58%) were <4 years of age. There were 17 boys and 9 girls. All patients were previously healthy. Sixteen patients (62%) had received oral antibiotics before admission.
CT RPA
Computed tomography Retropharyngeal abscess
Symptoms and signs noted are listed in the Table. The most frequent symptoms were fever, decreased oral intake, and sore throat. On physical examination, the most common signs were a visible or palpable neck mass (lymphadenopathy or parapharyngeal abscess) and asymmetric pharyngeal bulge. The mean leukocyte count was 22,500 (range, 8900-38,000). Imaging studies included computed tomography in all patients and lateral neck view roentgenograms in 13 patients. All the CT scans showed hypodensity, suggestive of inflammation, or ring-enhancing abscess in the retropharyngeal space. Treatment included antibiotic therapy with or without surgical incision and drainage. Five children (19%) without complete ring enhancement of the inflammatory mass were treated exclusively with antibiotics given parenterally. The remaining 21 children (81%) had surgical drainage in addi435
LEE, SCHWARTZ, AND BAHADORI
THE JOURNAL OF PEDIATRICS MARCH 2001
Table. Symptoms and signs of retropharyngeal abscess in 26 children
Number (%) Symptoms Fever Decreased oral intake Sore throat Pain on swallowing Neck pain Neck posturing or stiffness Signs Neck mass (large lymphadenopathy/parapharyngeal abscess) Asymmetrical bulge of oropharynx Drooling Torticollis Trismus
tion to antibiotic therapy; 16 patients had drainage performed with an intraoral approach only. The 5 children who had abscess cavities lateral to the great vessels of the neck had surgical drainage with combined intraoral and transcutaneous lateral neck incisions. Antibiotics used included nafcillin, cefuroxime, ceftriaxone, clindamycin, and ampicillin/sulbactam. Streptococcus pyogenes was recovered from 5 (24%) specimens of aspirate, Staphylococcus aureus from 2 (10%), anaerobic bacteria from 4 (19%), and Mycobacterium avium-intracellulare from one specimen. Prior antibiotic therapy negatively influenced isolation of the causative bacteria. A significant preoperative complication occurred in only one patient. A 5-month-old infant had significant upper airway obstruction that required emergent intubation and a prolonged stay in the pediatric intensive care unit. There were no major postoperative complications. Between 1993 and 1999, only 2 children with acute epiglottitis were admitted to our children’s hospital. In contrast, in 1998 and 1999, 12 children with RPA were admitted, which was a significantly greater number than the mean of the previous 5-year period (P = .06). 436
20 (77) 18 (69) 12 (46) 9 (35) 9 (35) 11 (42)
15 (58) 12 (46) 9 (35) 9 (35) 5 (19)
DISCUSSION Retropharyngeal lymph node infection in children classically results from extension of oropharyngeal infections including pharyngitis, tonsillitis, and adenitis. The infection progresses through 3 stages: cellulitis, phlegmon, and abscess. Probably only the last stage requires surgical drainage. Contrast-enhanced CT is invaluable in delineating the stage of inflammation, but boundaries (incomplete vs complete ring enhancement) between phlegmon and abscess stages may be blurred. In one study, the positive predictive value of CT was 84% and the negative predictive value was 44%.4 Trauma, often caused by a fall while holding a pencil or stick in the mouth, and dental infections are the usual underlying causes of RPA in older children and adults. Most symptoms and signs of RPA are identical to those of acute epiglottitis. They include fever, irritability, oropharyngeal pain, unusual positioning of the head and neck, and odynophagia. As the infection progresses, there may be refusal to swallow solids or liquids including saliva, which leads to pooling in the oropharynx and overflow drooling. The most suggestive physical signs of both diseases are hyperextension of the neck,
torticollis, muffled voice, stertor, and other signs of upper airway obstruction. Swelling of the side of the neck can be present with a mixed RPAparapharyngeal abscess. In several case series of patients with RPA, the classic physical sign of RPA, which is bulging of the posterior pharynx, was noted; however, this was present in <50% of infants.1,2 The major causative organisms are Streptococcus pyogenes, Staphylococcus aureus, and oropharyngeal anaerobic bacteria.5,6 The differential diagnosis includes acute epiglottitis, foreign body aspiration, vertebral osteomyelitis, hematoma (particularly in boys with hemophilia), and lymphoma.4 Diagnostic studies commonly include roentgenograms of the cervical area and CT scans.8 In order to minimize false-positive results, a lateral view roentgenogram may be helpful when obtained with the patient in the sitting position with the neck hyperextended and during inspiration, if possible.2 Normal buckling of upper cervical prevertebral soft tissues that occurs during flexion or expiration can simulate a retropharyngeal mass. A retropharyngeal space measured from the most anterior aspect of C2 to the soft tissues of the posterior pharyngeal wall >7 mm (normal, 3-6 mm) or a retrotracheal space >14 mm in a child suggests a mass caused by phlegmon, pus, or blood. Color flow Doppler ultrasonography is a new technique that may improve the diagnostic accuracy in differentiating phlegmon from abscess.7 Management of RPA depends on the maturity of the infection and the degree of airway compromise. Cellulitis or a phlegmon requires only targeted antibiotics active against common oral facultative and anaerobic bacteria. Historically, the treatment of an abscess has been surgical drainage. However, several recent studies have shown that medical management alone can be curative for >50% of children with RPA (usually defined by CT).9,10 Security of the airway is of paramount
LEE, SCHWARTZ, AND BAHADORI
THE JOURNAL OF PEDIATRICS VOLUME 138, NUMBER 3 importance. In our approach to management, if airway obstruction is severe, an endotracheal tube is placed and the child is admitted to the pediatric intensive care unit. All patients have a secure intravenous catheter placed and are given nothing by mouth. If a patient is stable and the benefit of avoiding a surgery outweighs the risk of complications from RPA, we have given a trial of intravenous antibiotics for 24 to 48 hours. If there is no improvement, either clinically or as determined by imaging, then the decision may be made to perform surgical drainage. Suppurative complications of RPA include rupture of the abscess with aspiration, asphyxiation, or pneumonia; empyema; and mediastinitis. Vascular complications include thrombophlebitis
of the internal jugular vein and erosion through the carotid artery sheath.
REFERENCES 1. Thompson JW, Cohen SR, Reddix P. Retropharyngeal abscess in children: a retrospective and historical analysis. Laryngoscope 1988;98:589-92. 2. Seid AB, Dunbar JS, Cotton RT. Retropharyngeal abscesses in children revisited. Laryngoscope 1979;84:171724. 3. Goldenberg D, Golz A, Joachims HZ. Retropharyngeal abscess: a clinical review. J Laryngol Otol 1997;511:546-50. 4. Barratt GE, Koopman CF, Coulthard SW. Retropharyngeal abscess—a tenyear experience. Laryngoscope 1984; 94:455-63. 5. Asmar BL. Bacteriology of retropharyngeal abscess in children. Pediatr Infect Dis J 1990;9:595-6.
6. Brook I. Microbiology of retropharyngeal abscess in children. Am J Dis Child 1987;141:202-4. 7. Glasier CM, Stark JE, Jacobs RF, Mancias P, Leithiser RE Jr, Seibert RW, et al. CT and ultrasound imaging of retropharyngeal abscesses in children. Am J Neuroradiol 1992;13:1191-5. 8. Stone ME, Walner DL, Koch BL, Egelhoff JC, Myer CM. Correlation between computed tomography and surgical findings in retropharyngeal inflammatory processes in children. Int J Pediatr Otorhinolaryngol 1999;49:121-5. 9. Broughton RA. Nonsurgical management of deep neck infections in children. Pediatr Infect Dis J 1992;11: 14-8. 10. Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, Gonzalez-Valdepena H, Bluestone CD. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995;112:375-82.
AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of The Journal of Pediatrics for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one third off on quantities of 24 or more. Please write to Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call 800-654-2452 or 407-345-4000 for information on availability of particular issues and prices. If unavailable from the publisher, photocopies of complete issues may be purchased from Bell & Howell Information and Learning, 300 N Zeeb Rd, Ann Arbor, MI 48106-1346, (734) 761-4700 or (800) 521-0600.
437