After the airway has been stabilized, the patient should receive analgesia and in most cases be prepared for surgery. Retropharyngeal cellulitis and very small localized abscesses may do well with antibiotics alone. All other cases should undergo an incision and drainage procedure. These decisions should be made in consultation with an otolaryngologist.
Most retropharyngeal abscesses are found to contain mixed flora when cultured. Common organisms include S. aureus, S. pyogenes, S. viridans, and beta lactamase-producing gram-negative rods such as Klebsiella. Oral anaerobes such as Peptostreptococcus species, Fusobacterium species, and Bacteroides species are also frequently seen. Antibiotic choice is controversial. Single-agent therapy with ampicillin/sulbactam may be best. Others use clindamycin and/or nafcillin with a third-generation cephalosporin. Some believe that high-dose penicillin G is most appropriate. In patients who are not allergic to penicillin, ampicillin/sulbactam provides the broadest coverage of the potential etiologic agents. Penicillin-allergic patients who are not known to be allergic to cephalosporins may achieve the best results with clindamycin and a third-generation cephalosporin.
Most patients do quite well, but complications do occur. Airway obstruction from sudden rupture of the abscess cavity can be rapidly fatal. Aspiration pneumonia, empyema, and frank asphyxia are described. Abscess extension throughout the neck and even to the psoas may occur. With extension, mediastinitis may develop. Erosion into the carotid artery and internal jugular vein thrombosis has been reported.
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