Dr. Women and Children's Hospital of Buffalo, United States
Introduction: The incidence of retropharyngeal abscess (RPA) in children may be increasing. While many cases are noted in patients between the ages of 3 and 5 years, no demographic is spared. Signs of toxicity and upper airway obstruction are typical; however, more indolent or atypical presentations are not uncommon. Importantly, the retropharyngeal space affords ample opportunity for extension into the mediastinum if left untreated. We present a case of RPA with such extension, noted incidentally on neuroimaging following cardiac arrest in a 9-month-old male.
Description: A 9-month-old male was admitted to our PICU following bradycardic arrest during endotracheal intubation at an outside hospital. Previously healthy, he had been evaluated several times in the weeks prior for worsening respiratory distress. On the date of presentation, the patient exhibited significant accessory muscle use and tachypnea in the outlying emergency department, prompting endotracheal intubation. Securing the airway necessitated numerous attempts and the patient experienced two distinct episodes of hypoxemic, bradycardic arrest requiring chest compressions and emergency medication. On arrival to our ICU, he had no vasoactive needs and minimal ventilator support. Blood cultures remained negative. Routine, post-arrest EEG and MRI brain were obtained; the latter suggestive of RPA. Follow-up imaging demonstrated a 3x3x7cm abscess extending into the mediastinum, displacing the trachea and esophagus. Operative drainage procured roughly 500mL of purulent material, ultimately speciating as Klebsiella oxytoca and Staphylococcus aureus. The patient was subsequently extubated without incident or sequela.
Discussion: While typical signs and symptoms of RPA (e.g., drooling, significant distress) enable maintenance of a high index of suspicion in target demographics, providers must be mindful of more indolent presentations. This may be especially prudent in cases of repeated evaluations for respiratory compromise or unexpected difficulties with advanced airway management. Children can harbor substantial pathogenic burden without overt systemic toxicity - as evidenced by this patient – making the diagnosis all the more essential.
