Learning objectives
- The consequences of airway infection and retropharyngeal abscess during intubation
- Management of airway infection and retropharyngeal abscess
Definition and mechanism
- Upper respiratory or ear infections can lead to retropharyngeal abscess formation (collection of pus in the retropharyngeal space)
- Tracheal intubation will be difficult due to distorted airway anatomy, edema, decreased mouth opening, and immobile tissue
- Vocal cords can be difficult to visualize
- A retropharyngeal abscess can rupture and aspiration of the content can occur during intubation
- The induction of general anesthesia may precipitate complete airway closure
Signs and symptoms
| Upper airway infection | Retropharyngeal abscess |
|---|---|
| Cough Runny nose Sneezing Throat pain Fever | Severe sore throat Swollen lymph nodes Difficulty breathing Difficulty speaking Noisy breathing Severe headache Stiff neck Coughing Fever |
Complications of a retropharyngeal abscess
- Blocked airway
- Aspiration pneumonia
- Swelling and inflammation in the thorax
- Sepsis
Risk factors & comorbidities
- Adults: HIV, IV drug use, diabetes, head & neck malignancies, alcohol
- Immunosuppression
- Pediatric: upper respiratory tract infections
Management
- Investigate the airway using an X-ray or CT-scan
- Perform preoxygenation
- Intubate using awake fiberoptic intubation
- Consider a tracheostomy if endotracheal intubation is not possible
- Challenge: distorted anatomy affects the location of landmarks
- Treat retropharyngeal abscess with broadspectrum IV antibiotics
- Consider draining the abscess
Keep in mind
- Full stomach & need for rapid sequence induction (RSI) vs difficult airway
- Full stomach & need for RSI plus need for deep level of anesthesia vs. risk of hemodynamic instability (sepsis)
- Awake fiberoptic intubation does not visualize ETT passing abscess & therefore potential to rupture it
Suggested reading
- Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022;136(1):31-81.
- Straker, Tracey, Shobana Rajan, and Mazen A. Maktabi (eds), ‘ Anesthetic Management of the Patient with Retropharyngeal Abscess with Emphasis on Perioperative and Airway Management’, in Tracey Straker, Shobana Rajan, and Magdalena Anitescu (eds), Anesthesiology: A Problem-Based Learning Approach, Anesthesiology A Problem Based Learning (New York, 2018; online edn, Oxford Academic, 1 Nov. 2018)
- Davies I, Jenkins I. Paediatric airway infections. BJA Educ. 2017;17(10):341-345.
- Cho SY, Woo JH, Kim YJ, et al. Airway management in patients with deep neck infections: A retrospective analysis [published correction appears in Medicine (Baltimore). 2016 Oct 21;95(42):e36c2]. Medicine (Baltimore). 2016;95(27):e4125.
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