Retropharyngeal abscess Dr S Parthasarathy MD DA DNB Dip DiabMD DCA Dip software based statistics PhD physiology Retropharyngeal abscess is collection of pus in the retropharyngeal space which extends from base ID: 762522
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Retropharyngeal abscess Dr. S. Parthasarathy MD, DA, DNB, Dip Diab.MD ,DCA, Dip software based statistics, PhD (physiology)
Retropharyngeal abscess is collection of pus in the retropharyngeal space which extends from base of the skull superiorly to the mediastinum inferiorly up to T1 level
Cervical fascia I. Superficial II. Deep Anterior – investing Middle -- pretracheal posterior -- Alar, prevertebral III. Visceral fascia - surrounds the esophagus, trachea and thyroid, ‘ buccopharyngeal fascia
Retopharyngeal space ?? Anterior -the posterior pharyngeal wall Posterior – alar fascia Laterally it is continuous with the parapharyngeal space. Space is divided by a midline septum – with nodes both sidesNodes atrophy in six years Common in kids
Retropharyngeal abscesses occur mostly in children aged 6 months to 6 years with a peak incidence at 3 years of age. It is slightly more common in boys Antibiotics decreased incidence Possible TB is coming up
Causes Classic URTI – lymph nodes – suppurate – RPA Trauma – penetrating injury, fish bones Iatrogenic trauma following laryngoscopy , endotracheal intubation, endoscopy, feeding tube placement and dental injections and procedures
Clinical features H/O URTI, fever , sore throat odynophagia , trismus , drooling Secondary dehydration ( not feeding ) Neck stiffness Muffled “hot potato” voice, stridor Respiratory distress. May be Insidious
On examination To maintain patent airway, patient may have mouth breathing, tongue protrusion or mandibular protrusion. Assess the degree of respiratory distress
Differential diagnosis Acute epiglottitis Foreign body aspiration Pharyngitis Cervical adenitis Meningitis
Confirmation of diagnosis Leucocytosis – nonspecific A lateral neck radiograph inspiration with the neck held in a normal position Space should not exceed adjacent vertebral body.
CT with contrast Size , abscess Vascular MRI – delay USG – diagnose Noninvasive but Surgical
MRI
Endoscopy showing unusual bulge in the throat
Complications – nearby structures airway compromise secondary to mass effect, rupture of the abscess with inhalation of contents leading to aspiration pneumonia – asphyxia spread of infection to adjacent structures in the neck (including carotid sheath), osteomyelitis of the cervical spine mediastinal infection. Necrotizing fasciitis is also a potential serious (and rare) complication
Lemierre s syndrome septicemia, IJV thrombophlebitis , septic emboli due to oropharyngeal infectionsExtra -- Anticoagulants and nutrition care for six weeks
Management Nil oral Airway monitoring IV antibiotics – clav - amoxy / cefuroxime + metrogyl Vancomicin in immune depleted patients Minimum 48 hours of parenteral antibiotics
Most of the abscesses are polymicrobial with predominant organisms being Staphylococcus aureus and group A Streptococcus Adults – HIV, diabetes- may be there tuberculous
Surgery progressive airway obstruction and failure to improve within 24 to 36 hours of antibiotic therapy. intraoral incision or through an external cervical approach.
Intraoral Intraoral aspiration and drainage is recommended under general anaesthesia if the abscess is limited to the upper retropharyngeal space Above hyoid bone Posterior pharyngeal wall –aspirate – pus- incise and dissect
Extraoral ---- SCM muscle – anterior border – below hyoid bone abscess
Anaesthetic implications
Preoperative All equipment ready including all tracheostomy tubes ENT and anaesth personnel Antibiotics, paracetomolIV fluids – RL - rehydrate
Airway pushed in front – can we access ??
Intraoperative Minimum monitoring NIBP, ECG, pulse oximetry , ETCO2 Head down position Glyco Inhalational induction Cuffed ET tube – gentle During induction airway obstruction ?? emergency tracheostomy or a transtracheal cannulation
Awake Fibreoptic intubation – option in certain cases Preop tracheostomy in difficult cases ! Pus intruding into the central compartment Tracheostomy ??
Anaesthesia - maintained with volatile anesthetic plus judicious incremental doses of opioid for analgesia. Muscle relaxants ?? avoided because of the potential for airway obstruction even once intubated Steroids Vasopressors if needed
Distorted airway – can we intubate ?? Rupture of abscess and aspiration of the contents during laryngoscopy and intubation Associated complications of RPA ?? Throat packing ?? !! Don’t rupture ??
DT – foley s
Topical anaesthesia Needle drainage Sepsis settles Anatomy normal – proceed later Local alone in adults
Severity degree of airway obstruction contamination manipulation oedema Post op ventilation
Post operative course closely monitored in the critical care unit for 24 – 48 hours post- extubation . ongoing oxygen, fluid and analgesia requirements. Appropriate antibiotic coverage should be continued for 5 – 7 days or as guided by culture
Summary Space – anatomy Etiology Microbes Clinical features Imaging Surgery when ? GA – spontaneous cuffed ETT Post op ventilation ??
Thank you all