Retropharyngeal abscess in a six-week-old child: an approach to management
A six-week-old thriving, full term male presented to a peripheral emergency department (ED) with a left anterolateral neck swelling. This was associated with overlying erythema and he was febrile at 38.1°. The parents of the child did not wait for the child to be seen but returned the following day for review. The erythema and swelling had increased and a palpable mass in the left neck with associated cervical lymphadenopathy was present. On initial blood investigations, he had a white cell count (WCC) of 16.6 and a C-reactive protein (CRP) of 69.2. He was admitted and commenced on IV flucloxacillin and cefotaxime. Ultrasound of the neck demonstrated a 3 × 2.7 × 2.1 cm lobulated lesion consistent with an abscess. His antibiotics were subsequently changed from flucloxacillin to vancomycin and arrangements were made to transfer the patient to a tertiary paediatric centre.\nOn arrival, the child had mild stertor but no increased work of breathing. He was saturating at 100% on room air. On examination, a large palpable suprahyoid left neck swelling anterior to the sternocleidomastoid muscle was present with overlying erythema. He had mild trismus and torticollis to the left. There was anterior displacement of the posterior and left lateral pharyngeal wall present on transoral examination. Repeat WCC was 8.6 and CRP was 72. A CT was performed that demonstrated a large RPA with inflammatory and phlegmonous changes into the left parapharyngeal space predominantly and extending inferiorly to the level of the C5 vertebra (). An opinion was sought from the otolaryngology department and theatre was booked to secure the airway and drain the abscess.\nA gaseous induction and a 3.0 oral endotracheal tube were used to secure the airway. A Lindholm laryngoscope was used to visualize the posterior oropharynx and needle aspiration utilizing a spinal needle was performed to confirm the presence of a collection. One millilitre of 1:100,000 xylocaine with adrenalin was used to infiltrate the posterior pharyngeal wall and a 2 cm vertical paramedian incision was made. Blunt dissection into the cavity combined with pressure to the left neck expressed approximately 6–7 ml of pus. Swabs were taken and sent for microscopy, culture and sensitivity. The wound was washed out with hydrogen peroxide and normal saline. A Penrose drain was inserted transorally into the cavity and secured with a 4.0 silk suture to the posterior pharyngeal wall adjacent to the incision.\nPost-operatively, the patient was admitted into the paediatric intensive care unit (ICU) and was continued on IV vancomycin, cefotaxime and metronidazole. The patient remained intubated, while the swelling resolved and was fed via nasogastric tube. The Penrose drain was removed on day 2 post-op in ICU and the child was extubated on day 3. Staphylococcus aureus sensitive to cephalothin, clindamycin and fluxloxacillin was cultured. IV vancomycin and cefotaxime was continued for five days with oral flucloxacillin for a further five days. Feeds were commenced as normal on day 5. He was transferred back to the peripheral hospital the following day without further complication.