POTD: Retropharyngeal Abscess

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Retropharyngeal Abscess


What is it?

  • Polymicrobial abscess in space between posterior pharyngeal wall and prevertebral fascia

  • Adults: Usually due to direct extension of local infection (ex. ludwig's angina, pharyngitis, dental abscess etc.)

  • Peds: Usually due to suppurative changes in local lymph nodes from an infection in the head or neck

  • Can also be caused from trauma- falling with pencil in mouth


Presentation:

  • Patients may prefer to lay down to prevent abscess from collapsing the airway. If your suspicion is high enough, don't sit these patients up!

  • Patients will complain most commonly of: sore throat, fever, torticollis, dysphagia

  • In late stages will develop airway involvement (looks for stritor, change in phonation, drooling, neck stiffness, tripoding, SOB)


Diagnosis:

  • CT Neck with IV contrast

  • On CT you will see loss of definition between the anatomic spaces in the neck, stranding in the subcutaneous tissues, tissue enhancement, and frank abscess formation, the location of the findings indicates whether it is a parapharyngeal or retropharyngeal space infection

  • You can get a soft tissue neck x-ray, but if your suspicion is still high and the x-rays are equivocal, you should still get a CT

  • MRI is useful for assessing the extent of soft tissue involvement and for delineating vascular complications

Management:

  • Get Anesthesia/ ENT involved early if there is any degree of upper airway obstruction!

  • These signs include: neck extension/head in sniffing position, stritor, change in phonation, drooling, neck stiffness, tripoding, SOB,  retractions

  • Coordinate with Anesthesia/ ENT to secure an airway (Tracheostomy in the OR or fiberoptic intubation should be considered)

  • If there is no airway compromise, consult ENT because many of these patients require I&D/ needle aspiration in the OR

  • Retropharyngeal abscess <2.5cm without airway compromise can potentially receive a trial of empiric IV abx for 24-48 hours without drainage  

  •  Antibiotics (Covering: GAS, Staph aureus, respiratory anaerobes, +/-MRSA)  options include: Ampicillin/Sulbactam 3g IV  or Clindamycin 600-900mg IV or Cefoxitin 2gm IV  

  • Admit

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Palliative Dyspnea

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Managing dyspnea in the palliative patient.

This comes down to 4 approaches:

  • Oxygen

  • Opiates

  • Benzodiazepenes

  • Addressing the underlying issue

  • Other measures of comfort

Oxygen

  • Several options here with pro's and con's to all

  • Nasal Cannula 

    • Comfortable at low flows

    • Limited in how much oxygen it can deliver as it provides no reservoir of oxygen; it depends on the patient's upper airway as the reservoir of oxygen

    • at high flow rates is uncomfortable and causes dryness and bleeding unless delivered with a humidifier)

    • Many patients mouth breathe at the end of life

  • Non-rebreather

    • provides more oxygen, enables oxygen delivery to mouth breathers

    • Uncomfortably noisy, must be drawn tightly against the face to be most effective

    • muffles communication at a time when it is of key importance in the dying patient

    • Dries patient's mouth and nares out

  • Venturi Mask

    • An underutilized therapy

    • Addresses mouth breathing

    • Mixes oxygen with room air

    • Able to provide relatively high flow rates of oxygen 

    • Does not need to be humidified as high flow rates of oxygen are mixed with ambient room air

  • High-flow nasal cannula

    • Comfortably provides humidified oxygen at extremely high rates

    • Does not provide oxygen to mouth breathers

    • If the patient is being admitted it requires admission to the MICU (or potentially PAMCU)

  • Non invasive ventilation (Bipap)

    • Noisy, uncomfortable, frightening

    • Decreases the ability to commmunicate

Opioids

  • THE KEY TO PALLIATIVE DYSPNEA

  • Can be delivered via the subcutaneous route, another underutilized therapy

  • Administer zofran to offset possible associated nausea

  • Decrease the intensity of air hunger and dyspnea related anxiety

  • Have been shown to NOT SHORTEN LIFE IN PALLIATIVE PATIENTS, which is important to communicate to the dying patient's family. 

Benzodiazepenes

  • Anxiety leads to worsening dyspnea; managing the anxiety therefore aids in management of dyspnea

  • Generally not used as monotherapy, however can be used in addition with opiates in the anxious and dyspneic patient

Other measures

  • Position the patient as they wish, though generally the more upright patient is the more comfortable patient

  • Death rattle: As patients lose consciousness they lose their ability to swallow and oral secretions can pool, causing gurgling noises. There is no evidence that this is disturbing to patients, but families often have a very hard time with these noises.

    • Glycopyrrolate can help mitigate this disturbing noise

Cause specific techniques = address the underlying issue

  • Must weigh the benefits vs. the discomfort of performing these interventions

  • Pleural effusions: Thoracentesis

  • Anemia: Transfusion

  • Obstructing airway mass: Steroids, palliative radiation if available

  • Pneumonia: Antibiotics

  • Fluid overload: Diuresis

  • Bronchospasm: Bronchodilators

See:

https://first10em.com/palliative-resuscitation-dyspnea/

https://www.rtmagazine.com/products-treatment/monitoring-treatment/therapy-devices/oxygen-administration-best-choice/

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Treating Laryngospasm

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LARYNGOSPASM
You’re doing a procedural sedation in pediatrics. Despite your attending’s forewarning, you push that IV ketamine a bit too quickly. Suddenly, you hear a loud “crowing” or “squeaking” sound and look up at the monitor to see a flat line on capnography. Your heart sinks as it dawns upon you that you caused the much-dreaded laryngospasm.

WHAT DO I DO?!
1. Stop all procedures
2. Perform Larson’s maneuver - this is a modified jaw thrust maneuver where pressure is applied towards the top of the ramus of the mandible

laryngospasm-notch.jpg

3. Use a bag valve mask with PEEP valve and 100% oxygen to provide continuous positive airway pressure
4. Ask your team to prepare for intubation
5. Deepen anesthesia with IV propofol (0.5mg/kg IV push)

Most cases of laryngospasm will resolve with these maneuvers and propofol. In the rare event it doesn’t…

6. Give an IV paralytic (rocuronium 1mg/kg IV or succinylcholine 1.5mg/kg IV) and proceed to intubate.

Sources: Justin Morgenstern, "Managing laryngospasm in the emergency department", First10EM blog, March 3, 2016. Available at: https://first10em.com/laryngospasm/.

Alejandro Romero

EM PGY-3



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