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Retropharyngeal and parapharyngeal abscess in

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treatment

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Retropharyngeal and parapharyngeal abscess in childrenEpidemiology,

clinical features and treatment
Galia Grisaru-Soen a,*, Orna Komisar b, Orna Aizenstein c, Michalle Soudack d, David Schwartz e,
Gideon Paret f
a
Pediatric Infectious Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
b
Pediatric Department, Dana Childrens Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
c
Department of Diagnostic Imaging, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
d
Department of Diagnostic Imaging, Pediatric Imaging Unit, Safra Childrens Hospital, Sheba Medical Center, Tel Aviv, Israel
e
Microbiology Laboratory, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
f
Department of Pediatric Intensive Care, Safra Childrens Hospital, Sheba Medical Center, Tel Aviv, Israel

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To describe the clinical presentation, diagnosis, management and complications of children
Received 15 February 2010 with retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs).
Received in revised form 23 May 2010 Methods: A retrospective chart review was conducted at two tertiary care, pediatric hospitals in Israel.
Accepted 25 May 2010
The medical records of all children <18 years who had been admitted with a diagnosis of RPA or PPA
Available online xxx
during an 11-year period (January 1997 to February 2008) were reviewed. Data on demographics,
presenting symptoms, physical examination ndings, imaging studies and interpretation, laboratory
Keywords:
results, hospital course, medical treatment and surgical interventions were retrieved.
Retropharyngeal abscess
Results: A total of 39 children were diagnosed as having RPA (n = 26, 67%) or PPA (n = 13, 33%). There was
Children
Treatment a predominance of boys (61.5%). The mean age of all the children at diagnosis was 4 years. The annual
incidence increased over the 11-year period. The most common symptoms at presentation included
fever (n = 27, 70%) and neck pain (n = 24, 62%). The physical examination revealed cervical
lymphadenopathy in 30 children (77%), limitation of neck movements in 25 (64%), torticollis in 21
(54%), drooling in three (8%), and stridor in two (5%). Computerized tomographic (CT) scanning with
contrast was performed in 37 patients (95%), of whom 17 underwent surgical drainage. Thirteen children
were positively diagnosed as having an abscess by the nding of pus at surgery, of whom 12 had been
found to have an abscess on their CT scan. All the patients received intravenous antibiotics. There was no
signicant difference in the duration of hospital stay between those who underwent surgery and those
who were treated with antibiotics alone. There were no treatment failures and no complications in either
of the two groups.
Conclusion: Children with RPA most commonly present with restricted neck movements, fever and
cervical lymphadenopathy, and rarely with respiratory distress or stridor. Many patients with RPA and
PPA can be treated successfully without surgery. CT scans are helpful in diagnosing and assessing the
extent of the infection, but they are not always accurate.
2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction signicant morbidity and mortality because of sepsis, mediastinitis,

airway obstruction, internal jugular vein thrombosis, and carotid
Retropharyngeal abscesses (RPAs) are uncommon complications artery aneurysm. Advances in imaging, early detection, and
of upper respiratory infections in children. They result from the antibiotic treatment have greatly reduced these devastating out-
spread of the infection to and eventual suppuration of retro- comes, and RPA now seldom lead to long-term consequences [1].
pharyngeal lymph nodes. Historically, these processes had caused The presentation of RPA is sometimes subtle, and the constellations
of ndings are varied. Because of their relative infrequency, the
variability in presenting symptoms and lack of readily visible
physical signs, they present a diagnostic challenge to emergency
* Corresponding author at: Head of Pediatric Infectious Diseases Service, Dana
Childrens Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv
physicians, pediatricians and otolaryngologists. In addition, the
64239, Israel. Tel.: +972 3 6974271; fax: +972 3 6974533. management of these infections is also controversial, especially with
E-mail address: galiag@post.tau.ac.il (G. Grisaru-Soen). regard to the timing of surgical intervention [2].

0165-5876/$ see front matter 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2010.05.030

Please cite this article in press as: G. Grisaru-Soen, et al., Retropharyngeal and parapharyngeal abscess in childrenEpidemiology,
clinical features and treatment, Int. J. Pediatr. Otorhinolaryngol. (2010), doi:10.1016/j.ijporl.2010.05.030
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In this study, our aim was to describe the clinical presentation,

the complications, and the contemporary means of diagnosis and
management of RPA and PPA in children.

2. Methods

We conducted a retrospective chart review at two tertiary care

pediatric hospitals in Israel, Dana Childrens Hospital at the Tel
Aviv Medical Center and Safra Childrens Hospital at the Sheba
Medical Center. The medical records of all patients younger than
18 years of age who had been admitted with a diagnosis of RPA or
parapharyngeal abscess (PPA) during a 10-year period (January
1997 to February 2008) were reviewed. Cases of posttraumatic RPA
were excluded. All charts were retrieved by one of the authors
(O.K.) and reviewed for data on demographics, presenting
symptoms, physical examination ndings, respiratory examina-
tion ndings (i.e., presence of stridor or wheezing), imaging studies
and interpretation, laboratory results, hospital course, medical
Fig. 1. Age distribution of all children with nontraumatic retropharyngeal abscesses
treatment and surgical interventions. Pediatric radiologists inter- (RPAs) and parapharyngeal abscess (PPA).
preted all of the imaging studies. Treatment failure was dened as
recurrent abscess, readmission, or need for a repeat surgical
procedure after the initial hospital stay. Institutional (PCMC) azithromycin (n = 4). Blood cultures were taken to 23 children. One
Medical Records Research Committee approval was obtained child had positive blood cultures for Streptoccocus viridans.
before the chart review was undertaken. Intraoperative cultures were obtained in 14 cases, and there
Analysis of data was performed using a simple descriptive was bacteriologic growth in four of them (28%): S. viridans (n = 2)
statistics T-test for continuous variables. Chi-square or Fisher exact group A Streptococcus (n = 1) and Streptococcus aureus and
tests were applied for categorical variables, and p values <0.05 Coagulase-negative Staphylococcus (n = 1).
were considered signicant. A commercially available statistical As part of their investigative work-up, 37 patients (95%)
program (SPSS statistical software) was used for analysis. All tests underwent computerized tomographic (CT) scanning with con-
were two-tailed. trast. The clinical symptoms and the lateral neck X-rays were
considered to be sufcient to diagnosis the remaining two patients.
3. Results Interpretation of the CT scans revealed a denite abscess in 25
(68%) patients, no abscess in 9 (24%), and a possible abscess
During the 10-year study period, 39 children were discharged (phlegmon indicative of a diffuse inammatory process without
with a diagnosis of RPA (n = 26, 67%) or PPA (n = 13, 33%). There formation of rim-enhancement) in three (8%). Nineteen patients
was a predominance of boys who comprised 61.5% of the study underwent surgical drainage, of whom 17 had undergone CTs prior
population (24 males and 15 females). Most of the 39 children to surgery. The surgical and CT ndings of these 17 patients were as
(n = 28, 71%) were younger than 5 years at diagnosis (mean 4 years, follows: pus was found in 13 of them during the surgery and their
range 0.515) (Fig. 1). Far more patients presented during the CT scans were interpreted as a showing a denite abscess in 12 and
winter months (16 during the winter, 8 during the fall, 9 during a possible abscess in one. No pus was found during surgery in the
the spring and 6 during the summer). The annual incidence of the other four patients although their CTs showed evidence of an
disease was 3.9 cases per year, and it gradually increased over the abscess. The sensitivity and specicity of the CT scans were 92%
10-year period (Fig. 2). and 0%, respectively.
There was a wide variety of clinical presentations. The most Nineteen patients (48%) underwent surgical drainage, and 20
common symptoms at presentation included fever (n = 27, 70%) (51%) were treated with antibiotics only. All the patients received
and neck pain (n = 24, 62%) followed by dysphagia (n = 20, 51%),
palpable neck mass (n = 18, 46%), sore throat (n = 12, 31%) and
respiratory distress (n = 2, 5%) (Table 1). The mean duration of
symptoms prior to admission was 3.5  3.05 days (range 114
days). At admission, 15 (38%) of the children were in good general
condition, 23 (59%) were in moderately ill and one (3%) was very ill
(restricted neck movements, torticollis and drooling). The mean body
temperature for the group was 38.2 8C  0.99 (range 36.540.8 8C).
The physical examination revealed cervical lymphadenopathy in 30
children (77%), restricted neck movements in 25 (64%), torticollis in
21 (54%), tonsillitis in 19 (49%) and tonsil displacement in 13 (33%).
Three patients (8%) had auscultatory lung ndings, three had drooling
(8%), and two had stridor and dyspnea (5%) (Table 2). Laboratory
ndings revealed a mean whole blood count (WBC) of 23,900  0.99
(range 47,0009000). C-reactive protein levels were available for 14
patients: the mean level was 107.8  59.9 mg/L (range 0.13186).
The ESR was available for 18 patients: the mean level was
99.2  26.2 mm/h (range 48160).
Eighteen of the thirty-nine children (46%) had received
treatment with antibiotics before RPA or PPA had been diagnosed, Fig. 2. Distribution of the annual incidence of retropharyngeal abscesses (RPAs) and
mostly amoxicillin/clavulanate (n = 4), ceftriaxone (n = 4), and parapharyngeal abscesses (PPAs).

Please cite this article in press as: G. Grisaru-Soen, et al., Retropharyngeal and parapharyngeal abscess in childrenEpidemiology,
clinical features and treatment, Int. J. Pediatr. Otorhinolaryngol. (2010), doi:10.1016/j.ijporl.2010.05.030
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Table 1 treated with antibiotics alone (2.5 years versus 5.6 years,
Symptoms at presentation.
respectively, p = 0.015). The length of the antibiotic treatment
Symptom Patients, n (%) prior to admission was shorter for the patients who underwent
Fever 27 (70) surgery compared to the patients who had been treated by
Neck pain 24 (61) antibiotics alone (1 day versus 6 days, respectively, p = 0.007). The
Dysphagia 20 (51) average WBC was higher in the combined antibiotic and surgery
Neck mass 18 (46) group than in the antibiotic only group (29,000 and 18,9000,
Sore throat 12 (30)
respectively, p = 0.001). The average platelets count was also
Respiratory distress 2 (5)
higher in the combined antibiotic and surgery group (513,000
versus 361,000 for the antibiotic only group, p = 0.001).
There was no signicant difference in the duration of hospital
Table 2 stay between those patients who underwent surgery and those
Signs at physical examination.
who were treated with antibiotics alone. There were no deaths, no
Sign Patients, n (%) treatment failures and no complications in either the antibiotic
Lymphadenopathy 30 (77) only group or the combined antibiotic and surgery group.
Limitation of neck movements 25 (64)
Torticollis 21 (54) 4. Discussion
Tonsillitis 19 (49)
Tonsil displacement 13 (33)
Drooling 3 (8)
In the current study, infections of the retropharyngeal and
Lung auscultation ndings 3 (8) parapharyngeal spaces (both abscesses and phlegmons) were more
Stridor 2 (5) frequent in our younger study children, with 80% occurring in the
Dyspnea 2 (5) ones under the age of 5 years. This incidence is similar to the
ndings in other series [27]. It has been postulated that younger
children are more likely to develop infections in this area because
intravenous antibiotics during their hospital stay. They mostly of the presence of lymph nodes that run in a paramedian chain in
included clindamycin (59%), ampicillin/clavulanate (56%) and the retropharyngeal space and which spontaneously regress after 5
ceftriaxone (46%). The mean length of intravenous antibiotic years [4,8]. This regression with increasing age lowers the disease
treatment was 7 days (range 214 days). The length of hospital stay risk. We found a strong unexplained predominance of males in our
ranged from 2 to 18 days (mean 8 days). Ten patients (25%) who did series that was also reported by others [2,3,911]. As had been
or did not undergo surgery were transferred from the hospital described in other recent series [3,12], we noted an increase in the
ward for closer supervision to the pediatric intensive care unit incidence of RPA during recent years. There were 39 nontraumatic
(PICU). One of these patients needed to be intubated. The mean cases of RPA and PPA during the entire 10-year study period (3.9
length of stay in the PICU was 2.4  1.34 days (range 15). cases per year). However, the frequency increased from 2.6 cases
There was a signicant difference in the age at admission per year during 19972000 to 6.6 cases per year during 20052008
between the patients who underwent surgery and those who were (Fig. 3). Although it would be difcult to accurately compare

Fig. 3. Diagnostic and medical decision algorithm.

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ndings between different regions in the world, it is interesting to anaerobes, and 12 of the 14 had mixed ora, with alpha- and
note the institutional case rate at other pediatric hospitals: Utah gamma-hemolytic streptococci, S. aureus, Hemophilus inuenzae,
reported 64 cases in 5 years (13 per year), Boston reported 75 cases and group A- hemolytic streptococci being the predominant
in 10 years (7.5 per year), Pittsburgh reported 27 cases in 6 years aerobes. Similar results were reported by Asmar [20] who found
(4.5 per year), Denver reported 17 cases in 10 years (1.7 per year), mixed organisms in 15 of 17 cases (aerobes in all of them and
Los Angeles reported 65 cases in 36 years (1.8 per year), and anaerobes in 53% of them). Craig and Schunks results [7] were
Sydney (Australia) reported 31 cases in 36 years (1 per year) similar to ours: group A Streptococcus and S. aureus predominated,
[3,4,6,7,13,14]. The Boston and Utah series are the most recent and whereas anaerobic organisms were noted infrequently. These
could suggest an increasing frequency of disease, different-sized results were also similar to those reported by Daya et al. [2]. The
population bases, different incidences of disease in different high rate of negative cultures in our study may be due to the fact
regions, or different patterns of antibiotic use [7]. An examination that many of the patients had received antibiotics prior to
of data from the Healthcare Cost and Utilization Project, which is a presentation. No anaerobic organisms were recovered in our
nationwide sample of inpatient admissions in the USA, showed study, possibly due to technical issues of sample collection or, less
that the frequency of pediatric RPA in the Healthcare Cost and likely, differences in bacteriologic pathogenesis within our sample
Utilization Project database increased from 1 in 5379 discharges in population. CT scanning is considered to be the imaging of choice
1997 to 1 in 2483 discharges in 2003. These data indicate that this for diagnosing RPA and PPA [20]. In our series. Thirty-seven
is more than a local or regional phenomenon [1,12]. The reason for patients (95%) underwent a CT scan (the clinical symptoms and
the increased incidence is not known. One possible explanation lateral neck X-rays sufcient to diagnosis the other two). In
might be the availability of CT scanning in most emergency agreement with previous studies [2], our results suggest that CT
departments, leading to earlier diagnosis and promoting earlier scans were highly sensitive in diagnosing an abscess (92%) but not
treatment. specic (Table 3). A number of recent studies have attempted to
The presenting features of infections of the retropharyngeal and correlate CT scan ndings with intraoperative ndings [3,7,8,21].
parapharyngeal space are highly variable and illustrate the The accuracy of the CT ranges between 63% and 95%. It is clear that
difculty in making a diagnosis based on symptoms alone. The neck CT scanning is awed in predicting that pus will be found at
most common symptoms at presentation in our series were fever surgery. The false-negative rate (no abscess on CT, recovered pus at
(70%) and neck pain (62%), followed by dysphagia (51%), palpable surgery) and the false-positive rate (abscess on CT no abscess at
neck mass (46%) and sore throat (31%). The most common ndings surgery) were 13% and 10%, respectively [8]. The accuracy of CT
in the physical examination included cervical lymphadenopathy was calculated by Courtney et al. [21] who compared the CT
(77%), limitation of neck movements (64%), torticollis (54%), ndings within the preceding 24 h of surgery and with the surgical
tonsillitis (49%) and tonsil displacement (33%). ndings in eight children. The CT nding of an abscess was
Only two of our study children (5%) had stridor and dyspnea. accurate in 6 of them, yielding an accuracy of 75% in correctly
RPA is frequently listed in the differential diagnosis for stridor or identifying an abscess and a false positive rate of 25%. We think
airway obstruction, and some authors suggested that there is a that CT is useful for diagnosing retropharyngeal infection, for
similarity in the presentation of RPA to epiglottitis [1517]. indicating the presence or absence of an abscess, for ruling out
Coulthard and Isaacs [4] found stridor in 71% of patients who were other pathology, and for serving as a reference for abscess relations
younger than 1 year and in 43% of patients who were older than 1 if surgical drainage is being contemplated. However, if the clinical
year. Stridor was present in 23% of patients in the series of symptoms and lateral neck X-ray are considered as being sufcient
Thompson and Cohen [13], whereas Morrison and Pashley [6] to diagnosis an RPA or PPA and if the child is clinically stable,
noted stridor or airway obstruction in most of their patients. Only conservative treatment with antibiotics without surgical inter-
two of our patients (5%) had respiratory ndings (stridor and vention is recommended. Magnetic resonance imaging (MRI) is
dyspnea). The recent experience of another childrens hospital strongly recommended today to use in children to diminish
noted no cases of respiratory distress while the patients were radiation. MRI is superior in imaging soft tissue masses compared
awake [18], and another large recent series found respiratory to CT. In the future (in places where available) we recommend the
ndings in 3% of the study patients [7]. This infrequency of use of MRI instead of CT.
respiratory signs represents a signicant departure from classic Conservative (medical) versus surgical treatment of neck
teaching. The absence of evolving airway obstruction might be abscesses has long been debated. Nineteen (48%) of our patients
attributable to a changing spectrum of the disease or, more likely, underwent surgery and 20 (51%) were treated successfully with IV
to earlier diagnosis before airway compromise. Because respirato- antibiotics alone. Nine of the 25 patients with dened abscess were
ry difculty and stridor are rare, restricted neck mobility in a child treated with antibiotics alone and the medical treatment did not
with fever and cervical lymphadenopathy should be the sentinel prolong the hospital stay or result in any complications. These
clinical clue to a diagnosis of RPA or PPA. results are in contrast to those of reports of 85100% surgery rates
Airway symptoms were unusual, but their occurrence empha- [3,6] and are consistent with other studies reporting nonsurgical
sizes the potential morbidity from these infections. Interestingly, resolution rates for abscesses of up to 100% [7,22,23]. The necessity
both of our patients with airway symptoms (one with stridor and for surgery may vary between studies, since inclusion criteria may
dyspnea and one with dyspnea) had pus at surgery. This reects vary and imaging techniques continue to become more precise. In a
the pathological process of RPA: as the collection of pus increases, recent report on 26 patients, 21 with clearly dened abscesses on
it is more likely to result in airway symptoms compared to local
soft tissue edema, which may or may not result in subsequent pus Table 3
formation. Comparison of ndings at surgery and on computerized tomographic (CT) scans.
Our series differs from other pediatric reports with regard to
CT scan ndings Total
microbiology. Blood cultures were positive only in 4% of the
patients and intraoperative cultures were positive in only 28%. Abscess No abscess Possible abscess
Group A, beta-hemolytic Streptococcus (Streptococcus pyogenes), S. Intra-operative ndings
viridans and S aureus were found, whereas no anaerobic organisms Pus 12 0 1 13
No pus 4 0 0 4
were isolated. Brook [19] reported 14 children with RPA who
Total 16 0 1 17
underwent needle aspiration. All 14 patients were found to have

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CT were treated with surgical drainage and ve without clear Acknowledgment

abscess were treated successfully with antibiotics alone [14]. In the
Pittsburgh series of 18 children with RPA, 12 (44%) were Esther Eshkol is thanked for editorial assistance.
successfully treated with antibiotics only [14]. In the Utah study
of 64 pediatric patients with RPA, 27 (42%) underwent surgery and References
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clinical features and treatment, Int. J. Pediatr. Otorhinolaryngol. (2010), doi:10.1016/j.ijporl.2010.05.030