Courtesy of Dr. Johnson
Case 1:
A 4-year-old presents to the pediatric ED with 4 days of fevers, sore throat, and decreased PO intake. The patient’s older sister recently had a sore throat with fever and was diagnosed with strep throat based on culture. On examination, the patient is febrile and irritable, with what appears to be torticollis, but no tonsillar exudates or hypertrophy are noted. On a lateral neck x-ray with inspiration, the patient has a prevertebral space of 30 mm at C6. She is diagnosed with a retropharyngeal abscess.
Figure 1: Retropharyngeal abscess.
– Retropharyngeal abscesses (RPA) are one type of infection in the deep space of the neck.
– As the name suggests these infections are located in the retropharyngeal space (see figure 1).
– These infections typically occur in patients less than 5 years of age as the space generally involutes and atrophies by that age.
– They are typically seeded by lymph drainage from a URI.
– The clinical presentation typically involves features of tonsillitis along with torticollis, anterior cervical chain lymphadenopathy, and swelling to the posterior pharyngeal wall.
– Due to the contiguity of the deep neck spaces, RPAs can evolve into mediastinitis and Lemeirre’s syndrome.
– These infections can compromise the airway.
– If the patient has stridor, altered mental status, or inability to tolerate their own secretions continue early airway interventions are necessary
– RPAs can be diagnosed on a lateral neck x-ray. This typically demonstrates an increased prevertebral space diameter. In children, the normal distance is 7 mm at C2 and 14 mm at C6. If the X-ray is inconclusive, proceed to CT w/contrast.
– These infections can start out as viral or bacterial. An abscess can be polymicrobial or group A strep dominant.
– Treatment is with drainage and administration of IV antibiotics (ampicillin-sulbactam or clindamycin)
References:
Case 2:
A 17-year-old female presents for fever and sore throat for 4 days. The patient states that she has a history of tonsillitis with multiple prior infections. Today, she notes that it is very painful to swallow and she is spitting her saliva into a cup. On exam, the patient’s voice sounds muffled and she has a deviated uvula (see figure 2).
Figure 2: Peritonsillar abscess
– Peritonsillar abscesses (PTA) arise in the peritonsillar space. They are the most common deep space infection of the neck and are typically a complication of tonsillitis.
– They occur most often in adolescents and young adults.
– Physical exam is notable for halitosis, unilateral tonsillitis, contralateral uvula deviation, and trismus.
– PTA can also present with muffled (hot potato) voice. As it progresses, patients may develop an inability to tolerate their secretions.
– These infections can compromise the airway.
– If untreated, PTA can progress to mediastinitis.
– PTA can lead to erosion into the carotid sheath leading to fasciitis.
– Diagnosis is clinical, sonographic via endocavitary probe (see figure 3) or via telescopic method (see figure 4), or through CT w/contrast of the neck.
– Treatment is with IV antibiotics if unable to tolerate PO and possible drainage.
– The infection is typically polymicrobial with group A strep and anaerobes and involves the area around the tonsil (see figure 5).
Figure 5: PTA drainage
– Antibiotic choice is generally clindamycin or a beta-lactam with a beta-lactamase inhibitor (ampicillin-sulbactam or amoxicillin-clavulanic acid)
– Bedside drainage is either blind or with the aid ultrasonography (the endocavitary probe generally takes up too much space, so the telescopic approach is preferred (ee figure 3).
– The carotid runs approx 2.5 cm behind and lateral to the tonsils and drainage carries a risk of injury to the carotids. A needle guard is generally recommended (Figure 6).
Figure 6: Needle guard
In otherwise stable patients with no airway compromise, providers can attempt treatment with steroids and IV antibiotics instead of I&D.
References:
- 1. Battaglia A, Burchette R, Hussman J, Silver MA, Martin P, Bernstein P. Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2018;158(2):280-286. doi:10.1177/0194599817739277
- 2. Galioto NJ. Peritonsillar Abscess. Am Fam Physician. 2017;95(8):501-506. http://www.ncbi.nlm.nih.gov/pubmed/28409615.
- 3. Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
Noah Berland
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