A transport request has been paged out to transfer a 3-year-old male in an Emergency Room at a nearby hospital. This 3-year-old male was brought in by ambulance to the referring hospital at 8:00 am this morning with complaints of fever, difficulty breathing, sore throat, and a stiff neck.
The mother of this child relates that her son has had an upper respiratory infection for the last week and this morning she noticed that he was drooling. She also states that she noticed that her child’s neck looked “a little “swollen last night, though she cannot recall and incidence of trauma that her son might have experienced recently.
Examination at the referring hospital revealed a well-nourished 3-year-old male sitting in his mother’s lap with his chin elevated and his head tipped to the right side. The child was irritable. No stridor was appreciated and he appeared to be drooling liberally. The child’s neck appeared to be swollen with cervical lymphadenopathy noted on the left side. Respirations were somewhat rapid and moderately shallow in the 28 to 34 range, his temperature was 38.4 axillary and his blood pressure was 80/60 with a heart rate of 108. Oxygen saturation was 97 % on 4 liters of blow-by.
A CBC was drawn as well as a blood culture. The lab findings were nonspecific. The WBC was 8000 per microliter. A chest x-ray and lateral film of the neck were taken with results are pending.
1. What is the top priority with this child, regarding transport to definitive care?
2. What would you expect to see on the lateral neck x-ray?
3. What support measures should the transfer team perform prior to transport?
4. What is the diagnosis? What could be the differential diagnosis?
5. What is the likely causative organism?
6. What antibiotic should you use to treat this disease?
The clinical picture should raise the index of suspicion for child a retropharyngeal abscess (RPA). The story is consistent with a typical presentation for a pediatric case given that there is a history of a upeer respiratory infection (URI) and pharyngitis for approximately one week with associated fever and more recently neck swelling.
The second most common infection route is secondary to penetrating trauma (often forgotten or unknown by the parents of children).
Some studies indicate that patients with RPA often present with:
Sore throat (84%) —Fever (85%) —Neck swelling (16% to 97%) —Decreased appetite (22%)— Voice changes (18%) —Difficulty breathing (8%) neck stiffness and cough (33%)—Agitation (43%).
Stridor is not a good indicator of RPA. One study revealed that in 64 cases only 5% of the subjects had stridor. Equally revealing in this study was that only 16% of these cases had neck swelling.
- Most patients with RPA are febrile, some appear toxic and irritable.
- Cervical lymphadenopathy, usually unilateral, is the most common finding in these patients.
- Many of these patient’s experience decreased or painful motion of the neck.
- A neck mass may be appreciated.
- May present with a muffled voice.
- Many patients prefer to sit, leaning forward with their head in the “sniffing” position. Many have some stridor with suprasternal retractions.
Laboratory results are often inconclusive and nonspecific. Studies have indicated that WBC counts can be elevated, with a mean level of 17,000 per microliter (ranging 4000 to 45,000 per microliter).
WBC counts in 18% of the patients in one study were less than 8000 per microliter: thus a normal WBC does not rule out the diagnosis of RPA.
X-rayswill likely reveal a widening of the retropharyngeal soft tissues (present in 88% of the cases studied). In general, most studies define swelling more than 7mm at C-2 and more than 22mm at C-6.
Imprecise but widely accepted in pediatrics, is the guide that the anteroposterior diameter of the prevertebral soft tissue space should not exceed less than one half that of the corresponding vertebral body.
Chest x-ray should be performed to rule out FB, pneumonia, mediastinal mass.
Differential Diagnoses include epiglottitis, dental infections, esophagitis, foreign body in esophagus or trachea, mediastinitis, mononucleosis, otitis media, croup, meningitis, peritonsillar abscess, sinusitis, torticollis, toxic ingestion, tumor or aneurysm.
Causative organisms: often polymicrobial with gram-positive and anaerobes predominating. Source is usually oropharyngeal flora.
- Most common: Beta-hemolytic streptococci and Staphylococcus aureus.
- Anaerobic organisms: Bacteroides and Veillonella
- Gram Negative organisms: Haemophilus parainfluenzae
Airway:
Securing an airway may be required if the patient with RPA has impending upper airway obstruction. Intubation may be attempted but may be extremely difficult. Extreme caution must be used when providing any sedation or neuromuscular blocking agents (NMBA) to these patients as relaxation of surrounding musculature can cause a complete airway obstruction.
Initial therapy depends upon the severity of the airway compromise. If severe, secure the airway (surgical intervention may be required) and proceed to emergent surgical drainage. If the airway is stable, the patient may be started on a trial of antibiotics with the need for surgical drainage dismissed or delayed.
Prophylactic intubation for a patient with RPA but without respiratory distress should not be considered. If inter-hospital transfer is planned and there are concerns for airway patency, strong consideration should be given to securing the airway in an operating room under general anesthesia. Apply supplemental oxygen, monitor saturations and place child in the sniffing position. It is reasonable to consider transporting the parent along with the child for comfort and control (both the airway and the child).
Intravenous Therapy:
IV fluids are required for dehydration due to difficulty swallowing and fever.
ANTIBIOTICS: Broad spectrum coverage is indicated.
- Clindamycin (first line treatment): 15 mg/kg dose (max single dose 900mg) every 8 hours intravenously -OR- Ampicillin-sulbactam: 50mg/kg dose every 6 hours intravenously.
- If no response to initial treatment with the empiric regimens noted previously, the patient should be started on Vancomycin: 40 to 60mg/kg/day divided into three or four doses. Maximum daily dose 2 to 4 grams.
Overall:
Protect the airway, initiate antibiotics, immediate consult with ENT, and transfer to definitive care. Prognosis is generally good if RPA is identified early, managed aggressively and complications do not occur (40% – 50% mortality in patients with serious complications).
References:
Craig, F. W., & Schunk, J. E. (2003). Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics, 111(6), 1394-1398.
Knorr, T. L., & Sinha, V. (2017). Abscess, Retropharyngeal. In StatPearls [Internet]. StatPearls Publishing.
Retropharyngeal Abscesses. (n.d.). Retrieved April 17, 2019, from https://pedclerk.bsd.uchicago.edu/page/retropharyngeal-abscesses
Wald, E. R. (2014). Retropharyngeal infections in children. UpToDate http://www. uptodate. com/contents/retro pharyngeal-infections-in-children.