Case 38: Retropharyngeal Abscess

Abstract

A 1-year-old girl (18 lbs.) presents with an acute retropharyngeal abscess. The child has great difficulty in swallowing. She is able to maintain a reasonable airway by holding her head in full extension with her mouth wide open (oxygen saturation 96 % on room air). Her history is unremarkable. The family history is negative for anesthesia-related complications. The patient is receiving a cephalosporin IV. Monitors are placed in the operating room. The child is very worried and will not let you examine her mouth. Fiber-optic intubation is not an option. An experienced Ear, Nose, Throat (ENT) surgeon is available with a tracheostomy set. Because the patient has her mouth wide open, you can see the uvula. She is allowed to sit forward resting her elbows on a Mayo stand. After preoxygenation for 3 min in the sitting position, a rapid-sequence induction with thiopental (25 mg) and succinylcholine (15 mg) is performed. The vocal cords are not seen due to severe swelling of the oropharynx. Despite this, you safely place a 4-mm internal diameter (i.d.) endotracheal tube (ETT) in the trachea. Anesthesia is maintained with fentanyl and sevoflurane in nitrous oxide (70 %) in oxygen. A fluctuating mass is seen bulging forward from the posterior pharyngeal wall. The abscess is incised and drained. The surgeon insists that he has made the oropharynx space larger and, hence, it is safe to extubate the patient. You are concerned and would rather leave the ETT in overnight. You state that although you got the ETT in at the start of the procedure, you may not be able to do it again if it should prove necessary. The surgeon insists that you attempt to extubate the patient. You let the cuff down and the patient can breathe around the tube.