Transoral Incision and Drainage of a Massive Retropharyngeal Abscess Involving the Danger Space

Retropharyngeal (RP) abscesses are uncommon yet serious sequala of pediatric head and neck
infections. The RP space extends from the skull-base to the carina and is located between the
buccopharyngeal fascia, alar fascia, and the carotid sheaths. Immediately deep to this, anterior
to the prevertebral fascia, is the “danger space,” allowing infection to spread into the thorax
and mediastinum. We present the use of a transoral incision, and suction assisted evacuation
for managing a massive RPA with danger space extension.
Our patient, a 19 months-old previously healthy female, presented with 10 days of progressive
congestion, cough, and fever. Evaluation demonstrated a toxic stridorous child. Chest
radiograph demonstrated significant superior mediastinal widening. Subsequent contrasted CT
imaging demonstrated a large, rim-enhancing, RP fluid collection extending from the neck to
the carina with tracheoesophageal compression and mediastinitis. The patient was taken
urgently the OR for drainage. Following bronchoscopy and intubation, a mouth gag was used to
expose the RP. Parasagittal incision was made with immediate expression of high volume
purulent material. Hemostat dissection was performed to disrupt loculations and extrinsic neck
compression was used to evacuate the abscess. To access the deepest components, an eight
French tracheal suction catheter was passed to assist with decompression of the mediastinal
components until no further material could be evacuated. Copious irrigation was performed
and the incision was left open. The patient was kept intubated for 48 hours, before uneventful
extubation.

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