Prognostic Factors for Retropharyngeal Abscess in Children Receiving Surgery or Antibiotic Therapy.

OBJECTIVE: Effective management of retropharyngeal abscess (RPA) may predicate upon identification of key patient characteristics. We analyzed characteristics and outcomes of pediatric patients with RPA to identify prognostic factors associated with successful surgical intervention. METHODS: A financial database was searched for pediatric otolaryngology patients with RPA from 2010 to 2021. Medical charts were reviewed for demographics, presenting history, physical examination, laboratory testing, imaging, surgical findings, and hospital course. Bivariate analyses were performed to identify potentially significant predictors of positive drainage. These variables were included in multivariate analysis of surgical outcomes. RESULTS: Of 245 total patients, 159 patients (65%) received surgery and 86 patients (35%) received antibiotics only. Patients with restricted cervical motion, neck swelling, and computed tomography (CT) cross-sectional area (CSA) >2 cm2 were more likely to receive surgery. Rim enhancement on CT imaging was associated with positive surgical drainage (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.16-5.74). However, no variables from clinical symptoms or physical exam were associated with positive drainage. Variables that approached significance were included in multivariate analysis, which revealed only rim enhancement predicted positive drainage (OR 2.57, 95% CI 1.13-5.83). The mean length of stay (LOS) was 2.6 versus 3.5 days (p < 0.001) for medical vs surgical treatment groups, respectively. CONCLUSION: Our study revealed a high success rate of medical management. Although patient characteristics and clinical features were not significant predictors of surgical outcomes, CT findings such as rim enhancement were strongly associated with positive surgical drainage. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:1955-1960, 2024.

Descending necrotizing mediastinitis secondary to retropharyngeal abscess.

We report a case of descending necrotizing mediastinitis (DNM) in a 68-year-old male who presented in acute respiratory distress accompanied with anterior cervical neck swelling and pain with swallowing. Contrast enhanced computed tomography (CECT) of the neck demonstrated a large, peripherally enhancing retropharyngeal fluid and air collection that appeared to communicate with a fluid and air collection within the mediastinum. CECT of the chest demonstrated punctate foci of air and fat stranding along the anterior and superior mediastinum. Radiological evidence and the presence of necrosis on surgical debridement of the retropharyngeal abscess established the diagnosis of DNM. This case emphasizes the role of computed tomography (CT) in the diagnosis of DNM and demonstrates the utility of chest imaging in a high-risk patient who presents with a retropharyngeal abscess.

Retropharyngeal Abscess With Mediastinal Extension: A Case Series and Review of the Literature.

Deep neck infections are common in infants and occur in several anatomic subsites including the retropharyngeal space. Retropharyngeal abscesses are significant given their propensity for mediastinal extension and can have life-threatening sequelae. We present 3 cases of retropharyngeal abscess with mediastinal extension in infants. In one case, an incompletely vaccinated 10-month-old boy presented with cough, rhinorrhea, and fever. Despite antibiotic treatment, he developed Horner's syndrome and hypoxia. A computed tomography (CT) scan showed a C1-T7 retropharyngeal abscess. He underwent transoral incision and drainage and recovered fully. In another case, a 12-month old infant presented with 8 days of fever and neck pain. A CT scan showed a retropharyngeal collection extending to the mediastinum and right hemithorax. Transoral incision and drainage and video-assisted thoracoscopic surgery thoracotomy were performed for abscess drainage. He recovered fully with antibiotics. In the third case, an 8-month-old boy presented to the emergency room following several days of fever, lethargy, and decreased neck range of motion. A CT scan showed a large retropharyngeal abscess that required both transoral and transcervical drainage. His case was complicated by septic shock, yet the patient eventually made a full recovery.

Late Retropharyngeal and Parapharyngeal Abscess in Patients with a History of Anterior Cervical Discectomy and Fusion.

OBJECTIVE: Anterior cervical discectomy and fusion is a common procedure performed by spine surgeons with rare complications and high treatment success. Late presentation of retropharyngeal abscess in patients with a history of anterior cervical discectomy and fusion is rare but can have devastating consequences. There is a paucity of data to guide medical and surgical management of retropharyngeal abscess in these patients. METHODS: We discuss 7 patients who presented to our institution with a late retropharyngeal abscess after having a history of anterior cervical discectomy and fusion. A review and description of the current literature regarding treatment and outcomes is described. RESULTS: Seven patients presented to our institution with a retropharyngeal abscess ranging from 10 months to 7 years after undergoing anterior cervical discectomy and fusion. All patients received at least a 6-week course of appropriate intravenous antibiotics. Only one patient had their initial ACDF instrumentation removed at the time of presentation for the abscess. Four out of the 7 patients were treated with irrigation and debridement in addition to intravenous antibiotics, whereas 3 patients were treated with no surgery and intravenous antibiotics alone. All patients were asymptomatic at final follow up. CONCLUSIONS: Late retropharyngeal abscess after anterior cervical discectomy and fusion is a rare complication. Surgical management should be considered along with long term antibiotics. Removal of implants may not be necessary for infection resolution. Antibiotic treatment alone may be indicated for patients who are not septic, do not have airway compromise, or and can be considered for poor surgical candidates.

Magnetic resonance imaging accuracy before surgery in children with retropharyngeal abscesses.

AIMS: Retropharyngeal abscess (RPA) is a deep neck infection occurring in childhood. The gold standard technique for diagnosis is computerised tomography (CT) with a contrast medium. The aim of this study is to answer the question of whether magnetic resonance imaging (MRI) can be an alternative in diagnosing RPA and predicting pus drainage at surgery. METHODS: This is a retrospective study conducted at the paediatric emergency department of a tertiary level children hospital. The medical records of 31 children admitted to the Otorhinolaryngology and Paediatric ward, with a suspected diagnosis of RPA, were reviewed. The primary study outcome was the diagnostic accuracy of CT and MRI in predicting the amount of pus during surgery. RESULTS: Twenty-two patients (71%) underwent surgery. Among them, 18 had imaging before surgery. Eleven patients evaluated with CT scan underwent surgery: four had non-significant purulent drainage, three of them were reported to have a significant fluid collection (negative predictive value 66% and positive predictive value of 55%). Nine patients evaluated with MRI underwent surgery: four cases had non-significant purulent drainage, three of them showed a significant fluid collection at MRI (negative predictive value of 60%; positive predictive value of 56%). CONCLUSION: MRI and CT scans showed similar accuracy in predicting successful pus drainage during surgery; therefore, it could be a valid alternative in the diagnosis of RPA in children.

Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses.

BACKGROUND AND OBJECTIVES: Treatment of retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs) includes antibiotics, with possible surgical drainage. Although corticosteroids may decrease inflammation, their role in the management of RPAs and PPAs is unclear. We evaluated the association of corticosteroid administration as part of initial medical management on drainage rates and length of stay for children admitted with RPAs and PPAs. METHODS: We conducted a retrospective study using administrative data of children aged 2 months to 8 years discharged with RPAs and PPAs from 2016 to 2019. Exposure was defined as systemic corticosteroids administered as part of initial management. Primary outcome was surgical drainage. Bivariate comparisons were made between patients in the corticosteroid and noncorticosteroid groups by using Wilcoxon rank or χ2 tests. Outcomes were modeled by using generalized linear mixed-effects models. RESULTS: Of the 2259 patients with RPAs and PPAs, 1677 (74.2%) were in the noncorticosteroid group and 582 (25.8%) were in the corticosteroid group. There were no significant differences in age, sex, or insurance status. There was a lower rate of drainage in the corticosteroid cohort (odds ratio: 0.28; confidence interval: 0.22-0.36). Patients in this group were more likely to have repeat computed tomography imaging performed, had lower hospital costs, and were less likely to have opioid medications administered. The corticosteroid cohort had a higher 7-day emergency department revisit rate, but there was no difference in length of stay (rate ratio 0.97; confidence interval: 0.92-1.02). CONCLUSIONS: Corticosteroids were associated with lower odds of surgical drainage among children with RPAs and PPAs.

Undiagnosed pharyngeal perforation following a penetrating neck trauma in a 5-year-old child: a proposed treatment algorithm.

External penetrating wounds of the neck leading to pharyngeal perforations are relatively uncommon. The small area of the neck contains the vital vascular, aerodigestive and nervous structures, which are difficult to access surgically. Pharyngeal perforations are challenging to treat, especially in children, as primary wound inspection may be difficult, leading to life-threatening complications like retropharyngeal abscesses, mediastinitis or airway compromise. The following is a case report of a 5-year-old girl who had a road traffic accident causing a neck laceration with a pharyngeal tear, which was only identified during emergency neck exploration in the operating room. A review of known literature and a proposed algorithm for managing penetrating neck injuries with pharyngeal injury is described.

Features associated with surgically significant abscesses on computed tomography evaluation of the neck in pediatric patients.

BACKGROUND: Neck-related chief complaints are common in the pediatric Emergency Department (ED), and although the incidence of pathology such as retropharyngeal abscesses is rare, the ability to rule out abscesses requiring surgical/procedural intervention is essential. However, there are no clear clinical guidelines regarding work-up and diagnosis in this population, possibly contributing to an excess use of potentially harmful and costly computed tomography (CT) imaging. OBJECTIVE: In this study we sought to identify historical, physical exam, and laboratory findings associated with surgically significant neck abscesses to better delineate CT neck imaging criteria. METHODS: We conducted a retrospective chart review of all patients ≤18 years presenting to a pediatric ED between 2013 and 2017 who underwent CT neck imaging. Surgically significant abscesses (SSAs) were defined as abscesses ≥2 cm, retropharyngeal abscesses (RPA), parapharyngeal abscesses (PPA), or peritonsillar abscesses (PTA). Historical factors, physical exam findings, laboratory results, demographics, and CT results were analyzed using univariate statistical analysis and regression models. RESULTS: A total of 718 patients received neck CTs and 153 SSAs were identified. In children younger than 6 years, factors associated with statistically significant increased odds of an SSA were reported throat pain (OR 1.18; 95% CI 1.05, 1.33), fussiness (OR 1.18; 1.01, 1.39), lethargy (OR 1.43; 1.07, 1.91), tonsillar enlargement (OR 1.17; 1.02, 1.34), C-reactive protein (CRP) > 10 (OR 1.22; 1.07, 1.40), and an ED visit within the preceding week (OR 1.18; 1.04, 1.33). In children older than 6 years, the factors associated with statistically significant increased odds of an SSA included current antibiotic use (OR 1.12; 1.02, 1.22) and a CRP >10 (OR 1.14; 1.03, 1.26). CONCLUSION: Some historical, physical exam, and laboratory findings are associated with SSAs, and while not definitive in isolation, may be beneficial additions to routine SSA assessment, as a supplement to clinical judgement regarding CT and observation decisions. This may potentially allow for the identification of patients requiring CT versus those who may not, and thus the opportunity to safely reduce the use of CT imaging in select patients.

Retropharyngeal Abscess in an Adult With Pneumonia During COVID-19 Outbreak.

BACKGROUND: Retropharyngeal abscesses are rarely reported in adults and occur mostly in patients with immunocompromised or as a foreign body complication. Admittedly, the treatment of retropharyngeal abscesses frequently involves surgical drainage to achieve the best results. However, when retropharyngeal abscesses occurred in a highly suspected patient with COVID-19, the managements and treatments should be caution to prevent the spread of the virus. CLINICAL PRESENTATION: On February 13, a 40-year-old male with retropharyngeal abscesses turned to our department complaining dyspnea and dysphagia. In addition, his chest CT scan shows a suspected COVID-19 infection, thus making out Multiple Disciplinary Team determine to perform percutaneous drainage and catheterization through left anterior cervical approach under the guidance of B-ultrasound. Finally, the patient recovered and was discharged from the hospital on February 27 after 14 days of isolation. There was no recurrence after half a year follow-up. CONCLUSIONS: By presenting this case, we aim at raising awareness of different surgical drainage methods and summarizing our experience in the management of retropharyngeal abscesses during the outbreak of COVID-19.

Abscés cervical profund associat a col·locació de mascareta laríngia / Absceso cervical profundo asociado a la colocación de mascarilla laríngea / Deep neck abscess associated to the placement of a laryngeal mask

INTRODUCCIÓ: Els abscessos parafaringi I retrofaringi són infeccions profundes del coll que solen associar-se a l'antecedent d'infecció de vies respiratòries altes. Ocasionalment poden ser causats per traumatismes com els que comporten algunes manipulacions mèdiques, per exemple, la col·locació de mascareta laríngia, molt utilitzada en cirurgia pediàtrica. CAS CLÍNIC: Es presenta el cas d'una nena de 6 anys amb torticoli de 8 dies d'evolució I febre de 24 hores, sense cap altra simptomatologia. La pacient havia estat intervinguda quirúrgicament sota anestèsia general amb col·locació de mascareta laríngia 36 hores abans de l'inici del quadre, sense incidències. En l'exploració, destaca una contractura cervical bilateral amb flexió del cap a la dreta, I a l'analítica es troba leucocitosi amb predomini de neutròfils I augment de la proteïna C reactiva. Es fa una ressonància magnètica cervical en què s'observa un abscés d'extensió parafaríngia I retrofaríngia, I s'indica una punció percutània ecoguiada de l'àrea abscessificada, que resulta positiva per a S. pyogenes. S'ingressa la pacient amb antibioteràpia endovenosa I s'aconsegueix la millora clínica I radiològica de l'abscés. COMENTARIS: Els abscessos cervicals profunds s'han de considerar davant de simptomatologia obstructiva I inflamatòria de la via aèria I el tracte digestiu superior, I símptomes locals o dolor al moviment cervical. El diagnòstic es basa en les troballes radiològiques, analítiques I microbiològiques, I cal instaurar antibioteràpia endovenosa empírica amb cobertura per a estafilococs, estreptococs I anaerobis. Tot I que aquests abscessos en la majoria de casos són secundaris a l'extensió d'infeccions del tracte respiratori superior, hi ha altres causes que cal considerar

INTRODUCCIÓN: Los abscesos retrofaríngeo y parafaríngeo son infecciones profundas del cuello que suelen asociarse al antecedente de infección de vías respiratorias altas. Ocasionalmente pueden ser causados por traumatismos como los que resultan de algunos procedimientos médicos, por ejemplo, la colocación de la mascarilla laríngea, muy utilizada en cirugía pediátrica. CASO CLÍNICO: Se presenta el caso de una niña de 6 años con tortícolis de 8 días de evolución y fiebre de 24 horas, sin otra sintomatología. La paciente había sido intervenida quirúrgicamente bajo anestesia general con colocación de mascarilla laríngea 36 horas antes del inicio del cuadro, sin incidencias. A la exploración, destaca una contractura cervical bilateral con flexión de la cabeza hacia la derecha, y en la analítica se encuentra leucocitosis con predominio neutrofílico y ligero aumento de proteína C reactiva. Se realiza una resonancia magnética cervical donde se observa un absceso de extensión parafaríngea y retrofaríngea, y se practica una punción percutánea ecoguiada de la zona abscesificada, que resulta positiva para S. pyogenes. La paciente ingresa con antibioterapia endovenosa y se consigue mejoría clínica y radiológica del absceso. COMENTARIO: Los abscesos cervicales profundos deben considerarse ante sintomatología obstructiva e inflamatoria de la vía aérea y del tracto digestivo superior, y síntomas locales o dolor al movimiento del cuello. El diagnóstico se basa en los hallazgos radiológicos, analíticos y microbiológicos y se debe instaurar antibioterapia endovenosa empírica con cobertura para estafilococos, estreptococos y anaerobios. Aunque en la mayoría de casos estos abscesos son secundarios a la extensión de infecciones del tracto respiratorio superior, existen otras causas que deben considerarse

INTRODUCTION: Retropharyngeal and parapharyngeal abscesses are deep neck infections that are usually associated with superior airway infections in children. However, they could also be caused by injuries secondary to medical procedures such as the placement of laryngeal masks, which are frequently used in pediatric surgery. CASE REPORT: A 6-year-old female presented to the emergency room with an 8-day history of torticollis and 24 hours of fever with no other associated symptomatology. She had undergone surgery under general anesthesia using a laryngeal mask 36 hours prior, without immediate complications. In the physical examination, the patient had bilateral cervical contracture with right bending. The blood examination showed leukocytosis with predominance of neutrophils and increase of C-reactive protein. Magnetic resonance imaging showed an abscess with parapharyngeal and retropharyngeal extension, and a percutaneous ultrasound-guided puncture of the abscessed area was performed, which resulted positive for S. pyogenes. The patient received intravenous antibiotic therapy and achieved clinical and radiological resolution of the abscess. COMMENTS: Deep neck abscesses should be considered in children with obstructive and inflammatory symptomatology of the airway and upper digestive tract and also local symptoms as neck pain. Diagnosis is based on radiological, analytical and microbiological findings and empirical intravenous antibiotics, with coverage for staphylococcus, streptococcus and anaerobics. Although in most cases these abscesses are secondary to the spread of upper respiratory tract infections, other causes should be considered

Severe parapharyngeal abscess that developed significant complications: management during the COVID-19 pandemic.

A 50-year-old Caucasian man presented to the emergency department during the early stages of the COVID-19 pandemic with a rapidly progressive facial swelling, fever, malaise and myalgia. The patient had recently travelled to a COVID-19-prevalent European country and was therefore treated as COVID-19 suspect. The day before, the patient sustained a burn to his left forearm after falling unconscious next to a radiator. A CT neck and thorax showed a parapharyngeal abscess, which was surgically drained, and the patient was discharged following an intensive care admission. He then developed mediastinitis 3 weeks post-discharge which required readmission and transfer to a cardiothoracic unit for surgical drainage. This report discusses the evolution of a deep neck space infection into a mediastinitis, a rare and life-threatening complication, despite early surgical drainage. This report also highlights the difficulties faced with managing patients during the COVID-19 pandemic.

Minimally invasive transoral image-guided drainage of a retropharyngeal abscess with mediastinal extension.

Retropharyngeal abscess (RPA) in children is a serious deep neck space infection that rarely is complicated by extension into the mediastinum. RPA with mediastinal abscess requires prompt surgical management, generally via external or transoral approach. We present the case of a 3-year-old boy with RPA with mediastinal extension who was managed with a unique multidisciplinary surgical approach with otolaryngology and interventional radiology. A transoral approach was utilized to pass a transnasal drain with image guidance into the mediastinal fluid collection. This report reviews the presentation and surgical management of RPA with mediastinal extension and describes a unique minimally invasive approach to drainage.

Necesidad de cirugía en los abscesos cervicales profundos pediátricos / Need for surgery in paediatric deep abcesses of the neck

No disponible

Kicking off a Retropharyngeal Abscess

Aim Retropharyngeal abscesses (RPA) are deep neck space infections that can pose an immediate life-threatening emergency, such as airway obstruction. [1] Methods We describe an atypical presentation of RPA in a three year old girl who attended with a history of post-traumatic Neck pain. Results MB presented to the Emergency department with neck pain and reduced range of motion following a kick to the neck by a sibling. Examination was unremarkable. Cervical spine x-ray showed psuedosubluxation of C2/C3 with a concern regarding facet joint injury. Ultimately, MRI revealed a RPA, which was incised and drained, and the patient treated with antibiotics. MB did not have any classic symptoms and signs of RPA. The history was misleading the treating physicians, and hence a delay in diagnosis. Conclusion This case highlights an unusual presentation of a retropharyngeal abscess and reminds us that trauma can often be a red herring in a patient's presentation.

Abscesos profundos de cuello en pediatría: experiencia del Hospital Dr. Sótero del Río entre los años 2011 y 2018 / Pediatric deep neck abscesses: Dr. Sótero del Río Hospital 2011-2018 experience

RESUMEN Introducción: Los abscesos profundos de cuello son colecciones de pus alojadas en los espacios profundos cervicales. En la población pediátrica son poco frecuentes, sin embargo, pueden presentar complicaciones potencialmente mortales. Objetivo: Caracterizar a los pacientes que consultan por abscesos profundos del cuello en el Servicio de Urgencia Pediátrico del Hospital Dr. Sótero del Rio. Material y método: Estudio de tipo descriptivo retrospectivo con datos obtenidos de fichas clínicas de pacientes. Se realizó una revisión de fichas clínicas de los pacientes diagnosticados con abscesos profundos de cuello en el Servicio de Urgencia Pediátrica del Hospital Sótero del Río entre los años 2011 y 2018. Se analizaron variables clínicas (anamnesis, examen físico, exámenes de laboratorio generales y específicos y su manejo) y demográficas. Los resultados se analizaron mediante estadística descriptiva con medidas de tendencia central y rango, utilizando Statistical Package for the Social Science (SPSS). Resultados: Se incluyeron 41 pacientes entre 0 y 15 años, con un promedio de edad de 7,2 años. Sesenta y tres por ciento de los pacientes fueron de sexo masculino. Se presentaron 23 (56%) pacientes con abscesos periamigdalinos (PA), 12 (29,2%) con abscesos retrofaríngeos (RF), 5 (12,1%) con abscesos parafaríngeos (PF) y 1 (2,4%) con absceso de tipo mixto (RF- PF). El 60% de los pacientes recibió algún tratamiento médico previo. Se realizó estudio imagenológico en 83% de los pacientes. Todos los pacientes presentaron parámetros inflamatorios elevados. En el 80% de los pacientes se realizó tratamiento médico y algún tipo de drenaje. Conclusiones: Los abscesos profundos del cuello son una entidad relativamente poco frecuente en pediatría, pero potencialmente peligrosa si no se detecta a tiempo, por lo que debemos tener un alto índice de sospecha para evitar las complicaciones.

ABSTRACT Introduction: Deep neck abscesses are pus collections lodged in the deep cervical spaces. They are rare in the pediatric population, however, they can present life-threatening complications. Objective: To characterize the patients who consult for deep neck abscesses in the pediatric emergency department of Dr. Sótero del Rio Hospital. Material and method: Descriptive retrospective study. A review of clinical records of patients diagnosed with deep neck abscesses in the pediatric emergency department of Dr. Sótero del Rio Hospital between 2011 and 2018 was made. The clinical (anamnesis, physical exam, general and specific laboratory exams and management) and demographic characteristics were evaluated. The results were analyzed by descriptive statistics with measures of central tendency and range, using Statistical Package for the Social Science (SPSS). Results: Forty-one patients between 0 and 15 years of age were included, with an average age of 7.2 years. 63% of the patients were male. There were 23 (56%) patients with peritonsillar abscesses (PA), 12 (29.2%) with retropharyngeal abscesses (RF), 5 (12.1%) with parapharyngeal abscesses (PF) and 1 (2.4%) with abscess of mixed type (RF-PF). 60% of the patients received some previous medical treatment. An imaging study was performed in 83% of the patients. All the patients presented high inflammatory parameters. In 80% of patients, medical treatment and some type of drainage were performed. Conclusions: Deep abscesses of the neck are a relatively rare entity in pediatrics, but potentially dangerous if not detected in time, so we must have a high index of suspicion to avoid complications.

Defining the role of surgical drainage in paediatric deep neck space infections.

OBJECTIVES: Surgical drainage is the traditional mainstay of treatment of paediatric deep neck space infection (DNSI), but recently non-operative management in selected cases has been advocated. We sought to identify any characteristics predictive of requirement for surgical intervention. DESIGN: Retrospective cohort study using receiver operating characteristics analyses. SETTING: Tertiary referral paediatric hospital. PARTICIPANTS: Children (≤16 years) with a radiologically confirmed diagnosis of retro- or parapharyngeal abscess over a ten-year period. MAIN OUTCOME MEASURES: Predictive value of clinical and radiological variables in determining the requirement for surgical intervention. Length of hospital stay (LoS) was also examined. RESULTS: Ninety-three children were studied, 15 (16.1%) of whom underwent immediate surgery, 42 (45.2%) of whom underwent delayed surgery following an initial period of conservative management, and 36 (38.7%) of whom were managed conservatively. Age, WCC and CRP were not predictive of the need for surgical drainage. Radiological abscess diameter, however, was predictive of requirement surgery (AUC = 0.85 [95% CI ± 0.09] P = 0.02), with a cut-off value of 2.5 cm determined assuming equal weight to sensitivity and specificity. All DNSIs were successfully treated with no adverse outcomes, and there was no significant difference in LoS between groups. In those managed surgically, outcome and LoS did not depend on yield of pus. CONCLUSIONS: Selected paediatric DNSIs can be successfully managed conservatively, with abscess diameter >2.5 cm a significant predictor of need for surgical intervention. Any benefit of surgery does not appear to depend on intra-operative yield of pus.

Retropharyngeal abscess as a paradoxical reaction in a child with multi-drug-resistant tuberculosis.

Paradoxical reactions (PRs) are exaggerated inflammatory responses owing to recovery of cellular immunity following initiation of anti-tuberculous therapy (ATT). The presentation is worsening of pre-existing symptoms or development of new lesions. A 14-year-old girl with multi-drug-resistant tuberculosis developed a recurrent asymptomatic retropharyngeal abscess while on ATT. She required multiple aspirations of the abscess. Xpert MTB/RIF detected Mycobacterium tuberculosis from the aspirate which was resistant to rifampicin; culture was negative. Following aspirations of the abscess, continued ATT and a 2-month course of corticosteroids, she remains well and has gained weight. A retropharyngeal abscess presenting in the form of a PR has not been reported previously in adults or children.