Central Annals of Otolaryngology and Rhinology

Case Report *Corresponding author

Lo Ren Hui, Department of Otorhinolaryngology, Hospital Ampang, 68000 Selangor, Malaysia, Tel: 60- Retropharyngeal Abscess in Child 123486938; Fax 603-42954666; Email:

– Dilemma in Airway Management Submitted: 13 September 2016 Accepted: 12 October 2016 1 1 1 Lo Ren Hui *, Mazlina Selamat , Zubaidah Hamid , Azreen Zaira Published: 14 October 2016 Abu Bakar1, and Tristan Hilary Thomas2 ISSN: 2379-948X 1Department of Otorhinolaryngology, Hospital Ampang, Malaysia Copyright 2Department of Radiology, Hospital Ampang, Malaysia © 2016 Hui et al. OPEN ACCESS Abstract Keywords Retropharyngeal abscesses in pediatric is becoming increasingly rare with the • Retropharyngeal abscess availability and advancement of broad spectrum antibiotics in recent years. It is a • Airway management life-threatening emergency condition because it can lead to airway compromise and • Pediatric induce other catastrophic complications. We report a child with supraglotitis which was then complicated with an extensive retropharyngeal abscess.

INTRODUCTION narrowed at the supraglottic region at the level of hyoid bone Retropharyngeal abscess is a deep neck space infection that usually affects mostly young children [1]. It is an abscess which (Figure 2). involves space that extends from base of skull to the mediastinum in view of impending airway compromised. Intubation was successfulPatient with was singleplanned attempt for immediate without rupturing incision and the drainage abscess. Intraoral incision was made at the most bulging part of the andat the posteriorly level of first by deepand second cervical thoracic fascia drainingvertebrae, upper anteriorly aero digestivebordered tract.by buccopharyngeal Retropharyngeal fascia, abscess laterally incidence by carotid is declining sheath because of the common use of antibiotic and improvement in posterior pharyngeal wall, and drained about ten milliliters of pus.She Post was operatively kept intubated was uneventful. for three days to secure the airway medical care for which commonly caused by upper respiratory while awaiting the supraglottic edema to subside. The culture Staphylococcus Aureus and Group A Streptococcus completing seven days of intravenous Tazocin and Clindamycin. percentinfection, of the commonly patients are younger than six years of age [4]. did not show any growth. Patient was discharged well after [2,3]. Predominantly male (2:1) with seventy CASE PRESENTATION one week history of upper respiratory tract infection and later developedA fifteen supraglottitis. months old previously She was healthy electively girl presented intubated with and responded well with intravenous Ceftriaxone. She was discharged well after completion of seven days of antibiotic. Unfortunately wastwo days mildly later, tachypnoeic she developed with noisy stable breathing vital signs. and There reduced was oral no obviousintake. Onneck examination, swelling seen there or palpable were audible on inspection stertor andand childneck palpation respectively. Fiber optic examination showed right retropharyngeal bulge extending from the level of nasopharynx to the tip of epiglottis. She was breathing with good oxygen saturation even though the laryngeal inlet could not be visualized at all due to the retropharyngeal bulge.

This is the contrast enhanced CT scan sagittal view of the Immediate CT scan was done, showing a large rim enhancing Figure 1 patient showing extensive retropharyngeal abscess, occluding the multipleretropharyngeal enlarged collection, cervical lymph extending nodes. from The the airway base appearsof skull airway. until C7 vertebral body measuring 2x4.6x5.2cm (Figure 1) with

Cite this article: Hui LR, Selamat M, Hamid Z, Abu Bakar AZ, Thomas TH (2016) Retropharyngeal Abscess in Child – Dilemma in Airway Management. Ann Otolaryngol Rhinol 3(11): 1141. Hui et al. (2016) Email: Central

antibiotic treatment for retropharyngeal abscess might slow down patient’s recovery compare to surgical intervention [4]. Apart from having a greater risk of compromised airway, the abscess might even ruptured spontaneously causing potentially fatal event [4].

the dilemma. Oral intubation may either fail or it may rupture the In abscess this patient, causing securing aspiration an airway to the beforelung as surgery the airway was in is likely to be distorted with edema and laryngeal displacement [11]. Tracheostomy in pediatric under gas inhalation or local anesthesia is not a worthy option to be considered, furthermore with the probable associate complication and post operative care. Hence, a good communication with an anesthetist is important for the patient’s best outcome which varies from patient to patient. The child was able to lie down supine without any sign of airway obstruction or respiratory depression overnight. Therefore, a trial of oral intubation by the anesthetic team in operation theatre was decided with otorhinolaryngology team Figure 2 CT scan axial view of the neck at the hyoid level showing the abscess with rim enhancement. tracheostomy for acute airway obstruction. The patient was inducedstand by as with anticipating inhalational difficult gas airway without and muscle potential relaxant emergency and DISCUSSION allowed for spontaneous breathing. Good tidal volume and chest Retropharyngeal abscess is a potentially life threatening expansion was observed. Lower head down position was ordered deep neck abscess disease. The initial presenting symptoms, to prevent any pus aspiration into the larynx in case the abscess is ruptured during manipulation of intubation [11]. Finally, the pain (38%), fever (17%), sore throat (17%) and poor oral intake child was successfully intubated with a single attempt without especially in children are usually nonspecific. It includes neck with stridor [5]. The number of reported cases is increasing in the abscess was uneventful. [5]. Only five percent retropharyngeal abscess patient presented any difficulty and morbidity. Intraoral incision and drainage of various centres [6]. This rise is probably due to early detection of CONCLUSIONS the disease because of improved access to investigation tools [7]. Most of the cases can easily being unnoticed and worsened due Management of retropharyngeal abscess in children is to high variation of presentation of the disease. Therefore, high challenging, especially when planning to secure the airway suspicious of the possible retropharyngeal abscess should always preoperatively. Thus, early detection of the disease with a good be ruled out in any of the patients with the above presenting collaboration from a multidiscipline department is essential in symptoms. preventing any morbidity or mortality from a life threatening acute upper airway disease. The most likely cause of the abscess in this patient is probably supraglotitis complicated with retropharygeal suppurative ACKNOWLEDGEMENTS The manuscript was accepted as a poster presentation are more likely to develop infections in this area because of the presencelymphadenitis. of lymph It hasnodes been that postulated run in a paramedian that younger chain children in the withat: 36th two Annual international General Meeting ENT meetings, of The Malaysian the 8th SocietyMalaysian of years [7]. Otorhinolaryngologists, Head and Neck Surgeons in conjuctionth retropharyngeal space and will spontaneously regress after five Asian CT scan is considered to be the imaging of choice in diagnosing Internationalon 26th to 28th CongressMay 2016. on Otorhinolaryngology and 18 Research Symptosium in Rhinology in Kuala Lumpur, Malaysia interventionretropharyngeal is recommended abscess. It is in highly patients sensitive who has in positive diagnosing CT REFERENCES an abscess (92%) even though it is not specific [8]. Surgical 1. view of the abscess collection has already worsened as shown scan finding. In this patient, surgical drainage was indicated in Jain S, Kumar S, Kumar N, Puttewar MP, Nagpure PS. Deep-neck space in the CT scan and might soon compromise the upper airway infections – a diagnostic dilemma. Indian J Otolaryngol Head Neck completely due to inability to see a normal laryngeal inlet during 2. Surg. 2008; 60: 349-352. Al-Sabah B, Bin Salleen H, Hagr A, Choi-Rosen J, Manoukian JJ, Tewfik an awakeTreating fibreoptic a retropharyngeal nasopharyngolaryngo abscess, especially scope. in children is TL. Retropharyngeal Abscess in Children:10-year study . J Otolaryngol. challenging. Mortality was reported as high as 6.7 to 15 percent 3. 2004; 33: 352-355. of paediatric retropharyngeal abscess our experience. Journal of in younger age group before the wide usage of broad spectrum Singh R, Guptha R, Jain A, Vajifdar H. Anaesthesia management with intravenous antibiotic alone [10]. However, sole intravenous 4. Anaesthesia and Clinical Pharmacology. 2008; 24: 57-60. antibiotic [9]. In early abscess, some patient may respond well Kirse DJ, Robserson DW. Surgical management of retropharyngeal Ann Otolaryngol Rhinol 3(11): 1141 (2016) B/1 Hui et al. (2016) Email: Central

8. 8.

5. space infections in children. Laryngoscope. 2001; 111: 1413-1422. Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngology-Head and Neck Craig FW, Schunk JE. Retropharyngeal Abscess in Children: Clinical 9. Surg.9. 2008; 138: 300-306. Presentation, utility of Imaging, and Current Management. Pediatrics 1130. 6. 2003; 111: 1394-1398. Richards L. Retropharyngeal absces. N Engl J Med. 1936; 215: 1120- 10. Wong DK, Brown C, Mills N, Spielmann P, Neeff M. To drain or not to treatment of deep neck space infections appropriate. Head Neck. drain - Management of pediatric deep neck abscesses: A case-control Plaza Mayor G, Martínez-San Millán J, Martínez-Vidal A. Is Conservative 7. study. Int J Pediatr Otorhinolaryngol. 2012; 76: 1810-1813. 11. 2001; 23: 126-133. Grisaru-Soen G, Komisar O, Aizenstein O, Soudack M, Schwartz D, Paret G. Retropharyngeal and parapharyngeal abscess in children Manjula Sudhakar Rao, YK Linga Raju, PN Vishwanathan. Anesthetic – Epidermiology, clinical features and treatment. Int J Pediatr management of difficult airway due to retropharyngeal abscess. Otorhinolaryngol. 2010; 74: 1016-1020. Indian J Anaesth. 2010; 54: 246-248.

Cite this article Hui LR, Selamat M, Hamid Z, Abu Bakar AZ, Thomas TH (2016) Retropharyngeal Abscess in Child – Dilemma in Airway Management. Ann Otolaryngol Rhinol 3(11): 1141.

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