Volume 4, Issue 2 , Pages 92-95, March 2009
Minimally invasive drainage of a giant retropharyngeal abscess
Article Outline
Summary
Objective: To report a case of a 17-month-old female presenting with a giant retropharyngeal abscess and to outline the minimally invasive technique that was used to drain it. Design: Case study. Results: A previously healthy 17-month-old female was found by contrast-enhanced computed tomography (CECT) to have a retropharyngeal abscess (RPA) which extended from the level of the nasopharynx to the level of the aortic arch. The RPA measured 4.5
cm transversely, 2.7cm antero-posteriorly and 8.0cm cephalocaudally. After orotracheal intubation, transoral incision and drainage of the abscess was performed. Based on the CECT findings, the baby Yankauer suction was advanced 6cm beyond the oropharyngeal incision (within the retropharynx) to break the distal septae and completely drain the RPA with a minimally invasive technique. Discussion: Our case describes the management of the largest RPA in the medical literature. We present the first report of the use of a baby Yankauer suction advanced through the oropharyngeal incision to drain intrathoracic RPA loculations.
Keywords: Airway obstruction, Suppurative infection, Pediatric
1. Case history and management
A previously healthy, 17-month-old female, presented to her community hospital with fever, nuchal rigidity and nausea. She was admitted to the local hospital and treated with intravenous penicillin for one day. Her symptoms improved and she was discharged home. However, over the next sixteen days, she developed progressive snoring, then low-pitched, biphasic stridor and drooling. A lateral X-ray suggested a massive RPA and considerable C-Spine kyphosis (Fig. 1). P Contrast enhanced CT (CECT) without sedation revealed that the RPA originated from a right node of Rouvier, crossed the midline at the level of the oropharynx and extended to the level of the aortic arch. The RPA measured 4.5cm transversely, 2.7cm antero-posteriorly and 8.0cm cephalocaudally. It bulged anteriorly in the midline suggesting destruction of the midline raphe that usually bisects the retropharyngeal space. The RPA displaced the trachea and esophagus anteriorly and the great vessels laterally (Fig. 2, Fig. 3).
Fig. 1.
Lateral neck X-ray revealed a massive prevertebral swelling which caused cervical spine kyphosis.
Fig. 2.
Axial CECT sections displaying the RPA originating from a right node of Rouvier (a) crossing the midline at the level of the oropharynx (b) and extending to the level of the aortic arch (c–g). These sections also show anterior displacement of the trachea and esophagus and lateral displacement of the great vessels.
Fig. 3.
(a and b) Coronal CECT sections show lateral displacement of the great vessels. The inferior septation that was found in the OR can be appreciated (b).
The patient was intubated orotracheally at her community hospital. Intubation was reportedly moderately difficult secondary to anterior displacement of her larynx. Intubation was achieved with cricoid pressure and “hockey stick” technique. The patient was afebrile but her heart rate was 140/min and white blood cell count was 28000/ml. Intravenous Clindamycin and Ceftriaxone were started and she was transported to BCCH by helicopter. She was brought to the OR for incision and drainage (I&D).
1.1. Details of operation
The patient was placed in the Trendelenberg position to help prevent potential aspiration of pus. There was no leak around the 4.5 cuffless standard endotracheal tube (ETT). A Jennings mouth gag was slid over the ETT tube, and slowly opened, then the tongue was carefully retracted. A large pale swelling of the right posterior oropharyngeal wall was noted. A 0.5cm incision was made and copious pus under pressure was released and aspirated. The pus was collected for Culture and Sensitivity (C&S). The baby Yankauer suction was first advanced across the midline to break abscess septae, then it was advanced 4cm distally to break distal septae. Resistance was felt when the baby Yankauer suction had been advanced about 4cm beyond the oropharyngeal incision. The CT suggested that the RPA extended further than this distance. Therefore, the baby Yankauer suction was pushed 2cm further distally and another loculation of pus was entered allowing further drainage of pus. Finally, the baby Yankauer suction was withdrawn, rotated 180° and advanced into right superior retropharynx to aspirate more pus. A total of 80cm3 of pus was drained. A red rubber catheter was then inserted into the abscess cavity to irrigate it with Bacitracin solution. The cavity was then re-aspirated until dry. The estimated blood loss was 15cm3.
1.2. Postoperative course
A postoperative Chest X-ray (CXR) showed no pneumomediastinum. On postoperative day 1 (POD #1), the patient was febrile and the Gram stain revealed some Gram negative rods. Consequently the antibiotics were changed to Cefotaxime, Metronidazole and Cloxacillin. Clindamycin was discontinued. On POD # 2, the patient continued to be febrile and became mildly septic. A repeat CT was performed and showed no residual abscess collection. Later that day, the patient improved and was electively extubated. On POD # 4, the patient was eating well. Blood cultures and sensitivity were negative. Orthopedic assessment of the C-Spine was normal. On POD #7, a peripherally inserted central venous catheter (PICC) was inserted and the patient was transferred to a local hospital to complete two weeks of Cefotaxime, Flagyl and Cloxacillin. She recovered with no sequelae.
2. Discussion
If not diagnosed and managed promptly, RPA can lead to serious complications such as: airway obstruction, extension to adjacent structures (potentially leading to mediastinitis, laryngeal nerve palsy, jugular vein thrombosis, carotid artery stenosis, atlanto-axial subluxation, cervical osteomyelitis and/or prevertebral abscess [1]) and sepsis [2]. Fortunately, despite the size of her RPA, our patient had none of these complications. RPA has traditionally been managed with intravenous antibiotics plus or minus incision and drainage. If the RPA has extended into the parapharyngeal space or lateral to the great vessels then transoral incision and drainage (I&D) is required. Clindamycin is considered the first line option, while third-generation Cephalosporins are used in cases of Clindamycin resistance or for smaller RPA. Surgical management is required if there is airway compromise or a lack of response to IV antibiotics [3]. Besides standard I&D, multiple options have been proposed to drain various neck abscesses. Karkos et al. used a modified angled needle to perform transoral drainage of a parapharyngeal abscess that measured 2cm×3cm on CT [4]. This approach would not have been effective in our case because of the size and distal loculations of the RPA. Yeow et al. drained a RPA that measured 2cm×4cm×7cm by CT using pigtail catheter placed with ultrasound guidance [5]. Their approach also required that the catheter be left in place in order to allow significant further abscess drainage. This would not be possible for transoral RPA drainage. Furthermore, the use of a Baby Yankauer suction to completely drain the abscess allowed also us to irrigate the abscess cavity with topical antibiotics.
In our case, the abscess was significantly larger than any previously described RPAs. It necessitated urgent surgical intervention to avoid airway compromise and/or rupture. The baby Yankauer suction facilitated a complete but minimally invasive I&D. The suction was advanced to break all the abscess septae based precisely on the CECT findings.
In all cases of transoral I&D, it is important to use the following measures in order to avoid pulmonary aspiration of pus:
3. Conclusion
This is the largest RPA reported in the medical literature. Premature rupture and pulmonary aspiration of pus was avoided with careful instrumentation. Use of a Baby Yankauer suction based precisely on the CECT findings allowed a minimally invasive but complete drainage of the abscess.
References
- . Retropharyngeal abscess in children. ANZ Journal of Surgery. 2002;72:417–420
- . Retropharyngeal abscess. Pediatrics in Review. 2006;27:e45–e46
- . Surgical management of retropharyngeal space infections in children. Laryngoscope. 2001;111:1413–1422
- . Drainage of parapharyngeal abscess with modified needle. International Journal of Pediatric Otorhinolaryngology Extra. 2007;2:14–16
- . US-guided percutaneous catheter drainage of a deep retropharyngeal abscess. Journal of Vascular and Interventional Radiology. 1999;10:1365–1369
PII: S1871-4048(08)00057-9
doi:10.1016/j.pedex.2008.08.004
© 2008 Elsevier Ireland Ltd. All rights reserved.
Volume 4, Issue 2 , Pages 92-95, March 2009
