What's the Diagnosis? By Dr. Lesley Walinchus-Foster

A 17 month old male with no past medical history presents to the ED with fever, L sided neck swelling, decreased PO intake and drooling x 1 day.  His immunizations are UTD. A CT scan is obtained. What's the diagnosis? (scroll down for answer) 




Answer: Retropharyngeal Abscess

  • Causes:
    • Suppuration of surrounding lymph nodes
    • Localized penetrating trauma
    • Instrumentation
    • Ventral extension of vertebral osteomyelitis
  • Signs and symptoms
    • Neck pain/swelling
    • Fever
    • Dysphagia
    • Excessive drooling
    • Neck stiffness/torticollis/neck held in hyperextension
  • Diagnosis:
    • Radiograph findings: Retropharyngeal space at C2 = twice diameter of vertebral body  OR  Retropharyngeal space > 1/2 width of C4 vertebral body
    • CT: limited ability to differentiate abscess vs. cellulitis/phlegmon
  • Treatment: 
    • Monitor airway; stabilize if needed prior to interventions
    • Minimize exams/noxious stimuli 
    • Small abscesses may be managed with antibiotics alone if patient stable; larger/unstable may require surgical intervention
    • Common organisms: S. arueus, S. pyogenes, Streptococcus viridans, Beta-lactamase producing gram-negative rods
    • Antibiotics: IV clindamycin or ampicillin/sulbactam



Mapelli E, Sabhaney V. Stridor and Drooling in Infants and Children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016