AUTHOR INFORMATION

Section 1 of 12

Authored by Joseph Kahn, MD, Director of Medical Student Education, Clinical Associate Professor, Department of Emergency Medicine, Boston Medical Center

Joseph Kahn, MD, is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Physicians for Social Responsibility, and Society for Academic Emergency Medicine

Edited by Michael Glick, DMD, Professor and Acting Chair, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center, Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Robert E O'Connor, MD, MPH, Director of Education and Research, Department of Emergency Medicine, Christiana Care Health System; Professor of Emergency Medicine, Thomas Jefferson University

Author's Email:	Joseph Kahn, MD
Editor's Email:	Michael Glick, DMD

eMedicine Journal, October 19 2005, VOLUME 6, Number 10

INTRODUCTION

Section 2 of 12

Background: Retropharyngeal abscess (RPA) occurs much less commonly today than in the past because of the widespread use of antibiotics for suppurative upper respiratory infections. RPA, once almost exclusively a disease of children, is observed with increasing frequency in adults. RPA poses a diagnostic challenge for the emergency physician because of its rare occurrence and variable presentation.

Early recognition and aggressive management of RPA are essential because RPA still carries significant morbidity and mortality.

Pathophysiology: The retropharyngeal space is posterior to the pharynx, bound by the buccopharyngeal fascia anteriorly, the prevertebral fascia posteriorly, and the carotid sheaths laterally. It extends superiorly to the base of the skull and inferiorly to the mediastinum.

Abscesses in this space can be caused by the following organisms:

• Aerobic organisms, such as beta-hemolytic streptococci and Staphylococcus aureus

• Anaerobic organisms, such as species of Bacteroides and Veillonella

• Gram-negative organisms, such as Haemophilus parainfluenzae

The high mortality rate of RPA is owing to its association with airway obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, and erosion into the carotid artery.

Mortality/Morbidity: Once mediastinitis occurs, mortality approaches 50%, even with antibiotic therapy. RPA can also cause internal jugular vein thrombosis, carotid artery erosion, pericarditis, and epidural abscess. In addition to invasion of contiguous structures, RPA can cause sepsis and airway compromise.

Overall mortality was 1% in a recent review of deep cervical space infections in Taiwan.

Race:

• In a 10-year review of RPA cases treated at Kings County Hospital in Brooklyn, NY, 70% of patients were African American, 25% were white, and 5% were Hispanic.

• A recent study of pediatric RPA patients at Wayne State University in Detroit revealed 43% of cases in blacks, 54% in whites, 1% in Hispanics, and 1% biracial.

Sex: RPA is more common in males than in females, with generally reported male preponderance of 53-55%.

• A recent study of children with RPA in Tronto reported 67% of cases in males.

• A recent study of RPA in children in Detroit found 56% of cases in males.

Age: Initially, RPA was thought to be a disease limited to children, but now it is being encountered with increasing frequency in adults.

• A recent review of RPA cases at Hospital for Sick Children in Toronto revealed that 66% of pediatric cases occur in children younger than 6 years.

• A 10-year review at Kings County Hospital in Brooklyn, NY, revealed that 30% of the cases were in pediatric patients aged 16 months to 8 years and 70% were in adults aged 21-64 years.

• A 35-year review of cases involving children who were treated for RPA at Children's Hospital of Los Angeles revealed that 50% of patients were younger than 3 years and 71% were younger than 6 years.

• A recent review or RPA in children in Detroit found a mean age of 4.1 years with a range from 2 months to 18 years.

• A review in Sydney, Australia, found that, in 55% of pediatric RPA cases, the children were younger than 1 year, with 10% diagnosed in the neonatal period.

• A review of RPA cases in children in Albuquerque revealed a median age of 36 months, with 75% of patients younger than 5 years and 16% of patients younger than 1 year.

CLINICAL

Section 3 of 12

History: History is variable, depending on the age group. Symptoms are different for adults, children, and infants.

• Symptoms in adults

• Sore throat

• Fever

• Dysphagia

• Odynophagia

• Neck pain

• Dyspnea

• Symptoms in children older than 1 year

• Sore throat (84%)

• Fever

• Neck stiffness

• Odynophagia

• Cough

• Symptoms in infants

• Fever (85%)

• Neck swelling (97%)

• Poor oral intake (55%)

• Rhinorrhea (55%)

• Lethargy (38%)

• Cough (33%)

Physical: Patients with RPA may present with signs of airway obstruction, but often they do not. Individuals who do not exhibit signs of airway obstruction initially may progress to airway obstruction. The most common presenting signs may be different for adult and pediatric patients.

• Physical signs in adults

• Posterior pharyngeal edema (37%)

• Nuchal rigidity

• Cervical adenopathy

• Fever

• Drooling

• Stridor

• Physical signs in infants and children

• Cervical adenopathy (83%)

• Retropharyngeal bulge (43%; do not palpate in children)

• Fever (86%)

• Stridor (3%)

• Torticollis (18%)

• Neck stiffness (59%)

• Drooling (22%)

• Agitation (43%)

• Neck mass (91%)

• Lethargy (42%)

• Respiratory distress (4%)

• Associated signs including tonsillitis, peritonsillitis, pharyngitis, and otitis media

Causes: RPA develops secondary to lymphatic drainage or contiguous spread of upper respiratory or oral infections. Pharyngeal trauma from endotracheal intubation, endoscopy, foreign body ingestion, and removal may cause a subsequent RPA. Patients who are immunocompromised or chronically ill, such as persons with diabetes, cancer, alcoholism, or AIDS, are at increased risk for RPA.

The most common organisms causing retropharyngeal abscesses include aerobes and anaerobes; gram-negative organisms also may be observed. Often, mixed flora are cultured.

• Organisms causing RPA in adults

• Beta-hemolytic streptococci

• Streptococcus viridans

• S aureus

• Klebsiella pneumoniae

• Bacteroides species

• Staphylococcus epidermidis

• Anaerobic streptococci

• Escherichia coli

• Prevotella species

• Mycobacterium tuberculosis

• Organisms causing RPA in children

• S aureus

• Haemophilus species

• Beta-hemolytic streptococcus (Streptococcus pyogenes)

• Bacteroides species

• Peptostreptococcus species

• Fusobacterium species

• Prevotella species

• Staphylococcus coagulase negative

DIFFERENTIALS

Section 4 of 12

Angioedema
Dental, Infections
Epidural and Subdural Infections
Epiglottitis, Adult
Esophagitis
Foreign Bodies, Gastrointestinal
Foreign Bodies, Trachea
Mediastinitis
Meningitis
Mononucleosis
Otitis Media
Pediatrics, Croup or Laryngotracheobronchitis
Pediatrics, Epiglottitis
Pediatrics, Fever
Pediatrics, Foreign Body Ingestion
Pediatrics, Meningitis and Encephalitis
Pediatrics, Otitis Media
Pediatrics, Pharyngitis
Pediatrics, Pneumonia
Peritonsillar Abscess
Pharyngitis
Pneumonia, Bacterial
Sinusitis
Torticollis
Toxicity, Caustic Ingestions

Other Problems to be Considered:

Airway obstruction

WORKUP

Section 5 of 12

Lab Studies:

• Complete blood count

• The mean white blood cell (WBC) count in 1 study was 17,000, with a range of 3100-45,900.

• WBC counts in 18% of the patients were less than 8000; thus, a normal WBC count does not rule out the diagnosis of RPA.

• Blood cultures are indicated before administration of IV antibiotics, but they may be negative in as many as 82% of RPA cases.

• A culture of pus, aspirated at the time of surgical drainage of the RPA, can grow out one or more organisms 91% of the time.

• C-reactive protein: In one study of adults and children with deep cervical space infections, patients with C-reactive protein greater than 100 had longer hospital stays.

Imaging Studies:

• Lateral neck x-ray

• Widening of the retropharyngeal soft tissues was observed in 88% of patients with RPA in a series that defined soft tissue swelling as more than 7 mm at C2 and more than 14 mm at C6. Most authors define retropharyngeal soft tissue swelling as more than 7 mm at C2 and more than 22 mm at C6; thus, lateral neck x-rays may be considerably less sensitive for detecting RPA than this study indicates.

• Generally, the anteroposterior diameter of the prevertebral soft tissue space in children should not exceed that of the contiguous vertebral bodies.

• In addition to showing widening of the prevertebral space, the lateral neck x-ray film rarely may show a gas-fluid level, gas in the tissues, or a foreign body.

• CT scan of the neck

• A CT scan of the neck with IV contrast is very useful in the diagnosis and management of RPA. RPA appears as a hypodense lesion in the retropharyngeal space with peripheral ring enhancement. Other findings on CT include soft-tissue swelling, obliterated fat planes, and mass effect.

• Obtain a CT scan of the neck with IV contrast when the findings on the lateral neck x-ray are equivocal or if the clinical suspicion for RPA is high in patients with negative lateral neck x-ray findings. Lateral neck x-ray findings may be misleading, especially in young children.

• A CT scan of the neck with IV contrast also may be useful if the x-ray findings are positive because the CT scan can differentiate between retropharyngeal abscess and cellulitis. The CT scan also shows the extent of the RPA and its relation to the great vessels, which is very helpful to the surgeon.

• A chest x-ray is indicated to look for aspiration pneumonia and mediastinitis.

• An MRI with gadolinium enhancement may demonstrate a RPA, but this modality has not been used widely.

• Ultrasonography may demonstrate the presence of an RPA, but its use has not yet been clarified.

Procedures:

• Nasopharyngolaryngoscopy

• A review of the literature did not reveal a role for nasopharyngolaryngoscopy use in the diagnosis of RPA.

• Safety of this procedure in the setting of RPA is unclear.

• Nasopharyngolaryngoscopy has been performed preoperatively in 2 adults; no reports of its use in children exist.

• Endotracheal intubation

• Securing the airway may be required if the patient with RPA is exhibiting signs of impending upper airway obstruction. Endotracheal intubation may be attempted, but it may be difficult because of distortion of the upper airway.

• Prophylactic intubation for a patient with RPA but without respiratory distress generally is not indicated unless an interhospital transfer is planned.

• If a patient with signs of upper airway obstruction cannot be intubated, a surgical or needle cricothyrotomy may be required.

• A tracheostomy may be required as definitive airway management in patients with RPA and respiratory distress.

TREATMENT

Section 6 of 12

Prehospital Care:

• Supplemental oxygen and attention to upper airway patency are the essential components of prehospital care in patients with suspected RPA.

• If a child exhibits respiratory distress, the sniffing position may be beneficial.

• Occasionally, endotracheal intubation or cricothyrotomy may be required if the patient exhibits signs of upper airway obstruction.

Emergency Department Care: ED management of RPA includes attention to the airway, fluid resuscitation if necessary, antibiotic treatment, and preparation for an emergency operation. Frequent vital sign checks and continuous oxygen saturation monitoring are essential.

• Airway management

• Apply supplemental oxygen. In young children, this can be done in a nonthreatening way by letting the parent direct blow-by oxygen at the child's face.

• Endotracheal intubation may be required if the patient has signs of upper airway obstruction. It may be difficult because of upper airway swelling.

• Cricothyrotomy (surgical or needle) may be required in the patient with upper airway obstruction who cannot be intubated. Tracheostomy may be required for definitive airway management.

• Intravenous fluids are required if the patient is dehydrated because of fever and difficulty swallowing.

Consultations: An emergent consultation with an ear, nose, and throat (ENT) specialist is necessary.

• Consult an ENT specialist as soon as the diagnosis of RPA is established or as soon as the diagnosis is suspected if the patient is exhibiting signs of upper airway obstruction.

• If an abscess is present, an ENT specialist can drain it in the operating room.

• An ENT specialist also may perform a tracheostomy.

MEDICATION

Section 7 of 12

The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications. IV broad-spectrum antibiotic coverage is indicated in the treatment of RPA.

Drug Category: Antibiotics -- Gram-positive organisms (including beta-lactamase producing), gram-negative organisms, and anaerobes must be covered. The list of antibiotic regimens in the table below is from The Sanford Guide to Antimicrobial Therapy 2005.

Some recommend the following regimens, which were not mentioned in the Sanford guide: penicillin and oxacillin, second- or third-generation cephalosporin and clindamycin, penicillinase-resistant penicillin combined with either clindamycin or metronidazole, or third-generation cephalosporin in combination with clindamycin, nafcillin, or both (triple therapy).

Drug Name	Clindamycin (Cleocin) -- Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.
Adult Dose	600-900 mg IV q8h
Pediatric Dose	25-40 mg/kg/d IV divided q6-8h
Contraindications	Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
Interactions	Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Drug Name	Penicillin G (Pfizerpen) and metronidazole (Flagyl) -- Second DOC, Penicillin G interferes with the synthesis of cell wall mucopeptide during active multiplication resulting in bactericidal activity against susceptible microorganisms. Metronidazole is active against various anaerobic bacteria and protozoa. Cells of microorganisms that contain nitroreductase absorb metronidazole. Unstable intermediate compounds are then formed that bind DNA and inhibit synthesis, causing cell death.
Adult Dose	Penicillin G 24 million U/d IV by continuous infusion or divided q4-6h, plus metronidazole 1 g IV loading dose, followed by metronidazole 500 mg IV q6h
Pediatric Dose	Penicillin G 25,000 U/kg IV q6h, plus metronidazole 30 mg/kg/d IV divided q8h
Contraindications	Documented hypersensitivity
Interactions	Penicillin G: Probenecid can increase effects; coadministration of tetracyclines can decrease effects Metronidazole: May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Penicillin G: Caution in impaired renal function Metronidazole: Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

Drug Name	Cefoxitin (Mefoxin) -- Considered an alternative therapy. A second-generation cephalosporin indicated for the management of infections caused by susceptible gram-positive cocci and gram-negative rods. Many infections caused by gram-negative bacteria resistant to some cephalosporins and penicillins respond to cefoxitin.
Adult Dose	2 g IV q8h
Pediatric Dose	80-160 mg/kg/d IV divided q6h
Contraindications	Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Interactions	Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis

Drug Name	Ticarcillin and clavulanate (Timentin) -- Alternative treatment that inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive organisms, most gram-negative organisms, and most anaerobes.
Adult Dose	3.1 g IV q6h
Pediatric Dose	100 mg/kg IV q8h
Contraindications	Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage
Interactions	Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Perform CBCs before initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Drug Name	Piperacillin and tazobactam (Zosyn) -- Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits the biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication.
Adult Dose	3.375 g IV q6h or 4.5 g q8h
Pediatric Dose	75 mg/kg IV q6h
Contraindications	Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage
Interactions	Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Perform CBCs before initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Drug Name	Ampicillin and sulbactam (Unasyn) -- Drug combination that utilizes a beta-lactamase inhibitor with ampicillin, which covers skin, enteric flora, and anaerobes but is not ideal for nosocomial pathogens.
Adult Dose	3 g IV/IM q6h
Pediatric Dose	25 mg/kg IV/IM q6h
Contraindications	Documented hypersensitivity
Interactions	Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

FOLLOW-UP

Section 8 of 12

Further Inpatient Care:

• Once the diagnosis of RPA is established, initiate IV antibiotics and admit the patient to the hospital.

• If any signs of respiratory distress are present, admit the patient to the intensive care unit.

• Careful monitoring of airway status is essential and may require intensive care unit admission, even in the absence of respiratory distress in the ED.

• The ENT physician decides whether to incise and drain the abscess in the operating room or whether a trial of medical therapy is indicated first (eg, retropharyngeal cellulitis).

• Incision and drainage of RPA in the ED may lead to aspiration and generally is not recommended.

Transfer:

• Community hospitals without CT scanning or access to an ENT surgeon may need to transfer patients with suspected or known RPA.

• Patients with known or suspected RPA may need to be intubated before transport, depending on their clinical status.

• Intravenous antibiotics may be given prior to transfer but should not delay the transfer.

Deterrence/Prevention:

• Good oral hygiene

• Antibiotic therapy of bacterial oral and pharyngeal infections

Complications:

• Airway obstruction

• Mediastinitis

• Pleural involvement

• Atlantooccipital dislocation

• Epidural abscess

• Sepsis

• Adult respiratory distress syndrome (ARDS)

• Erosion of the second and third cervical vertebrae

• Cranial nerve deficits (cranial nerves IX-XII are contained in the cervical fascia)

• Septic thrombosis of jugular vein or hemorrhage secondary to erosion into carotid artery.

Prognosis:

• Prognosis generally is good if RPA is identified early, managed aggressively, and complications do not occur.

• The mortality rate may be as high as 40-50% in patients in whom serious complications develop.

Patient Education:

• Patients should be brought to the ED immediately if they develop the inability to swallow or have difficulty breathing in conjunction with a sore throat.

• For excellent patient education resources, visit eMedicine's Infections Center. Also, see eMedicine's patient education articles Abscess and Antibiotics.

MISCELLANEOUS

Section 9 of 12

Medical/Legal Pitfalls:

• Diagnosis may be overlooked if patients with RPA are treated for an uncomplicated sore throat and released with or without antibiotics.

• When patients with RPA must be sent to the radiology department, emergency airway equipment and staff experienced with its use should accompany the patient.

• Incising an RPA in a child in the ED may lead to aspiration.

• Intubation may be difficult because of swelling of the upper airway. Involve an ENT physician and an anesthesiologist if time permits. If intubating the patient proves difficult, vigorous bagging with high-flow oxygen may help.

• Patients may need to be intubated before transport, depending on their respiratory status.

TEST QUESTIONS

Section 10 of 12

CME Question 1: Which of the following may be a complication of a retropharyngeal abscess?

A: Airway obstruction
B: Mediastinitis
C: Aspiration pneumonia
D: Sepsis
E: All of the above

The correct answer is E: Many complications of retropharyngeal abscesses may occur, including airway obstruction, mediastinitis, aspiration pneumonia, sepsis, epidural abscess, atlantooccipital dislocation, pleural involvement, acute respiratory distress syndrome (ARDS), erosion of the second and third cervical vertebrae, cranial nerve deficits, septic thrombosis of the jugular vein, and hemorrhage secondary to erosion into the carotid artery.

CME Question 2: A 5-year-old boy presents with a worsening sore throat for 5 days with a temperature of 102° F. He is not in respiratory distress and can swallow with pain. An inflamed bulging pharynx is observed on examination. What is the most appropriate treatment?

A: Attempt incision and drainage of the retropharyngeal space in the ED.
B: Discharge the patient on penicillin and arrange follow-up with an ear, nose, and throat (ENT) specialist the next day.
C: Order a lateral soft tissue neck x-ray and proceed to treat other patients.
D: Notify an ENT specialist and send the patient for a lateral soft tissue neck x-ray accompanied by emergency airway equipment and personnel who know how to use it.
E: Palpate the retropharyngeal bulge to see if it is fluctuant.

The correct answer is D: A child with retropharyngeal abscess (RPA) should not have the pharynx palpated or incised in the ED because of the risk of rupturing the abscess and causing aspiration pneumonia. RPAs cannot be treated on an outpatient basis with antibiotics because of risk of airway obstruction. Children should not be sent for an x-ray unaccompanied because of risk of airway obstruction. The safest course of action is to notify the ENT specialist early and obtain the soft tissue lateral neck x-ray while the child is being observed closely by someone trained in advanced airway management with airway equipment available.

Pearl Question 1 (T/F): Staphylococcus aureus and group A beta-hemolytic streptococci are 2 causes of retropharyngeal abscess (RPA) in children.

The correct answer is True: Staphylococcus aureus, group A beta-hemolytic streptococci, Haemophilus species, Bacteroides species, Peptostreptococcus species, Fusobacterium species, Prevotella species, Pseudomonas aeruginosa, and Staphylococcus coagulase negative are all causes of RPA in children.

Pearl Question 2 (T/F): Beta-hemolytic streptococci, Streptococcus viridans, Staphylococcus aureus, and Klebsiella pneumoniae all may cause retropharyngeal abscess (RPA) in adults.

The correct answer is True: Beta-hemolytic streptococci, anaerobic streptococci, Streptococcus viridans, Staphylococcus aureus, Klebsiella pneumoniae, Staphylococcus epidermidis, Escherichia coli, Mycobacterium tuberculosis, Bacteroides species, Prevotella species, and Pseudomonas aeruginosa are all causes of RPA in adults.

Pearl Question 3 (T/F): A CT scan of the neck with IV contrast can confirm the presence and extent of retropharyngeal abscess (RPA) suspected clinically or on soft tissue lateral neck x-ray.

The correct answer is True: A CT scan of the neck with IV contrast can confirm presence and extent of RPA; an MRI probably would work also, but has not been used widely for this.

Pearl Question 4 (T/F): Penicillin G plus metronidazole, cefoxitin, or clindamycin may be used to treat retropharyngeal abscess (RPA) empirically while cultures are pending.

The correct answer is True: Penicillin G plus metronidazole, cefoxitin, clindamycin, ticarcillin and clavulanate, piperacillin and tazobactam, and ampicillin and sulbactam are all antibiotics that may be used to treat RPA.

PICTURES

Section 11 of 12

Caption: Picture 1. A 5-year-old boy presented to the ED with 2 days of neck pain and fever but with no sore throat. The child had vomited once, and the mother reported that he was irritable. The child's temperature was 101.7° F, pulse was 118 beats per minute, respirations were 24 per minute, and blood pressure was 122/65 mm Hg. A decreased range of motion of the neck and a right anterior cervical node were observed; the child refused to swallow. Lateral neck x-ray findings show increased retropharyngeal space (white arrow). The CT scan did not demonstrate an abscess. The child was seen by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved for 2-3 days and then worsened. Repeat neck CT scan findings demonstrated a retropharyngeal abscess. Incision and drainage was performed in the operating room. Cultures of the pus grew group A beta-hemolytic streptococci and alpha-streptococci, both sensitive to clindamycin. He improved and was discharged on the tenth hospital day on oral clindamycin.
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Caption: Picture 2. An 8-month-old infant boy presented with fever and a stiff neck. According to the mother, the baby was not moving his neck as much as usual. The mother also reported decreased oral intake. His temperature was 100° F, pulse was 104 beats per minute, respirations were 48 per minute, oxygen saturation was 98% (room air [RA]). The left tympanic membrane (TM) was inflamed and nonmobile. Left submandibular and left postauricular nodes were noted. The lateral neck x-ray film shows increased retropharyngeal space. The CT scan demonstrated a small retropharyngeal abscess. The WBC count was 26,000 (24 polymorphonuclear leukocytes [P], 5 bands [B], 63 lymphocytes [L], 8 monocytes [M]). The baby was examined by an ear, nose, and throat specialist; he was admitted and started on IV clindamycin. He improved over the next few days and was discharged on the fifth hospital day on oral clindamycin with plan for repeat CT scans of the neck on an outpatientbasis.
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