Retropharyngeal Abscess

Sharp, shooting posterior neck pain prompted a 29-year-old man to seek medical attention. The pain began 4 days earlier and progressed to the point that it occurred with swallowing. He wore a wool scarf to restrict his cervical range of motion. During the history taking, he remained rigid and avoided rotation and flexion or extension of the spine.

The patient was afebrile. There was no pharyngeal erythema, deviation of the uvula, or obvious edema of the pharynx. Cervical rotation was decreased, more to the left than the right, and reproduced the pain in both directions. Flexion and extension of the cervical vertebrae were also decreased and reproduced the pain.

An MRI without contrast revealed a 6-cm focus of increased T2 and diminished T1 signal within the prevertebral/retropharyngeal space, anterior to the C2 through C5 vertebrae. The patient was sent for emergent otolaryngological evaluation.

A CT scan with intravenous contrast revealed an irregular fluid collection of 2.5 × 0.9 × 7.0 cm in the retropharyngeal space (arrow) that originated at the posterior pharynx and extended inferiorly to the level of the C6 vertebra. The fluid collection demonstrated rim enhancement and was suggestive of an abscess.

Intravenous clindamycin( was administered, and irrigation with debridement of the abscess was performed. Cultures revealed Haemophilus parainfluenzae (2 morphologies), Neisseria species (not meningitidis or gonorrhoeae), and α-hemolytic Streptococcus without anaerobic species. Amoxicillin(/clavulanate was prescribed, and the patient was discharged the next day. At follow-up 2 weeks later, he was asymptomatic.

Retropharyngeal abscesses are uncommon in adults; however, they have become more frequent as the number of pediatric cases has decreased because of prompt antibiotic therapy.¹ Common causes of retropharyngeal abscesses include upper respiratory tract infection with suppuration of retropharyngeal lymph nodes and foreign body perforation of the pharynx or esophagus. The abscesses may develop after endoscopy or intubation trauma, pharyngitis, osteomyelitis, petrositis, and dental procedures.² Compression of the larynx and upper trachea may lead to airway obstruction and possibly stridor, although this is more common in children.² Progressive infections can lead to spontaneous perforation, aspiration pneumonia, sepsis, chest empyema, thrombosis of the internal jugular vein, erosion of the carotid artery, and atlantoaxial dislocation.²

In asymptomatic patients, oral antibiotic therapy may be sufficient. In those who have pharyngitis, fever, dysphagia, odynophagia, neck pain, or dyspnea—the most common presenting symptoms—surgery is appropriate.