Peritonsillar and retropharyngeal abscesses (PTA and RPA, respectively) are commonly seen in children. The intent of this chapter is to help the clinician establish an accurate diagnosis early and to achieve cure by the judicious and adjunctive use of antibiotics, radiography, and surgery.
The pharyngeal tonsils are paired organs, which serve as the lateral lymphoid guardians at the posterior aspect of the oropharynx. PTA is an infected collection in the potential space surrounding the palatine tonsils. PTA usually presents with a pointing collection at the superior tonsillar pole.1,2 The loose areolar tissue surrounding the tonsils provides a potential space into which infections may spread.
In 1995, Herzon and Hassis estimated that children accounted for approximately one-third of the 45,000 episodes of PTA that occur annually.3 Most children with PTA present in the early teen years.4 While group A beta-hemolytic Streptococcus (GABHS) is the most commonly cultured organism, isolated in approximately one-third of cases,5 it is not the only bacterial pathogen identified. Most PTAs are polymicrobial, with GABHS, Staphylococcus aureus and Haemophilus influenzae accounting for most of the aerobic organisms and Prevotella spp., Porphyromonas spp., Fusobacterium spp., and Peptostreptococcus spp. comprising the common anaerobes.2,4
The retropharyngeal space is a potential space located between the visceral layer of deep cervical fascia anteriorly and the alar division of deep cervical fascia posteriorly.6
Suppuration of lymphoid tissue imbricated between these layers is responsible for retropharyngeal infections. The lateral retropharyngeal nodes traditionally associated with RPA are eponymously referred to as the nodes of Rouviere.7 Infections may spread readily from the oropharynx to mediastinum via this “highway” of the neck. The retropharyngeal nodes regress around the age of 3–5 years.6,8
Consistent with nodal regression by the age of 5 years, most children present before age of 6 years with RPA, with the median age of around 3 years.4,6,9 The prevalence is in general thought to be increasing and was 4.94 cases/10,000 population in the Wayne State experience.8 RPA accounted for approximately 5% of deep neck space infections in Papua, New Guinea.10
Acute upper respiratory infection is the usual antecedent cause of RPA in children, as opposed to adults in whom foreign bodies, trauma, and dental infections are considered etiologic. Microbiology of RPA demonstrates a mixture of aerobic and anaerobic organisms. Common aerobic organisms include alpha- and beta-hemolytic streptococcal species, S. aureus, Neisseria spp., Eikenella spp., and nontypable H. influenzae. Common anaerobes include Bacteroides spp., peptostreptococci, Fusobacterium spp., and Prevotella spp. An increase over the past decade in the prevalence of GABHS has been noted.8 Less common organisms responsible for RPA include Epstein–Barr virus and Mycobacterium tuberculosis.6,11
PTAs typically occur when ...