N e u r o r a d i o l o g y / H e a d a n d N e c k I m a g i n g • P i c t o r i a l E s s ay

Hoang et al.
Multiplanar Imaging of Retropharyngeal Space

Neuroradiology/Head and Neck Imaging

Pictorial Essay
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Multiplanar CT and MRI of

Collections in the Retropharyngeal
Space: Is It an Abscess?
Jenny K. Hoang1 OBJECTIVE. The purpose of this article is to describe a practical imaging approach to
Barton F. Branstetter IV2 evaluating collections in the retropharyngeal space.
James D. Eastwood1 CONCLUSION. The differential diagnoses for fluid in the retropharyngeal space in­
Christine M. Glastonbury 3 clude both noninfectious and infectious processes. The multiplanar capabilities of CT and
MRI are ideal for characterizing and delineating collections. In this pictorial essay, we de­
Hoang JK, Branstetter BF IV, Eastwood JD, scribe the anatomy of the retropharyngeal space and offer a four-step approach to evaluating
Glastonbury CM retropharyngeal collections on multiplanar imaging.

Keywords: retropharyngeal abscess, retropharyngeal
cellulitis, retropharyngeal edema, retropharyngeal
nodes, retropharyngeal space
DOI:10.2214/AJR.10.5116
Received June 8, 2010; accepted after revision
August 23, 2010.
C. M. Glastonbury is an investor and consultant for
Amirsys.
J. K. Hoang is a GE-AUR fellow for 2010–2011.
1
Department of Radiology, Division of Neuroradiology,
Duke University Medical Center, Box 3808, Erwin Rd,
Durham, NC 27710. Address correspondence to
J. K. Hoang (jenny.hoang@duke.edu).
2
Department of Radiology, University of Pittsburgh,
Pittsburgh, PA.
3
Departments of Radiology and Biomedical Imaging,
Otolaryngology–Head and Neck Surgery, and Radiation
Oncology, University of California, San Francisco,
San Francisco, CA.
WEB
This is a Web exclusive article.
AJR 2011; 196:W426–W432
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© American Roentgen Ray Society
T
he retropharyngeal space spans
the skull base to the mediasti­
num and normally contains fat
and lymph nodes. The main
causes of fluid expanding the retropharyn­
geal space can be divided into noninfectious
retropharyngeal edema and retropharyngeal
infection, including suppurative retrophar­
yngeal nodes and retropharyngeal abscess.
The multiplanar capabilities of CT and MRI
are ideal for characterizing and delineating
collections. In this pictorial essay, we present
the anatomy of the retropharyngeal space
and offer a practical approach to evaluating
retropharyngeal collections on multiplanar
imaging. Important points to remember are
that one, a suppurative retropharyngeal node
is contained by the nodal capsule; two, a ret­
ropharyngeal space abscess is contained
only by the fascia of the retropharyngeal
space and has the potential for devastating
complications from mass effect and the
spread of infection; and three, retropharyn­
geal space edema is noninfectious and re­
solves spontaneously as its cause is treated.
Normal Anatomy
Understanding the anatomy of the retro­
pharyngeal space is the key to appreciating
the spread of infection and formation of a
retropharyngeal abscess [1] (Fig. 1). The ret­
ropharyngeal space is posterior to the phar­
ynx and esophagus and anterior to the pre­
vertebral muscles. It is bound by the visceral
fascia anteriorly, the prevertebral fascia pos­
teriorly, and the carotid sheaths laterally.
The alar fascia, a deep layer of the deep
cervical fascia, divides the retropharyngeal
space into two components: the true retropha­
ryngeal space and the danger space (Fig. 1).
The anterior true retropharyngeal space ex­
tends from the clivus to a variable level from
T1 to T6 vertebrae, where the alar fascia fuses
with the visceral fascia to obliterate the true
retropharyngeal space [2]. The posteriorly lo­
cated danger space, however, extends further
inferiorly into the posterior mediastinum and
to the level of the diaphragm. Because the
alar fascia is very thin, the danger space and
true retropharyngeal space cannot be distin­
guished on imaging in a healthy patient.
The normal contents of the retropharynge­
al space include fat, small vessels, and lymph
nodes. The retropharyngeal nodes drain the na­
sopharynx, oropharynx, nasal cavity, parana­
sal sinuses, middle ears, and prevertebral space.
Retropharyngeal nodes are often large in chil­
dren and begin to atrophy before puberty.
Imaging Approach
We recommend that the interpretive ap­
proach to a retropharyngeal space collection
include an evaluation of multiplanar imaging
for four characteristics: distribution of fluid,
configuration and mass effect, presence or
absence of a thick enhancing wall, and ancil­
lary findings (Table 1).
Retropharyngeal Edema
Retropharyngeal edema is the presence of
nonpurulent fluid in the retropharyngeal space.
The accumulation of fluid is thought to be due

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 Multiplanar Imaging of Retropharyngeal Space

TABLE 1:  Four-Step Interpretive Approach to Retropharyngeal Space Collection on Multiplanar Imaging
Step Retropharyngeal Edema Suppurative Retropharyngeal Node Retropharyngeal Abscess
Fluid distribution Fills the retropharyngeal space from Unilateral Fills the retropharyngeal space from
side to side side to side
Configuration and mass effect Axial images show ovoid, rectangular, Rounded or ovoid configuration; mass Rounded or ovoid configuration;
or “bow-tie” configuration; sagittal effect varies moderate-to-marked mass effect
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images show diffuse configuration

Thick enhancing wall
Ancillary findings
with tapered inferior and superior
margins; mild mass effect
No
Neck infection adjacent to the
retropharyngeal space or suppurative
retropharyngeal node; internal jugular
vein thrombosis; focal calcification
anterior to C1–C2; other inflammatory
signs of radiotherapy
Can have an enhancing wall
Primary infectious source such as otitis
media or tonsillitis; retropharyngeal
edema is a common associated
finding
Most have an enhancing wall
Primary infectious source such as otitis
media or tonsillitis; presence of a
foreign body in traumatic causes;
complications in the airway,
mediastinum, or vessels

to altered lymphatic drainage or excess lymph
production. There are multiple causes of retro­
pharyngeal edema, including radiotherapy, in­
ternal jugular vein (IJV) thrombosis (Fig. 2),
and retropharyngeal calcific tendinitis (Fig. 3).
The latter is an inflammatory condition due to
calcium hydroxyapatite deposition in the lon­
gus colli tendons [3]. Rupture of crystal de­
posits provokes an inflammatory response and
results in acute neck pain and retropharyn­
geal space edema. Another common cause of
retrophar­yngeal edema is infection in spaces
surrounding the retropharyngeal space. In an
adult, the prevertebral space is the most com­
mon source of infection (Fig. 4), compared
with the pharynx in children (Figs. 5 and 6).
Our four-step approach for evaluating ret­
ropharyngeal edema is as follows: first, with
regard to fluid distribution, edema uniformly
fills the retropharyngeal space from side to
side. Second, edema has a smooth ovoid, rect­
angular, or “bow-tie” configuration on axial
imaging and a diffuse craniocaudal distribu­
tion on sagittal images, with tapered inferi­
or and superior margins; there is only mild
mass effect. Third, there is no wall thicken­
ing or enhancement. Fourth, ancillary find­
ings include IJV thrombosis, adjacent neck
infection, and focal calcification anterior to
C1–C2 in the longus colli tendons [4, 5].
Retropharyngeal edema does not require
surgical drainage. Most cases resolve as the
cause of edema is treated.
Suppurative Retropharyngeal Node
A suppurative retropharyngeal node is a re­
active lymph node that has undergone lique­
factive necrosis but is contained by the nodal
capsule (also known as retropharyngeal ad­
enitis or intranodal abscess) (Figs. 5 and 6).
The process begins as a bacterial infection in
the pharynx, paranasal sinuses, middle ear, or
the prevertebral space. As infection drains to
the retropharyngeal node, the node enlarges
as the result of proliferation and invasion of
inflammatory cells (i.e., reactive lymphade­
nopathy). Next, the node can become edem­
atous and this is referred to as the presup­
purative phase [6]. Finally, necrosis and pus
formation occur to create a suppurative ret­
ropharyngeal node. Such infections are most
commonly seen in early childhood before the
retropharyngeal nodes atrophy.
Our four-step approach for evaluating suppu­
rative retropharyngeal nodes is as follows: first,
with regard to fluid distribution, such nodes are
laterally located. Second, these nodes have a
rounded or oval configuration, and the mass
effect varies depending on the degree of nod­
al enlargement. Third, with regard to the wall,
a thin hyperdense or enhancing rim may be
found around this low-density node [7, 8]; an
edematous node in the presuppurative phase
can also be low density. Fourth, ancillary
findings include evidence of the primary in­
fectious source, such as otitis media or tonsil­
litis. Retropharyngeal edema is a common as­
sociated finding.
There is confusion in the literature about
the terms “suppurative retropharyngeal node”
and “retropharyngeal abscess.” Suppurative
retropharyngeal node, or adenitis, is regard­
ed as a more accurate description for infection
contained by the nodal capsule. The distinc­
tion from abscess is important because many
cases do not have purulent material at surgery
and can be successfully managed medically.
The sign of rim enhancement and a low-den­
sity center is less than 57% specificity for pu­
rulent material at surgery [6]. Shefelbine et al.
[6] found that the volume of the hypodense
focus is a better predictor of pus at surgery.
In that study, patients with purulence present
at surgery had a mean hypodense volume on
CT of 4.4 cm3 [6]. Patients without purulence
at surgery were grouped with those who re­
sponded to medical therapy. This group had
CT scans with a smaller mean volume in the
low-attenuation focus (2.2 cm3). The current
treatment for suppurative retropharyngeal
nodes is a trial of IV antibiotics if the patient’s
condition is stable [9, 10]. Surgical drain­
age is considered if there is progression after
medical therapy or if the suppurative node is
large at presentation.
Retropharyngeal Abscess
Retropharyngeal abscess is most common­
ly due to rupture of a suppurative retrophar­
yngeal node into the retropharyngeal space
(Fig. 7) and is contained only by the fascia
surrounding the retropharyngeal space. Oth­
er less common causes of a retropharyngeal
abscess are spread of infection from contig­
uous spaces across the fascial boundaries
or direct inoculation from penetrating trau­
ma (Fig. 8). Before infection evolves into a
walled abscess, it is known as retropharyn­
geal cellulitis or phlegmon. This condition
can be difficult to differentiate from retro­
pharyngeal edema. The typical clinical pre­
sentation of retropharyngeal abscess is acute
to subacute onset of neck pain, dysphagia or
odynophagia, and a low-grade fever.
Our four-step approach for evaluating ret­
ropharyngeal abscess is as follows: first, with
regard to fluid distribution, a retropharyngeal
abscess fills the retropharyngeal space from
side to side [7, 8]. Second, retropharyngeal
abscesses have an oval or rounded configura­
tion; moderate-to-marked mass effect can pro­
duce anterior displacement of the pharynx and
flattening of prevertebral muscles. Third, retro­
pharyngeal abscess usually has a thick enhanc­
ing wall. Fourth, ancillary findings include
evidence of primary infection or presence of a

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 Hoang et al.

foreign body in traumatic causes. In addition,
the radiologist should search carefully for
complications [10, 11].
The mortality rate for retropharyngeal ab­
scess is less than 1% [12] and has declined in
the last 50 years because of the availability of
antibiotics and early diagnosis with CT. The
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differentiate between noninfectious and in­
fectious causes.
Acknowledgment
We thank Roxana Gafton for her editorial
assistance in preparing the manuscript.
pharynx. Neuroimaging Clin N Am 2003; 13:393–
410 [ix]
8. Hudgins PA. Nodal and nonnodal inflammatory
processes of the pediatric neck. Neuroimaging
Clin N Am 2000; 10:181–192 [ix]
9. Craig FW, Schunk JE. Retropharyngeal abscess
in children: clinical presentation, utility of imag­

most urgent complication is airway compres­
sion from mass effect on the larynx and phar­
ynx. Airway compromise is suggested in up to
3% of patients by the clinical symptom of stri­
dor [12]. The other feared complications are
rare and documented in the literature as case
reports and case series. Infection can spread in­
feriorly via the danger space to the mediasti­
num, where it can result in mediastinitis, peri­
carditis, pleuritis, and empyema [13] (Fig. 9).
Infection can also break through the surround­
ing fascial planes and cause infection in the air­
way, spine, or carotid space. Vascular compli­
cations of carotid space infection include IJV
thrombosis, carotid artery rupture, and pseudo­
aneurysm [14–16]. Finally, the infection itself
can evolve into necrotizing fasciitis and sepsis
[13]. Because these complications are associ­
ated with significant morbidity and mortality,
a true retropharyngeal abscess usually requires
prompt surgical drainage.
Conclusion
The accurate diagnosis of retropharynge­
al collections will help triage patients for ap­
propriate management. A four-step imaging
assessment with multiplanar imaging will
help to recognize key imaging findings that
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tanabe AS. Retropharyngeal space: evaluation of
normal anatomy and diseases with CT and MR
imaging. Radiology 1990; 174:59–64
3. Ring D, Vaccaro AR, Scuderi G, Pathria MN,
Garfin SR. Acute calcific retropharyngeal tendi­
nitis: clinical presentation and pathological char­
acterization. J Bone Joint Surg Am 1994; 76:1636–
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4. Kanzaria H, Stein JC. A severe sore throat in a
middle-aged man: calcific tendonitis of the longus
colli tendon. J Emerg Med 2008 [epub ahead of
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5. Eastwood JD, Hudgins PA, Malone D. Retrophar­
yngeal effusion in acute calcific prevertebral ten­
dinitis: diagnosis with CT and MR imaging.
AJNR 1998; 19:1789–1792
6. Shefelbine SE, Mancuso AA, Gajewski BJ, Ojiri
H, Stringer S, Sedwick JD. Pediatric retropharyn­
geal lymphadenitis: differentiation from retro­
phar­yngeal abscess and treatment implications.
Otolaryngol Head Neck Surg 2007; 136:182–188
7. Branstetter BF 4th, Weissman JL. Infection of the
facial area, oral cavity, oropharynx, and retro­
ing, and current management. Pediatrics 2003;
111:1394–1398
10. Johnston D, Schmidt R, Barth P. Parapharyngeal
and retropharyngeal infections in children: argu­
ment for a trial of medical therapy and intraoral
drainage for medical treatment failures. Int J Pe-
diatr Otorhinolaryngol 2009; 73:761–765
11. Page NC, Bauer EM, Lieu JE. Clinical features
and treatment of retropharyngeal abscess in chil­
dren. Otolaryngol Head Neck Surg 2008; 138:
300–306
12. Coulthard M, Isaacs D. Retropharyngeal abscess.
Arch Dis Child 1991; 66:1227–1230
13. Papalia E, Rena O, Oliaro A, et al. Descending
necrotizing mediastinitis: surgical management.
Eur J Cardiothorac Surg 2001; 20:739–742
14. Beningfield A, Nehus E, Chen AY, Yellin S.
Pseudoaneurysm of the internal carotid artery af­
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Neck Surg 2006; 134:338–339
15. Hudgins PA, Dorey JH, Jacobs IN. Internal ca­
rotid artery narrowing in children with retro­
pharyngeal lymphadenitis and abscess. AJNR
1998; 19:1841–1843
16. Ide C, Bodart E, Remacle M, De Coene B, Nisolle
JF, Trigaux JP. An early MR observation of ca­
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AJNR 1998; 19:499–501

A B C
Fig. 1—Normal anatomy of retropharyngeal space.
A, Diagram of fascial layers of retropharyngeal space (double-headed arrow). True retropharyngeal space is between visceral fascia and alar fascia of deep layer of deep
cervical fascia. Danger space is between alar and prevertebral layers of deep cervical fascia. These two components cannot be distinguished on MRI and CT in healthy patient.
B and C, Axial enhanced CT (B) and T2-weighted MRI (C) images show normal thin fat-containing retropharyngeal space (arrowheads, B; single arrowhead, C). Anterior
visceral fascia surrounds pharynx and esophagus. Posterior prevertebral fascia invests longus colli and other prevertebral muscles. Carotid spaces form lateral walls
of retropharyngeal space and contain internal or common carotid artery (CCA) and internal jugular vein (IJV). Lymph nodes lie in true retropharyngeal space and are
subdivided into lateral and medial groups. Lateral lymph nodes are located lateral to longus colli and capitis muscles and extend from skull base to C3.
(Fig. 1 continues on next page)

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 Multiplanar Imaging of Retropharyngeal Space

Fig. 1 (continued)—Normal anatomy of

retropharyngeal space.
D and E, Sagittal enhanced CT (D) and T1-weighted
MRI (E) images show normal thin fat-containing
retropharyngeal space (arrowheads, D and E). Fascial
layers that form anterior and posterior walls attach
to clivus. Danger space of retropharyngeal space
extends from clivus to mediastinum.
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D E

A B

Fig. 2—32-year-old man with retropharyngeal edema

due to internal jugular vein (IJV) thrombophlebitis.
Infected catheter used for renal dialysis was
removed 3 weeks earlier. New subclavian catheter
was placed. One week later, patient presented with
fever and right neck tenderness.
A and B, Axial unenhanced CT images show
collection (arrowheads, A and B) filling from side to
side in retropharyngeal space, with mild mass effect.
This is consistent with retropharyngeal edema. There
is high-density thrombosis in right IJV (arrow, A and
B) and edema in surrounding carotid space.
C, Sagittal unenhanced reformatted CT image
shows fluid expanding in retropharyngeal space
(arrowheads).
D, Axial enhanced CT image performed 10 hours later
shows reduction in amount of retropharyngeal edema
(arrowheads). There is contrast-filling defect (arrow)
in thrombosed IJV.
C D

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 Hoang et al.
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A B C
Fig. 3—26-year-old man with retropharyngeal edema secondary to calcific tendinitis. He presented with 2-day history of neck pain, stiffness, and tenderness.
A and B, Axial unenhanced (A) and sagittal reformatted (B) CT images show diffuse low attenuation collection (arrowheads, A and B) in retropharyngeal space with mild
mass effect and tapered margins. These findings are in keeping with retropharyngeal edema.
C, Parasagittal reformatted CT image in bone windows shows focal calcification (arrow) in right longus colli tendon at C1–C2 level. (Courtesy of Everton KL, Durham, NC)

A B C
Fig. 4—47-year-old man with retropharyngeal edema due to cervical spine epidural abscess. Patient had history of IV heroin use and presented with 1-week history of
neck pain.
A, Axial fat-suppressed gradient-echo MRI scan shows fluid collection (arrowheads) filling retropharyngeal space from side to side with mild mass effect. There is also
hyperintensity in right longus colli muscle and other prevertebral muscles (curved arrow). CCA = common carotid artery, IJV = internal jugular vein, LC = longus collis.
B and C, T1-weighted (B) and T2-weighted (C) MRI scans show anterior epidural collection (arrow, B and C) extending from C2 to C4 vertebral levels. T1-weighted
image shows hyperintense stripe (arrowheads, B) in keeping with fat-containing true retropharyngeal space. Posterior to fat stripe is thin diffuse T1 isointense and T2
hyperintense signal collection (arrowhead, C) in danger space (asterisks, B and C) from C2 to mediastinum. These findings are consistent with retropharyngeal edema in
danger space secondary to prevertebral space infection.

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 Multiplanar Imaging of Retropharyngeal Space

Fig. 5—3-year-old boy with retropharyngeal

suppurative node and retropharyngeal edema. He
presented with fever and neck pain and 1-week
history of upper respiratory tract infection symptoms.
A, Axial enhanced CT scan at level of nasopharynx
shows unilateral collection in left retropharyngeal
space (arrow). There is mild mass effect and
thin high-density rim. This is consistent with
retropharyngeal suppurative node.
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B, Axial enhanced CT scan at level of oropharynx

A B
shows fluid density bilaterally in retropharyngeal
space (arrowheads) with mild mass effect and no
rim enhancement. This is in keeping with reactive
retropharyngeal edema.
C and D, Coronal (C) and sagittal (D) reformatted
CT images show oval-shaped left retropharyngeal
suppurative node (arrow, C) and retropharyngeal
edema (arrowheads, C and D). Patient improved with
IV antibiotics and did not require surgical drainage.
CCA = common carotid artery, ICA = internal carotid
artery, LC = longus collis.

C D

A B C
Fig. 6—10-year-old boy with retropharyngeal suppurative node and retropharyngeal edema. He presented with 1-day history of fever after 3 days of odynophagia and left
neck pain and stiffness.
A and B, Axial enhanced (A) and coronal reformatted (B) CT images show rounded unilateral collection in left retropharyngeal space (straight arrow, A and B). There
is mild mass effect and thin high-density rim. This is consistent with retropharyngeal suppurative node. There is also enlarged right retropharyngeal node without low
density (curved arrow, A and B) in keeping with reactive lymphadenopathy.
C, Axial enhanced CT image at higher level in oropharynx shows collection (arrowheads) filling retropharyngeal space from side to side with mild mass effect and no rim
enhancement. This is in keeping with reactive retropharyngeal edema. Intraoperative examination found patient to have firm palpable mass behind tonsil pillars. From
transoral approach, only tiny amount of pus was expressed. He improved with IV antibiotic therapy and was discharged on oral antibiotics.

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 Hoang et al.

Fig. 7—1-year-old girl with retropharyngeal abscess.

She presented with fever and 1-week history of
worsening stridor. This was preceded by otitis media
treated with oral antibiotics.
A and B, Axial (A) and sagittal reformatted (B)
enhanced CT images show large collection
(arrowheads, A and B) filling both sides of
retropharyngeal space. Collection has marked mass
effect with obliteration of airway (asterisk, A). There
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are enhancing septations and thick enhancing wall.

Endotracheal tube (arrow, A) was required before
CT scan.

A B

Fig. 8—3-year-old girl with retropharyngeal cellulitis

due to penetrating injury to oropharynx, which
resulted from fall while running with stick in her
mouth. She presented 5 days later with fever and
odynophagia.
A and B, Axial (A) and sagittal reformatted (B)
enhanced CT images show large mucosal defect
(arrow, A and B) in posterior oropharyngeal wall and
gas (asterisks, A and B) and fluid (arrowheads, A and
B) in retropharyngeal space. There is mild diffuse
expansion of retropharyngeal space but no wall
thickening or enhancement. On surgical exploration,
breech in mucosa was noted in posterior pharyngeal
wall. There was no purulent material or fluctuant
mass. Patient improved with 2-day course of IV
antibiotics and was discharged with oral antibiotics.

A B

Fig. 9—37-year-old man with retropharyngeal

abscess and necrotizing fasciitis in neck complicated
by descending mediastinitis.
A, Axial enhanced CT image of neck at level of hyoid
shows collection (arrowheads) filling retropharyngeal
space from side to side. There is only mild mass
effect, but thin wall enhancement is present. Edema
is also noted in pharyngeal mucosal space (asterisk),
parapharyngeal space, and submandibular space
(arrows).
B, Axial enhanced CT image of upper thorax
shows fluid collection (arrowheads) in posterior
mediastinum tracking into right middle mediastinum.
In comparison, there is normal low density fat in
anterior mediastinum (curved arrow). Patient also had
reactive bilateral pleural effusions.
A B

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