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Retropharyngeal Abscess in a Medically Complex Child Presenting With Respiratory Failure
Pediatrics SESSION TITLE: Fellow Case Report Poster- Pediatrics SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Retropharyngeal Abscess in a Medically Complex Child Presenting With Respiratory Failure Kristin Dolan MD*; and Wendy Estrellado MD Children’s Mercy Hospital, Kansas City, MO INTRODUCTION: Retropharyngeal abscess (RPA) is a potentially serious and even fatal condition among children. This is a case of a medically complex infant who was found to have a retropharyngeal abscess presenting with hypoventlation and respiratory failure. CASE PRESENTATION: A 9 month old female with congenital intraventricular cyst and shunted hydrocephalus at birth was admitted due to vomiting, irritability and tenderness of her right neck. On admission, she was febrile and fussy with significant macrocephaly. Moderate pain occured with movement of her neck. There were no overlying skin changes. Her neurologic exam was non-focal. Shunt series and CT of the head were negative for shunt malfunction. Laboratory findings showed leukocytosis and elevated inflammatory markers. Blood, urine and cerebrospinal fluid cultures were negative. She was started empirically on ampicillin/sulbactam for suspected aspiration pneumonia secondary to recent vomiting. She began having episodes of oxygen desaturations during sleep that became more frequent and severe. A venous blood gas showed uncompensated respiratory acidosis. Patient was transferred to the Pediatric Intensive Care Unit and was placed on high flow nasal cannula. She progressed to respiratory failure and was intubated. Brain MRI (Fig.1-2) was obtained looking for a central etiology of hypoventilation. This revealed a large fluid collection in the right parapharyngeal soft tissues. The RPA was drained and grew streptococcal species. She was treated with antibiotics, extubated and her hypoventilation resolved.
PEDIATRICS
DISCUSSION: Retropharyngeal abscess is a result of suppuration of paramedian lymph nodes following an upper respiratory infection.1 The presentation of RPA is often subtle, and the constellation of findings are variable. Infants may present with nonspecific symptoms of fever, neck swelling, poor oral intake and stridor.1,2 In older children, symptoms such as odynophagia, sore throat, neck swelling and tenderness occur.2 Rarely, RPAs can present with airway obstruction causing hypoventilation and respiratory failure.1 Diagnosis of RPA is based on clinical suspicion with supportive imaging studies. Management often consists of antimicrobial therapy and surgical drainage. CONCLUSIONS: Diagnosis of RPA in children can be challenging. A high clinical suspicion is crucial especially in medically complex children to prevent life-threatening complications. As illustrated by our case, it is important to consider this diagnosis in children with signs of upper airway obstruction as this can rapidly progress to respiratory failure. Reference #1: Craig F, Schunk J. Retropharyngeal Abscess in Children: Clinical Presentation, Utility of Imaging, and Current Management. PEDIATRICS. 2003;111(6):1394-1398. doi:10.1542/peds.111.6.1394. Reference #2: Cmejrek R, Coticchia J, Arnold J. Presentation, Diagnosis, and Management of Deep-Neck Abscesses in Infants. Arch Otolaryngol Head Neck Surg. 2002;128(12):1361. doi:10.1001/archotol.128.12.1361. DISCLOSURE: The following authors have nothing to disclose: Kristin Dolan, Wendy Estrellado No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1057
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
954A
[
150#4S CHEST OCTOBER 2016
]
Retropharyngeal Abscess in a Medically Complex Child Presenting With Respiratory Failure Kristin Dolan MD*; and Wendy Estrellado MD Children’s Mercy Hospital, Kansas City, MO INTRODUCTION: Retropharyngeal abscess (RPA) is a potentially serious and even fatal condition among children. This is a case of a medically complex infant who was found to have a retropharyngeal abscess presenting with hypoventlation and respiratory failure. CASE PRESENTATION: A 9 month old female with congenital intraventricular cyst and shunted hydrocephalus at birth was admitted due to vomiting, irritability and tenderness of her right neck. On admission, she was febrile and fussy with significant macrocephaly. Moderate pain occured with movement of her neck. There were no overlying skin changes. Her neurologic exam was non-focal. Shunt series and CT of the head were negative for shunt malfunction. Laboratory findings showed leukocytosis and elevated inflammatory markers. Blood, urine and cerebrospinal fluid cultures were negative. She was started empirically on ampicillin/sulbactam for suspected aspiration pneumonia secondary to recent vomiting. She began having episodes of oxygen desaturations during sleep that became more frequent and severe. A venous blood gas showed uncompensated respiratory acidosis. Patient was transferred to the Pediatric Intensive Care Unit and was placed on high flow nasal cannula. She progressed to respiratory failure and was intubated. Brain MRI (Fig.1-2) was obtained looking for a central etiology of hypoventilation. This revealed a large fluid collection in the right parapharyngeal soft tissues. The RPA was drained and grew streptococcal species. She was treated with antibiotics, extubated and her hypoventilation resolved.
PEDIATRICS
DISCUSSION: Retropharyngeal abscess is a result of suppuration of paramedian lymph nodes following an upper respiratory infection.1 The presentation of RPA is often subtle, and the constellation of findings are variable. Infants may present with nonspecific symptoms of fever, neck swelling, poor oral intake and stridor.1,2 In older children, symptoms such as odynophagia, sore throat, neck swelling and tenderness occur.2 Rarely, RPAs can present with airway obstruction causing hypoventilation and respiratory failure.1 Diagnosis of RPA is based on clinical suspicion with supportive imaging studies. Management often consists of antimicrobial therapy and surgical drainage. CONCLUSIONS: Diagnosis of RPA in children can be challenging. A high clinical suspicion is crucial especially in medically complex children to prevent life-threatening complications. As illustrated by our case, it is important to consider this diagnosis in children with signs of upper airway obstruction as this can rapidly progress to respiratory failure. Reference #1: Craig F, Schunk J. Retropharyngeal Abscess in Children: Clinical Presentation, Utility of Imaging, and Current Management. PEDIATRICS. 2003;111(6):1394-1398. doi:10.1542/peds.111.6.1394. Reference #2: Cmejrek R, Coticchia J, Arnold J. Presentation, Diagnosis, and Management of Deep-Neck Abscesses in Infants. Arch Otolaryngol Head Neck Surg. 2002;128(12):1361. doi:10.1001/archotol.128.12.1361. DISCLOSURE: The following authors have nothing to disclose: Kristin Dolan, Wendy Estrellado No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1057
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
954A
[
150#4S CHEST OCTOBER 2016
]