Post on 28-Oct-2014
Retropharyngeal Abscess
Cervical Fascia - Anatomy
Cervical fascia
Superficial Deep
Superficial Deep
Alar layer
Prevertebral layer
Middle
Muscular divisionVisceral division
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; Lincoln’s 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 nodes which disappear at 3-4 years of age. Also contained in this space is loose areolar tissue and fat.
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
Peritonsillar space – Lateral to the tonsil
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 theAdenoidsNasopharynxPosterior nasal sinusesNasal cavity
Adults - Penetrating injury of posterior pharyngeal wall or cervical oesophagusPus from acute mastoiditis tracks along the undersurface of petrous bone to present as retropharyngeal abscess(rare)
SymptomsDysphagia 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
Treatment1) 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
MeningitisHaemorrhageLaryngeal spasmBronchial erosionSepticaemiaMetastatic abscessJugular vein thrombosis
Rupture with aspiration pneumoniaPericardial tamponadeMediastinitisAcute hemiplegia of childhoodSpread 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
SymptomsDiscomfort 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
TreatmentIncision 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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