• Potentially life-threatening infection of the retropharyngeal space
  • Potential space from the base of the skull to the posterior mediastinum
    • Retropharyngeal nodes become infected and develop into an abscess
    • Retropharyngeal nodes more prominent in young children
      • 50% RPA (not due to trauma) occur 6-12 months
      • 96% RPA (not due to trauma) occur <6 years
    • Risk Factors
      • Preceding head and neck infection (otitis, pharyngitis, sinusitis)
      • Penetrating trauma: e.g. from a fall with a foreign body in the mouth (toothbrush)
      • Airway procedures (intubation, dental procedures, NG tube placement)


  • History and physical examination findings are often nonspecific
  • Presents with fever, toxic appearance and respiratory distress
    • Symptom progression is less acute than epiglottitis
    • Fever and neck stiffness may mimic meningitis
  • Considered RPA with a severe sore throat and a normal pharyngeal exam
  • Patients at risk for airway obstruction should be examined in the OR


  • Laboratory evaluation may reveal nonspecific elevation in the white blood cell count and acute phase reactants


  • Lateral neck soft tissue XRAY: Evaluation of prevertebral soft tissue
  • Should be obtained in extension on inspiration: Flexion of the neck, expiration and crying may result in pseudo-enlargement
    • Swelling of the prevertebral space
    • <1/2 adjacent vertebra width C1-4 or C2 ≤7mm
    • <1 adjacent vertebral width C5-8 or C6 ≤14mm (<15 yrs), ≤22mm (>15 yrs)
    • Air or an air fluid level
    • Loss of normal cervical lordosis due to muscle spasm and inflammation
    • Evaluate for epiglottitis and foreign bodies
  • Chest XRAY: Pneumonia/empyema and mediastinitis
  • Neck CT with contrast: Guide need for operative intervention
    • Nature: Cellulitis versus abscess
    • Extent: Proximity to vasculature, lateral spread
    • ID radiolucent foreign body
    • Muscle relaxation due to sedation may precipitate complete airway obstruction
    • Requires airway equipment, personnel trained in advanced airway management


  • Maintain in a position of comfort (e.g. sitting in their parent’s lap)
  • Supportive care: Airway maintenance/monitoring, hydration, analgesia
  • Consider: Dexamethasone, nebulized Epinephrine to reduce swelling


  • Indications: Have not been definitively established
    • Airway compromise
    • Large abscess (>2 cm)
    • Failed initial antibiotic therapy


  • Typically polymicrobial
    • Gram positive: Group A Strep, Staph aureus (MSSA and MRSA)
    • Respiratory anaerobes: Bacteroides, Fusobacterium, Peptostreptococcus
    • Rare: Gram (-), Eikenella corrodens, Bartonella hensalae, Mycobacterium TB
  • No comparative treatment studies
  • Empiric therapy: Group A Strep, Staph aureus, respiratory anaerobes.
    • Adjust base on culture and/or clinical response.
    • Ampicillin/Sulbactam does not cover MRSA.
    • Clindamycin covers MSSA but depending on local resistance does not cover MRSA and some group A Strep.


  • Admit to PICU for airway monitoring if does not go directly to surgery


Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics. 2003 Jun;111(6 Pt 1):1394-8., PMID: 12777558

Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg. 2008 Mar;138(3):300-6., PMID: 18312875