Signs and Symptoms

The symptoms most commonly found in patients with retropharyngeal abscess are, individually, not specific for this disease, but, taken together, they point toward the correct diagnosis. Although the symptoms are not commonly recognized in preverbal children, older children will complain of sore throat and most have a history of high fever. Other symptoms include dysphagia, decreased oral intake, and stiff neck.

In general, children with retropharyngeal abscess appear quite ill. Signs of retropharyngeal abscess include muffled voice, persistently hyperextended neck, inspiratory stridor, meningismus, and, if partial airway obstruction is present, respiratory distress and tachypnea. Ipsilateral cervical adenopathy has also been described but is not specific. Often a unilateral or bilateral retropharyngeal mass can be visualized during examination of the oropharynx. Unilateral masses are typically easier to detect than bilateral ones. Although palpation will commonly demonstrate fluctuance, this practice is dangerous and unnecessary. Laboratory testing is neither sensitive nor specific for retropharyngeal abscess.

Classic teaching is that a lateral neck radiograph should be obtained when one suspects this infection. This radiograph should be taken during inspiration with the neck extended so as to limit false-positive results. Diagnostic criteria for this radiograph are controversial ( Fig 129-7). Most would agree that the normal prevertebral soft tissue should be no wider at the second cervical vertebra than the diameter of the vertebral body at the same level. Radiographs showing slightly wider prevertebral soft tissues at this level without obvious bulging have a low specificity for retropharyngeal abscess. If the criterion for a positive test is considered two times the diameter of the vertebral body at the same level, the sensitivity is about 90 percent, but the specificity still not very good unless air-fluid levels are seen within the retropharyngeal soft tissues.5 Still others have suggested using values of 7-mm prevertebral soft tissue width at C2 and 14-mm prevertebral soft tissue width at C6 as the criteria for the presence of a retropharyngeal abscess. The sensitivity and specificity of these criteria would seem to be quite dependent on the age and position of the patient. Ravindranath et al. found no correlation between the findings on lateral neck radiographs and CT scans in patients who clinically appeared to have a retropharyngeal abscess.34 Therefore, definitive diagnosis should be based on CT scan results whenever possible. CT scan differentiates cellulitis from abscess and helps with surgical planning by demonstrating the degree of extension that has occurred. 5 It can also be used to clarify equivocal x-ray findings. 34 CT's sensitivity for retropharyngeal abscess is thought to be near 100 percent. 5 Unstable patients should be intubated before going to the CT scan suite. A physician accustomed to managing the difficult pediatric airway and appropriate equipment should accompany stable patients.

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