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Transoral incision and drainage of retropharyngeal abscess.

Authors: Matthew Kim, Vikash Modi.

This is a demonstration of transoral incision and drainage of retropharyngeal abscess in a 5-year-old male who presented with fever and neck stiffness. An initial CT scan with intravenous contrast showed retropharyngeal edema without organized abscess. A repeat scan 4 days later revealed a peripherally enhancing, multi-loculated hypodense collection centered in the left retropharyngeal space.

After induction of general anesthesia and orotracheal intubation with a 4.5 cuffed oral RAE endotracheal tube, the patient is placed in suspension with a Crowe-Davis mouth gag. The abscess forms a noticeable bulge in the posterior pharyngeal wall. A flexible suction catheter is passed through the right nasal cavity and used to retract the soft palate and uvula to maximize exposure.

After retracting the tonsillar pillars laterally with a Hurd elevator, a Beaver 6400 mini blade is used to make a vertical incision in the pharyngeal mucosa centered over the abscess. There is immediate return of purulence – a culture swab is used to obtain a sample for microbiological testing. A Yankauer suction bluntly enlarges the opening while simultaneously suctioning out purulent debris.

The incision is widened superiorly and inferiorly with curved Metzenbaum scissors. Spreading the instrument vertically minimizes risk of vascular injury. An Adson clamp is then used to bluntly explore the abscess cavity laterally and superiorly. Further purulent drainage is expressed. The abscess cavity is further explored and widened with digital dissection.

The abscess cavity is copiously irrigated with saline. After confirming hemostasis, the patient was extubated uneventfully. He was started on an oral diet immediately after surgery and discharged the following day.

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Well-localized abscesses in the superior retropharyngeal space are amenable to transoral incision and drainage. Abscesses >2cm are more likely to require surgical intervention despite medical therapy (1,2).
Small abscess (<2cm) in otherwise nontoxic patients may resolve with intravenous antibiotics. Large abscess extending inferiorly and those with significant airway obstruction may require tracheotomy to secure airway and percutaneous or transcervical approaches.
General anesthesia with endotracheal intubation in Trendelenburg position to protect airway Crowe-Davis mouth gag (multiple manufacturers) Insulated Hurd tonsil dissector and pillar retractor (multiple manufacturers) 6400 Mini-Blade stainless steel disposable scalpel (Beaver-Visitec) or any other scalpel Yankauer suction (multiple manufacturers) Flexible suction catheter (multiple manufacturers)
Complete blood count (white blood cell count, hemoglobin/hematocrit, platelet count) Preoperative imaging (CT with intravenous contrast, MRI, ultrasound)
N/A
N/A
Mediastinitis Dysphagia Residual/recurrent abscess
No conflicts to disclose.
We thank Mary Jane Yoon for narrating this video.
1. Kosko J, Casey J. Ear Nose Throat J. 2017 Jan;96(1):E12-E15. 2. Cheng J, Elden L. Otolaryngol Head Neck Surg. 2013 Jun;148(6):1037-42.

Review Transoral incision and drainage of retropharyngeal abscess..

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