RETROPHARYNGEAL ABSCESS N.pptx

RETROPHARYNGEAL ABSCESS
Retropharyngeal abscess ia an infection of the retropharyngeal space
Retropharyngeal space is a potential space posterior to the pharynx and the cervical oesophagus
Often presents late, most times in airway obstruction
It is life threatening,adequate care and management is needed
Mortality and morbidity often follows delayed or missed diagnosis

1. RETROPHARYNGEAL ABSCESS DR. NZEMEKE, ISIOMA R. R E S I D E NT D O C T OR D E P T O F E N T , L U T H N I G E R IA .

2. OUTLINE INTRODUCTION RELEVANT ANATOMY EPIDEMIOLOGY CLASSIFICATION AETIOPATHOGENESIS CLINICAL FEATURES INVESTIGATIONS DIFFERENTIAL DIAGNOSIS TREATMENT COMPLICATIONS CONCLUSION REFERENCES

3. INTRODUCTION Retropharyngeal abscess ia an infection of the retropharyngeal space Retropharyngeal space is a potential space posterior to the pharynx and the cervical oesophagus Often presents late, most times in airway obstruction It is life threatening,a dequate care and management is needed Mortality and morbidity often follows delayed or missed diagnosis

4. EPIDEMIOLOGY Incidence is commoner in children than adults mostly children 2-5years, following airway infection Higher in males than females No racial predilection Incidence is declining -wide availability of antibiotics -improvement in medical care OGB Nworgu et at (2005) UCH review 30patients within 10yrs M:F - 1:1 Age- 3mths-38yrs (23pxs ˂ 5yrs)

5. RELEVANT ANATOMY Retropharyngeal space lies posterior to the pharynx and cervical oesophagus It extends from the skull base to the level of vertebra T1 -T4, Boundaries: alar fascia, buccopharyngeal fascia,parapharyngeal space, carotid shealth Divided by a midline raphe

6. RELEVANT ANATOMY Contents lypmph; suprahyoid fats LYMPH NODES medial nodes;atrophies lateral nodes node of Rouviere; superior most drains the nasal cavity, paranasal sinuses, soft palate,auditory canal and middle ear

7. CLASSIFICATION ACUTE Commoner in children Causes; upper respiratory infection trauma/foreign body impaction CHRONIC common with tuberculosis of the cervical spine usually spreads from the prevertebral space Insidous in onset Mild symptoms or asymptomatic

8. AETIOPATHOGENESIS Retropharyngeal abscess is polymicrobial; implicatedcated in upper airway infections;rhinosinusitis,adenioditis,tonsilitis Most common is group A beta-hemolytic Streptococcus. Others; Staphylococcus auerus Fusobacterium Haemophilus Also occurs following direct trauma and subsequent innoculation into the retropharyngeal space direct spread of infection from vertebral osteomyelitis or discitis, tuberculosis and fracture of the spine

9. AETIOPATHOGENESIS Following infection; Activation of interleukins Release of inflammatory cells(neutrophils, macrophages,lymphocytes) fever pain oedema celluiltis Phagocytosis, necrosis (liquefaction) Abscess formation In TB spread to lymph nodes spread from tubercular vertebral abscess The risk increases in immunocompromised state ,manultrition, poor socioeconomic status

10. CLINICAL FEATURES Acute Symptoms Fever Nasal discharge cough vomiting Sorethroat odynophagia/refusal to feed dysphagia neck pain and swelling dyspnoea change in voice(muffled, hot potatoe voice)

11. CLINICAL FEATURES Signs ill-looking and toxic pyrexia dyspnoeic drooling torticollis cervical lymphadenopathy In older patients,trauma to the posterior pharyngeal wall resulting in inoculation in the retropharyngeal space Inflammed and lateral bulging of the pharyngeal wall

12. CLINICAL FEATURES Chronic painless lump in the throat dysphagia Cough weight loss anorexia chest pain median bulging of the posterior pharyngeal wall

13. INVESTIGATIONS Specific Plain soft tissue lateral neck radiograph contrast computed tomography scan of the neck Magnetic resonance imaging Acid fast bacillus test/Mantoux test/TB QuantiFEREON test Culture and sensitivity

14. INVESTIGATION Full blood count Leucocytosis/Leucocytopaenia Neutrophilia/neutropaenia Eosinophilia Lymphocytosis Anaemia Erythrocyte sedimentation rate ↑ Serum glucose Retroviral screening Chest xray mediastinitis pneumonia

15. INVESTIGATION Plain soft tissue lateral neck radiograph widening of the prevertebral soft tissue >1/2 and 1/3rd of the corresponding vertebral body in adults and children respectively straightening of the cervical spine and loss of the usual cervical lordosis. pockets of gases Caries and calcifications of the spine

16. INVESTIGATION Computed Tomograpy Scan hypodensed lesion with peripheral/rim enhancement differentiates abscess from cellulitis extent of the abscess and complications

17. DIFFERENTIAL DIAGNOSIS Croup steeple’s sign on xray Acute epiglottitis thumbs up appearance on xray Peritonsillar abscess Parapharyngeal abscess Odontal abscess

18. TREATMENT Multidiscipline; ENT surgeons, Anaesthestist, paediatricians, orthopaedics/spine surgeons, infectious disease control unit/microbiologist Depends on stage at presentation Principles/Aims of Treatment airway management drainage of abscess antimicrobial therapy prevent and manage complications

19. TREATMENT Admit/resuscitation Rehydrate Antibiotics/A ntituberculosis Analgesics Surgical airway management; cricothyrotomy Tracheostomy Surgical drainage

20. TREATMENT Approaches Transoral Transcervical(anterior or posterior) for large abscess chronic abscess significant inferior abscess across fascia planes involving other deep neck spaces

21. TREATMENT Transoral Abscess drainage preop blood workup GXM blood Obtain informed consent Usually done under general anaesthesia via oroendotracheal tube or tracheostomy care must be taken to avoid rupturing the abscess during intubation and should be done by the most ewxperienced anaesthestist

22. TREATMENT Patient is placed in supine position with the neck extended,shoulder roll applied, the head tilted downwards and stabilised Draping Mouth gag is applied Pharynx is packed Antibiotic administer

23. TREATMENT Minimal decompression with needle and syringe Vertical incision is made at the point of most fluctuancy The abscess widely opened with a large clamp, the locu l i broken and the contents suctioned completely. Anaesthesia reversed Endotracheal intubation may be left in place Pus aspirate sent for MCS

24. TREATMENT Post op care Maintain nil per os Airway monitor and control Antibiotics Analgesics Iv fuid Treatment of underlying conditions and oral intake when stable

25. COMPLICATIONS Extension of infection into mediastinum other neck spaces Haemorrhage Spontaneous rupture and aspiration Laryngeal spasm pneumonia Septicemia Reaccumulation of abscess

26. CONCLUSION Retrophryngeal abscess is a life threatening conditions requiring urgent ENT care prognosis is good if it is recognised and treated early Prompt evaluation and care are important in limiting its fetal complications It is also important to manage and possibly avoid the likely causes to minimise the risk of developing retropharyngeal abscess

27. REFERENCE Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery 7th edition Textbook of Ear, Nose, Throat and Head Neck Surgery Clinical and Practical fourth Edition Operative otorhinolaryngology SURGICAL ANATOMY OF THE HEAD AND NECK Introductory Head and Neck Imaging; Eugene Yu MD FRCPC University of Toronto Canada, Lalitha Shankar MD FRCPC University of Toronto Canada

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