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Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 128-130

Deep neck space infection (retropharyngeal and parapharyngeal abscesses) with upper airway obstruction in a 7-day-old neonate

1 Department of Paediatrics, Federal Medical Centre, Katsina, Katsina State, Nigeria
2 Department of Otorhinolaryngology, Federal Medical Centre, Katsina, Katsina State, Nigeria

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Olayinka Rasheed Ibrahim
Department of Paediatrics, Federal Medical Centre, Murtala Mohammed Way (Jibia Bypass), P.M.B 2121, Katsina, Katsina State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.JCN_111_18

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Deep neck space infections (DNSIs) are rare in neonates. When they do occur, the infections are more aggressive than in older children and adults and can lead to life-threatening complications. Thus, a high index of suspicion is important for early diagnosis and prompt treatment. We report a rare case of DNSIs (retropharyngeal and parapharyngeal abscesses) in a 7-day-old neonate. The baby presented with fever, neck swelling, and difficulty in breathing. Plain neck radiograph showed widening of the retropharyngeal space and β-hemolytic Streptococcus was cultured from the aspirate. He was successfully managed with incision and drainage as well as broad-spectrum antibiotics (cefuroxime and metronidazole for 14 days and gentamicin for 7 days).

Keywords: Abscess, neonate, parapharyngeal, retropharyngeal, upper airway obstruction

How to cite this article:
Ibrahim OR, Lugga AS, Suleiman BM, Yohanna J. Deep neck space infection (retropharyngeal and parapharyngeal abscesses) with upper airway obstruction in a 7-day-old neonate. J Clin Neonatol 2019;8:128-30

How to cite this URL:
Ibrahim OR, Lugga AS, Suleiman BM, Yohanna J. Deep neck space infection (retropharyngeal and parapharyngeal abscesses) with upper airway obstruction in a 7-day-old neonate. J Clin Neonatol [serial online] 2019 [cited 2019 Nov 18];8:128-30. Available from: http://www.jcnonweb.com/text.asp?2019/8/2/128/257131

  Introduction Top

Deep neck space infections (DNSIs) occur in potential spaces between the folds of the deep cervical fascia (retropharyngeal, lateral/parapharyngeal, submandibular, peritonsillar, masticular, parotid, prevertebral, and visceral vascular spaces).[1] Of these spaces, the retropharyngeal, peritonsillar, and parapharyngeal spaces are the most commonly infected.[2] Infection accompanied by the collection of pus in these spaces (retropharyngeal, peritonsillar, and parapharyngeal) is termed retropharyngeal abscess (RPA), peritonsillar abscess, and parapharyngeal abscess (PPA) respectively.[2] The most common causes of RPA and PPA are Gram-positive aerobes (Group A β-hemolytic Streptococcus and Staphylococcus aureus).[1],[3] Gram-negative aerobes and anaerobes are less encountered.[1],[3]

Although both RPA and PPA are common among older children, they are less common in infancy and are rare in the neonatal period.[3] When they occur in neonates, early diagnosis and prompt intervention are vital to prevent the potential compromise of airway which could be fatal.[4]

Herewith, we report a rare presentation of deep neck abscesses (RPA and PPA) with upper airway obstruction in a 7-day-old neonate.

  Case History Top

A 7-day-old male neonate presented to the special care baby unit with a fever of 5 days, swelling on the neck of 4 days, and difficulty in breathing of 3 days. The mother first noticed neck swelling as a small boil on the anterior part of the neck that grew rapidly to cover most of the anterior part of the neck. A day before the presentation, he developed progressive difficulty in breathing with associated noisy breathing and extension of the neck. Pregnancy was carried to term, but not supervised. Mother had fever and dysuria about 1 week before delivery. Labor was neither prolonged nor prolonged rupture of membranes, and delivery was at home by spontaneous vertex delivery, supervised by an untrained traditional birth attendant.

Physical examination revealed an acutely ill neonate in severe respiratory distress with retrocollis [Figure 1] and cried inconsolably. He had pyrexia with an axillary temperature of 38.4°C. There was an irregular swelling on the anterior part of the neck, which was more to the right, measured about 8 cm × 8 cm × 5 cm [Figure 1]. The overlying skin was intact, and the swelling was tender, warm, soft, cystic, and fluctuant and did not transilluminate. He had a respiratory rate of 80 breaths per min, with inspiratory stridor, intercostal recessions, and tracheal tugging. Breath sounds were bronchovesicular and peripheral oxygen saturation by pulse oximetry was 90% while breathing room air. Oropharyngeal examination revealed a bulge in the posterior wall of the pharynx. The vocal cords were narrowed and displaced anteriorly. Other systemic examinations findings were unremarkable.
Figure 1: The index patient with anterolateral neck swelling and retrocollis before surgery

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Initial airway management instituted included endotracheal tube insertion, suctioning of the airway, and administration of supplemental oxygen with some improvement in respiratory distress.

Plain radiograph of the neck showed widening of the retropharyngeal space on the lateral view [Figure 2]. Chest radiograph was normal. Complete blood count showed mild anemia (hemoglobin concentration of 11 g/dL) and leukocytosis (total white blood cell count of 18.8 × 109/L) with a predominance of neutrophils (58%). Pus was aspirated from the anterior neck swelling [Figure 3] which revealed numerous pus cells on microscopy, and Gram staining showed Gram-positive cocci in chains. Beta-hemolytic Streptococcus was cultured from the aspirate. No organism was cultured from the blood.
Figure 2: Lateral view of the plain radiograph of the neck showing enlargement of the retropharyngeal space and anterior displacement of the trachea

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Figure 3: Pus aspirated from the deep neck space abscess

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Direct laryngoscopy revealed a bulge in the posterior wall of the pharynx, anterior displacement and narrowing of the vocal cords, and displacement of the trachea to the left. Tracheostomy was done to secure the airway, and the abscesses were incised and adequately drained. The tracheostomy tube was removed after 2 days of insertion. The child was placed on intravenous broad-spectrum antibiotics (cefuroxime and metronidazole for 14 days and gentamicin for 7 days), and daily dressing of the incision and drainage site was done. He was discharged from the hospital on the 14th day of admission following resolution of all initial symptoms and signs.

  Discussion Top

RPA occurs due to suppuration of the retropharyngeal lymph nodes which are located in the retropharyngeal space between the prevertebral fascia and the buccopharyngeal fascia of the posterior pharyngeal wall.[5] Similarly, PPA occurs due to suppuration in the parapharyngeal space between the buccopharyngeal fascia of the lateral pharyngeal wall and the prevertebral fascia.[5] Both abscesses arise following acute infection of the upper respiratory tract, commonly pharyngotonsillitis.[5] Furthermore, RPA and PPA are primarily diseases of children below the age of 5 years because of their relatively large lymphoid tissues which atrophy with advancing age and a higher incidence of upper respiratory tract infections.[5],[6],[7] Although they are uncommon in neonates, they present with a more aggressive course, due to their less developed immune system and relative narrow anatomic neck space.[5],[6],[7]

Besides presenting at the 7th day of life, the baby also had both RPA and PPA that coexisted at this very young age. Although most of the reported cases in neonates were isolated case of RPA or PPA, the communications between the neck spaces may allow the infection to spread from one space to another in this vulnerable group. When both occur, the airway compromise may be fatal due to worsening obstruction on account of narrowing from both sides by the PPA and from behind by the RPA.

In this index patient, β-hemolytic Streptococcus was the causative organism isolated. This finding agrees with what has been reported in the literature where β-hemolytic streptococcus Group A, S. aureus, and anaerobes were the most frequent causative organisms.[8]

The preferred radiologic investigation is a computerized tomography (CT) scan with intravenous contrast which typically shows air-fluid level and localizes the abscess.[9] In resource-poor setting, the plain neck radiograph may give valuable information and was opted for in this baby, because a CT scan could not be done due to financial constraint. Plain neck radiograph may show increase prevertebral soft tissue shadow with anterior displacement of the laryngotracheal air column on lateral view in the case of RPA and lateral displacement of the trachea in the case of PPA.[9]

Maintenance of a patent airway is vital in the treatment of DNSIs. This baby had an endotracheal tube inserted at presentation with improvement in the respiratory distress and improvement in SpO2 from 90% to 94% and eventually to 100% following tracheostomy. Antibiotics therapy alone has been used to successfully treat RPA in up to 58% of neonates, with the remainder requiring surgical intervention (aspiration and less frequently incision and drainage).[4],[8] The position, size, and extent of the abscess and its relationship to the neck vessels are considered in choosing the best surgical approach.[3] If the abscess is medial to the great vessels, drainage of the abscess can be performed through a transoral approach.[3] The external cervical approach is the choice for abscesses that dissect along or are lateral to the great vessels.[3] The index case was successfully managed with incision and drainage using the external cervical approach and was given broad-spectrum antibiotics for 14 days.

  Conclusion Top

Deep neck space abscesses are uncommon in neonates and may present with are a potentially life-threatening complication of upper airway obstruction. Hence, the need for a high index of suspicion especially in neonates presenting with neck swelling and respiratory distress will allow in early diagnosis and institution of prompt treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Rakesh S, Amit M. Deep neck space infection : A clinical study and review of literature. Sch J Appl Med Sci 2016;4:1143-56.  Back to cited text no. 1
Brito-Mutunayagam S, Chew YK, Sivakumar K, Prepageran N. Parapharyngeal and retropharyngeal abscess: Anatomical complexity and etiology. Med J Malaysia 2007;62:413-5.  Back to cited text no. 2
Snow JB. Ballenger's Manual of Otorhinolaryngology Head and Neck Surgery. 1st ed. Hamilton: BC Decker Inc.; 2002.  Back to cited text no. 3
Gathwala G, Singh J, Kumar R, Agarwal S. Retropharyngeal abscess in the neonate. Indian J Pediatr 2010;77:579-80.  Back to cited text no. 4
Tawfik A, El-Morshedy N, Rashad M, Mohamed A, El-Degwi A, El-Okda M, et al. Suppurations related to the pharynx. In: Essentials of Otorhinolaryngology. Monsoura: Dar El-Safa Inc.; 2007. p. 137-8.  Back to cited text no. 5
Marques PM, Spratley JE, Leal LM, Cardoso E, Santos M. Parapharyngeal abscess in children: Five year retrospective study. Braz J Otorhinolaryngol 2009;75:826-30.  Back to cited text no. 6
Marco HR, Niall DJ, Tom K. Retropharyngeal abscess in a six-week-old child: An approach to management. J R Soc Med Sh Rep 2013;4:1-3.  Back to cited text no. 7
Sharma S. Pediatric retropharyngeal abscess. Glob J Otolaryngol 2016;1:3-5.  Back to cited text no. 8
Pappas ED, Hendley OJ. Retropharyngeal abscess, lateral pharyngeal abscess, and peritonsillar cellulitis/abscess. In: Kliegman RM, editor. Nelson Textbook Of Pediatrics. Philadelphia: Saunders, Elsevier Inc.; 2016. p. 2021-3.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3]


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