Retropharyngeal Abscess Prediction Remains Limited

Is it possible to determine more standardized clinical practice guidelines (CPGs) for retropharyngeal abscesses (RPAs)?

Background: RPAs are difficult to diagnose in children, and complications such as mediastinal spread and airway obstruction can occur. An increase in the overall incidence of RPAs has been observed in the literature. The authors have previously argued that surgical incision and drainage is the gold standard for RPA management; others have reported management with IV antibiotics.

Study design: Prospective observational study of 111 children, where an RPA was suspected and they were treated according to the clinical guideline between July 2001 and March 2004.

Setting: Children’s Hospital Boston.

Synopsis: Clinical suspicion was initially assessed in the ED or on the floor. The most common signs and symptoms at presentation were fever, torticollis, neck mass and poor oral intake. Patients with moderate or high clinical suspicion had a neck CT with contrast and were then triaged into three groups: Group 1 (probable cellulitis without phlegmon or significant adenopathy; five patients), Group 2 (probable phlegmon, early seminecrotic node; 72 patients) and Group 3 (probable abscess; 34 patients). No Group 1 patients were managed operatively, and only the youngest required an ICU admission. All but four Group 2 patients had a repeat CT scan after 48 to 72 hours of antibiotics; 39 ultimately required surgical drainage, and seven of those required ICU admission. Twenty-nine Group 3 patients had frank pus upon incision and drainage, 13 required an ICU admission and 11 required a peripherally inserted central catheter despite surgical drainage. There were no significant differences in presenting signs or symptoms between patients managed surgically versus those managed with IV antibiotics only. Comparison values are limited, as patients were not randomized and those who received surgery were substantially younger; surgery was consistently recommended for all patients.

Bottom line: The authors’ ability to predict pus was no greater than what has been previously reported, but it is possible to treat pediatric RPAs according to a CPG with liberal use of CT and prompt surgical drainage.

Citation: Saluja S, Brietzke SE, Egan KE, et al. A prospective study of 113 deep neck infections managed using a clinical practice guideline. Laryngoscope. 2013;123:3211-3218.

—Reviewed by Amy Eckner