Retropharyngea l Abscess

Cervical fascia

Superficial

Deep
Middle Deep

Superficial

Muscular division Visceral division

Alar layer
Prevertebral layer

Cervical Fascia - Anatomy

Retropharyngeal Space
Retropharyngeal space is a deep neck space

extending along its entire length situated posterior to the pharynx and the oesophagus and anterior to the alar layer of deep cervical fascia
It extends from the skull base to T4 i.e. the level

of bifurcation of the trachea

Synonyms : Posterior visceral space ; space of

Gillette; Lincolns Highway ; Retroesophageal space

Retropharyngeal Space and other spaces in relation to pharynx

Boundaries and Contents

Anterior : Buccopharyngeal Fascia Posterior : Alar Fascia Lateral : Parapharyngeal Space

Medial : A fibrous raphe which divides it into 2

spaces Superior : Base of the skull Inferior : Extends upto the superior mediastinum till the level of bifurcation of the trachea Each lateral space contains retropharyngeal lymph

Spaces related to retropharyngeal space

Prevertebral Space Between vertebrae on one side

and prevertebral muscles and fascia on the other

Parapharyngeal space Between buccopharyngeal

fascia covering lateral aspect of the pharynx medially and fascia covering pterygoid muscles, mandible and parotid gland laterally
Danger space Between prevertebral fascia and alar

fascia

Retropharyngeal Abscess
Retropharyngeal abscess (RPA) is a collection of pus in the tissues in the back of the throat behind the posterior pharyngeal wall (the retropharyngeal space) Types: Acute Retropharyngeal Abscess Chronic Retropharyngeal Abscess

Acute Retropharyngeal Abscess

Aetiology
Children Below 3 years of age - Suppuration of retropharyngeal lymph nodes secondary to infection of the Adenoids Nasopharynx Posterior nasal sinuses Nasal cavity Adults Penetrating injury of posterior pharyngeal wall or cervical oesophagus Pus from acute mastoiditis tracks along the undersurface of petrous bone to present as retropharyngeal

Symptoms
Dysphagia and difficulty in breathing

due to obstruction of the air and food passages

Stridor and croupy cough
Torticollis stiff neck and extended

head
Bulge in the posterior pharyngeal

wall usually seen on one side of the midline

Signs
Systemic Fever Toxic look of the child Local Paramedian bulge in the posterior pharyngeal wall Grossly inflamed mucosa Dribbling and pooling of saliva Larynx and trachea pushed forwards Trismus is often absent

Differential Diagnosis
Croup- Breathing difficulty and a "barking" cough

common in infants and children due to

swelling around the vocal cords
Acute epiglottitis Peritonsillar Abscess Eosinophilic granuloma of cervical spine

Investigations
1)Lateral neck radiographs
Widening of the prevertebral

shadow Displacement of larynx and trachea forwards Straightening of cervical spine due to prevertebral muscle spasm Air shadow in prevertebral space with or without fluid level 2) CT Scan or MRI

Treatment
1) Hospitalisation 2) I.V. fluids and antibiotics 3) Incision and drainage of the abscess Usually done without anaesthesia due to risk of rupture of abscess during intubation/difficulty due to displaced or inflamed larynx/ posterior pharyngeal bulge/ non compliant patient

Treatment

Child is kept supine with head low. Mouth is opened with a gag A vertical incision is given in the most fluctuant area of the abscess. Suction should always be available to prevent aspiration of pus.

4) Tracheostomy Indicated when a large abscess causes mechanical obstruction to the airway or leads to laryngeal oedema leading to stridor

Complications

Meningitis Haemorrhage Laryngeal spasm Bronchial erosion Septicaemia Metastatic abscess Jugular vein thrombosis

Rupture with aspiration

pneumonia Pericardial tamponade Mediastinitis Acute hemiplegia of childhood Spread into other spaces

Chronic Retropharyngeal Abscess

Aetiology
Being tubercular in nature, it is a result of
Caries of the cervical spine presents centrally

behind the prevertebral fascia

Tuberculous infection of the retropharyngeal

lymph nodes secondary to tuberculosis of deep cervical nodes limited to one side of the midline as in true retropharyngeal abscess behind the buccopharyngeal fascia

Symptoms
Discomfort in the throat Dysphagia (though present is not marked) Fluctuant swelling centrally or on one side of the

midline of the posterior pharyngeal wall

Systemic features of tuberculosis may or may not

be present
Cervical pain may radiate to the upper limbs

with/without neurological deficits

Investigations and Signs

Plain radiograph, CT scan or MRI of cervical spine show Caries of the spine with collapse of the body of vertebrae Prevertebral widening may be seen Median bulge on the posterior pharyngeal wall Signs of cervical spine or lymph node tuberculosis and neurological radiculopathies may be present No signs of acute inflammation

Treatment
Incision and drainage of the abscess

It can be done through a vertical incision along the anterior border of sternocleidomastoid (for low abscess) or along its posterior border (for high abscess)
Full course of anti- tubercular therapy to be given

Complications
Pus from various spaces can extend caudally Danger space : extends from base of the skull to the diaphragm and lies between prevertebral fascia and alar fascia Prevertebral Space : extends from the base of the skull to the coccyx and lies between vertebrae on one side and prevertebral muscles and fascia on the other

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