What is Retropharyngeal Abscess?
Retropharyngeal abscesses, which are pockets of pus in the back of the throat, are uncommon but can be life-threatening. These are most often seen in children under 5 years of age but can also occur in adults. They usually form after upper respiratory infections like the common cold in younger children, and can lead to inflamed lymph nodes in the neck and the formation of these abscesses.
In older children and adults, an injury to the back of the throat can create a similar condition. Viral upper respiratory infections typically come before the abscess forms, but dental diseases or injuries to the mouth and throat can cause them as well.
While infections of tonsils and teeth can sometimes lead to retropharyngeal abscesses, they are more likely to lead to other types of abscesses like peritonsillar (near the tonsils) or parapharyngeal (around the throat). Another uncommon way these abscesses can form is from the spread of infection from certain bone diseases in the spine.
If a retropharyngeal abscess gets larger, it could block the upper airway, potentially causing suffocation.
If left untreated, these abscesses can block the upper airway and cause breathing difficulties. They are typically treated with long-term courses of strong antibiotics given through an IV, along with surgery to drain the abscess if necessary. Patients with these infections might need to be admitted to a hospital and evaluated by a ear, nose, and throat specialist.
After the infection has cleared, some patients may have to stay in the hospital for a longer time, might require a tracheostomy (an opening in the windpipe to help with breathing), or need a feeding tube inserted through their nose due to continued inflammation in their upper airway and digestive system.
What Causes Retropharyngeal Abscess?
Understanding the layers of tissue in the neck is key to understanding how retropharyngeal abscesses, or abscesses behind the throat, develop. The neck has two main types of tissue layers – superficial (on the outside) and deep (inside). The deep tissue in the neck is further divided into superficial, middle, and deep layers.
The outermost tissue surrounds a muscle called the platysma, some vessels, nerves, lymph channels which carry white blood cells, and fatty tissue.
The superficial layer of the deep tissue in the neck, is wrapped around certain muscles and glands in your neck. This tissue extends downwards up to your collar bones.
The middle layer of deep tissue in your neck has two parts, one that surrounds muscles, and another that covers parts of your throat and neck like the muscles that help you swallow, the voice box, windpipe, and thyroid gland. Then there’s the buccopharyngeal fascia, another sort of tissue that forms the front border of the retropharyngeal space, or the area behind your throat.
This retropharyngeal space goes down to a central part of the chest, where the windpipe splits into two. At this point, the buccopharyngeal fascia merges with the alar division, part of yet another layer of deep tissue in your neck. The deep part of the deep tissue also goes down to the diaphragm in a space that’s often called the “danger zone” between two other deep tissues. There’s also a space between the tissues and the spinal column that extends all the way down to the tailbone.
A retropharyngeal abscess is basically build-up of infected material in the retropharyngeal space. There are lymph nodes (small glands that filter and carry harmful substances) in this space that drain the area behind the nose, adenoids (glands at the back of the nasal passage), sinuses, and middle part of the ear. These lymph nodes are particularly active in young kids, but typically start to shrink and become less active by around age 4 to 5. Half of the time, these abscesses occur after an upper respiratory infection, leading to the lymph nodes becoming overly active and forming an abscess.
In adults and older kids, trauma or injury to the back of the throat is commonly the main reason behind these abscesses, causing an infection and subsequently, an abscess formation. One-fourth of these abscesses are associated with trauma leading to introduction of bacteria and inflammation in the retropharyngeal space, eventually forming an abscess. Poor dental hygiene, diabetes, immune issues, and lower socioeconomic status are some factors that can increase the risk of infections in the retropharyngeal space.
Risk Factors and Frequency for Retropharyngeal Abscess
Retropharyngeal abscesses, or pus-filled sores in the area behind the throat, are most commonly observed in children aged 2 to 4. They tend to be more common in males, making up about 53% to 55% of all infections. Half of these abscesses start with an upper respiratory infection, which leads to infected lymph nodes in the neck and eventually the formation of an abscess.
- Retropharyngeal abscesses mainly occur in children between the ages of 2 and 4.
- About 53% to 55% of these infections are found in males.
- Half of these abscesses begin with an upper respiratory infection, eventually leading to the abscess.
- A quarter of these abscesses result from trauma to the back of the throat, causing bacteria to infect the area and form an abscess.
- Though not common, data from 2000 to 2009 shows a rising trend in the occurrence of these abscesses.
Signs and Symptoms of Retropharyngeal Abscess
A retropharyngeal abscess is an infection that occurs in the throat, and initially, it might resemble a simple sore throat. You should suspect this infection if there was a recent upper respiratory infection or trauma to the back part of the throat. As the infection advances, symptoms of airway obstruction might become more noticeable, often getting worse over several days.
The following symptoms may prompt concern about airway obstruction due to this infection:
- Difficulty in swallowing
- Painful swallowing
- Difficulty handling oral secretions
- Stiffness of the neck
- Twisted neck
- Pain or discomfort when extending the neck
- Change in voice quality (e.g., “hot potato” voice or muffled voice)
- Lockjaw
- Swelling in the neck
- Enlargement of the neck lymph nodes
- Chest pain (possible chest involvement)
- Difficulty in breathing (e.g., noisy breathing, rapid breathing, and retractions)
People suffering from retropharyngeal abscesses are usually feverish and appear sick. In the initial stages, they may have slight to moderate throat redness and difficulty eating. Throat redness and swelling become more evident as the illness progresses, making it tough to handle oral secretions. These individuals often feel severe neck discomfort when extending their neck and usually decide to flex their necks.
Careful examination should be carried out by health professionals skilled in emergency airway management when there is suspicion of a retropharyngeal abscess. This is due to the risk of rupturing the abscess during the examination, which could result in aspiration and potential lung inflammation. Precautions should be taken, such as placing the patients in a position that minimizes the risk of aspiration and keeping suction equipment ready at all times. During the examination, the back wall of the throat might present a bulge where the abscess is, although this might not be visible if the abscess is situated below the tongue level. Typically, there’s no swelling on the palate, and rare occasions present a one-sided throat exudation. It’s also worth noting that symptoms such as tonsil displacement and trismus are less common with retropharyngeal abscesses. However, they are more commonly seen in peritonsillar abscesses (another type of throat infection).
Testing for Retropharyngeal Abscess
If your doctor suspects you might have a retropharyngeal abscess, which is a pocket of pus forming in the tissue at the back of your throat, they’ll likely want to conduct some laboratory tests. These tests could include a complete blood count, measuring your levels of C-reactive protein (an indicator of inflammation), and taking blood cultures to find out if and what kind of bacteria are causing the problem. However, if getting these tests done would distress you and could potentially cause your symptoms to get worse, the doctor might wait before conducting these tests. When you’re very anxious, the symptoms might get worse, which could lead to difficulty breathing, especially in young children. Both aerobic and anaerobic blood cultures are required. It’s also crucial to note that white blood cell counts in patients with such abscesses are usually more significant than 12,000/μL in 91% of cases.
Imaging tests can be useful, too. Doctors often start with a type of X-ray called a lateral neck radiograph, especially in younger children. This technique uses less radiation and is usually easier for patients to tolerate. This X-ray needs to be taken while the patient is breathing in and has their neck in a natural position to get the best image. The X-ray can show if the space at the back of your throat is thicker than it should be, which could indicate an abscess. The normal upper limit for this thickness is 7mm at C2 and 14mm at C6 for healthy children, while in healthy adults, it’s 7mm at C2 and 2mm at C6. A thickness of 20mm at C6 suggests an abscess collection.
If you’re experiencing retropharyngeal abscess symptoms and chest pain, your doctor might want a chest X-ray to check for problems in the area between your lungs. Moreover, a CT scan is the best form of imaging for individuals suspected to have a retropharyngeal abscess, but if there’s a risk of breathing problems during the scan, a doctor trained in managing airways in emergencies should be present.
Meanwhile, in children, an ultrasound might be more advisable than a CT scan because it doesn’t expose them to radiation and it’s more convenient as it can be done by the bedside. In qualified hands, ultrasound can detect the presence of a retropharyngeal abscess with 89% accuracy. Lastly, an MRI scan could also be used in cases of cellulitis, which is an inflammation of the skin and subcutaneous tissues.
Treatment Options for Retropharyngeal Abscess
If you have a confirmed infection in the area at the back of your throat (known as a retropharyngeal infection), you would need to be admitted to the hospital. There, you would start receiving powerful medicines, called antibiotics, through an IV drip to fight the infection. These antibiotics are chosen to target the common germs that cause upper respiratory infections.
Sometimes these infections can cause difficulties in breathing due to obstruction. In such cases, immediate surgery is necessary to remove the fluid build-up. However, if your breathing is not severely affected, doctors might first try IV antibiotics for 24 to 48 hours. After this initial treatment, a specialist doctor in ear, nose, and throat conditions would evaluate whether surgery is needed to drain the fluid build-up from the back of your throat.
Patients who might need surgical intervention can be those whose symptoms have been present for more than 2 days and if the size of the fluid-filled area (known as an abscess) is quite large (more than 2 cm2). However, research doesn’t suggest that patients with very large abscesses (more than 3 cm2) benefit from immediate surgery, they too can be given a 24 to 48 hours trial of antibiotics. It’s important to note that during the initial period of treatment, careful monitoring of your airways becomes very essential.
If the initial antibiotics don’t seem to help your condition or if you show signs of a body-wide infection known as sepsis, your doctors may consider additional antibiotics. You would continue to receive antibiotics through the IV until your symptoms improve and you don’t have fever for at least 24 hours. When you start to feel better and remain fever-free, you can be switched to oral antibiotics. Doctors usually prescribe a 14-day course of these oral antibiotics, after which you could be discharged from the hospital. You would be given instructions on when to return, should your condition worsen.
Surgery becomes a strong consideration if your condition doesn’t improve after 24 to 48 hours of antibiotics, or if the abscess is large. The surgery is usually done through the mouth, which is easy and doesn’t leave a visible scar on your skin. This involves making a small cut over the abscess and draining out the fluid content.
In some cases, the infection may be located in a difficult-to-reach place, lower down from third neck bone (the C3). In such situations, a different approach to reach the abscess might be necessary. This involves a small cut made on the neck. The stay in the hospital could be slightly longer for patients who undergo this type of surgery. Rest assured, the risk of complications is about the same for both types of surgical approaches.
What else can Retropharyngeal Abscess be?
When a doctor is trying to diagnose a retropharyngeal abscess, which is an infection in the throat, they need to also rule out other conditions that might present similar symptoms. These include:
- Airway foreign body (something stuck in the throat)
- Pneumonia (lung infection)
- Mediastinitis (infection in the chest)
- Parapharyngeal abscess (another form of throat infection)
- Peritonsillar abscess (infection near the tonsils)
- Odontogenic infection or abscess (infection related to the teeth)
- Sialadenitis (infection of the salivary glands)
- Epiglottitis (inflammation of the flap at the base of the tongue)
- Pharyngitis (throat inflammation)
- Ludwig angina (a type of skin infection)
- Lemierre syndrome (a rare but serious infection)
What to expect with Retropharyngeal Abscess
The chances of recovering from a retropharyngeal abscess, which is a pocket of pus in the back of the throat, are usually good if it is detected early and treated quickly. The death rates from this condition can be up to 2.6% in adults, and often, it’s even lower in children. But, strong treatment is generally needed.
This often means the person has to be cared for in an intensive care unit (ICU), a specialist department in a hospital where they can get constant, close monitoring. If the diagnosis and treatment are delayed, it can lead to serious complications. This can greatly increase the risk of other medical problems and also the potential for death.
Possible Complications When Diagnosed with Retropharyngeal Abscess
Retropharyngeal abscesses, or infections in the deep tissues in the back of the throat, can lead to various complications. Some issues include blocking of the airway, wear and tear on the bronchial tubes, inflammation of the chest cavity’s inner layer, severe body-wide infection, severe difficulty in breathing, facial muscle weakness, throat perforation, damage to the main blood vessels in the neck, and inflammation of the brain and surrounding tissues.
The complications include:
- Blocking of the airway
- Damage to the bronchial tubes (parts of the lung)
- Inflammation of the chest cavity’s inner layer
- Severe body-wide infection (sepsis)
- Serious breathing difficulty
- Facial muscle weakness
- Perforation of the esophagus
- Damage to primary neck blood vessels
- Inflammation of the brain and surrounding tissues
Recovery from Retropharyngeal Abscess
After surgery, patients are advised not to eat or drink anything until all signs of the abscess are gone. This practice is often referred to as NPO, an abbreviation for a Latin phrase that translates to “nothing by mouth.” In an intensive care unit (ICU) setting, close and careful monitoring of patients is required to look out for possible complications involving their airway. If there’s any sign of swelling in the airway after draining an abscess, the patient might need to be intubated, which means a tube is inserted into their windpipe to help them breathe, for 24 to 48 hours after surgery.
Initially, patients are given broad-spectrum antibiotics through an intravenous (IV) line. In some cases, alternative methods of feeding might be needed if the patient can’t eat or drink. Once the patient’s condition has stabilized, they may be switched to antibiotics taken by mouth that are chosen based on the type of bacteria found in their abscess.
Preventing Retropharyngeal Abscess
While it can be tough to prevent the common colds or throat injuries that can cause a throat abscess, taking steps like wearing masks and washing your hands frequently can be beneficial. Throat abscess is a pocket of pus that forms in the throat due to infection or trauma. Furthermore, taking care of your teeth with regular cleaning and check-ups can help prevent any abscess caused by a dental infection. Keeping up good mouth health is crucial in preventing these types of abscesses.
