Approach
Management is initially medical. If this fails, surgical intervention is required, with the consultation of an otolaryngologist. All patients should be admitted to the hospital. Safe and appropriate management of the airway is paramount. This is usually achieved through conservative or surgical means. Treatment primarily depends on the severity of respiratory distress.
Airway compromise
If there is a strong suspicion of an RPA and the airway is compromised (indicated by stridor, tachypnea, and decreased oxygen saturation as the patient becomes fatigued), the patient should be admitted to the hospital immediately. Initial medical management includes the use of corticosteroids, nebulized epinephrine (adrenaline), and antibiotics.[31][32] If this is not rapidly effective, the patient should be taken to the operating room for examination under anesthesic (EUA) with a view to surgical drainage. Intubation or a surgical airway such as a tracheostomy will be required and should be performed by an experienced pediatric or adult anesthetist. Fiberoptic intubation is sometimes favored in these cases to prevent bursting of the abscess and to gain a good view of the airway.[21][32] If the tube is uncuffed, it is helpful to insert a pack allowing a view of the posterior pharyngeal wall for surgical access.[32] If an RPA is confirmed on surgical exam (bulging of posterior oropharyngeal wall seen and/or by aspiration of purulent fluid), the surgeon should perform a transoral incision and drainage. Cultures are taken and sent to the laboratory. In cases where there is extension to the posterior mediastinum, drainage of purulent discharge and debridement of necrotic material from the pericardial area and pleural space may be required, possibly in conjunction with a cardiothoracic team.[33]
If the airway is still unstable, the patient should be monitored closely in an intensive care unit and started on empiric intravenous antibiotics; prolonged intubation or tracheostomy may be required. Patients with a stable airway after surgery should also be started on empiric intravenous antibiotics.
No airway compromise
Even in the absence of airway compromise, the patient should still be admitted to the hospital and carefully observed. If the airway is not an immediate concern and there is no evidence of mediastinal extension of the abscess, treatment with empiric intravenous antibiotics for 24 to 48 hours should be initiated promptly.[5][33] Corticosteroids may be used in conjunction with the intravenous antibiotics.[31]
Prompt treatment with antibiotics, with or without corticosteroids, can cause resolution or prevention of disease progression, in some patients with an early presentation (e.g. where there is only cellulitis rather than true abscess formation), thereby avoiding the need for surgical drainage.
Failure of initial medical treatment (i.e., no symptomatic improvement, continuing swinging pyrexia, deterioration of vital signs) and/or the presence of a defined abscess on imaging should prompt the need for EUA with a view to peroral surgical drainage. Although the general rule of thumb is to consider drainage for abscesses over the size of 2 cm, it is important to value clinical presentation and initial response to intravenous antibiotics even in larger abscesses.[34] Repeat CT imaging may be necessary to precisely locate the abscess. In pediatric patients, it is usually preferable to anesthetize prior to the CT scan, whereas adults can generally undergo imaging without the need for anesthesia. Intravenous antibiotics are continued after surgical drainage, either as an empiric regimen or according to sensitivities when available.
The presence of a defined abscess on imaging is typically an indication for drainage. However, the efficacy of medical management for CT-confirmed, deep neck abscesses in children was evaluated in a 2012 systematic review. The authors found that medical therapy alone might be an effective alternative to surgery in some patients, although the evidence was weak.[35] Delaying surgery in favour of medical management for confirmed abscesses remains controversial, given the risk of disease progression and subsequent airway compromise. Additionally, a lack of microbiology samples may hamper the ability to tailor antibiotic therapy.
Empiric antibiotic therapy
Antibiotics should cover the most commonly implicated organisms: Streptococcus viridans, Staphylococcus aureus, Streptococcus epidermidis, and beta-hemolytic streptococci. Less common causes include Veillonella species, Bacteroides melaninogenicus, Haemophilus parainfluenzae, and Klebsiella pneumoniae. Normal commensals of the upper respiratory tract can become pathologically offending organisms in an RPA.[13][14][15] Typical antibiotic regimens include ampicillin/sulbactam, clindamycin, cefuroxime, ceftriaxone, metronidazole, and amoxicillin/clavulanic acid. Combination regimens of these antibiotics may be necessary to adequately cover likely organisms (e.g., ceftriaxone plus metronidazole or clindamycin plus cefuroxime).[33] Metronidazole would cover for anerobic bacteria as there may be a connection with the parapharyngeal space and therefore the oral cavity.
Clinical improvement should be seen within 24 to 48 hours; if this is not the case, the patient should be re-evaluated. The antibiotic spectrum may need to be broadened. In refractory cases, atypical mycobacteria or MRSA should be suspected. Empiric antibiotics should be continued until the patient is afebrile or able to tolerate oral medications to complete a 14-day course. Patients may be switched to targeted therapy based on cultures if drainage is performed.
Supportive care
Patients should have their airway monitored throughout treatment, and patients with an unstable airway after surgery should be monitored closely in an intensive care unit. Adequate intravenous hydration and nutrition should be given until oral intake of food and drink is tolerated. Some patients may require analgesia. Patients should be monitored closely for development of complications.
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