CT-Guided Navigation for Complex Retropharyngeal Abscesses: A Case Series

ObjectivesTo describe our experience with CT-based neuronavigation-assisted transoral drainage for anatomically complex pediatric retropharyngeal abscesses (RPAs) and to propose selection criteria for its use. Pediatric deep neck infections, particularly RPAs, pose diagnostic and therapeutic challenges because of complex anatomy and proximity to the internal carotid artery, internal jugular vein, and lower cranial nerves. Standard management combines intravenous antibiotics with selective surgical drainage; however, obscured landmarks, absent mucosal bulging, and adjacent neurovascular structures can compromise accurate localization, especially in high, deep, or multiloculated collections.MethodsWe reviewed three children (aged 12 months to 12 years) who presented with multiloculated RPAs that enlarged or failed to improve despite intravenous antibiotics, including collections extending toward the skull base and adjacent to the internal carotid artery. All underwent transoral incision and drainage with intraoperative CT-based image-guided navigation using a dedicated navigation acquisition protocol.ResultsNavigation enabled complete evacuation of all collections without intraoperative complications. Recovery was uneventful, and follow-up showed complete resolution without recurrence. While most superficial RPAs can be managed safely with standard transoral drainage, high, deep, multiloculated, or distant collections increase the risk of incomplete drainage and complications. Image-guided navigation improved localization and trajectory planning. Because navigation platforms are optimized for rigid (bony) landmarks, accuracy may degrade with head repositioning, retraction, or soft-tissue shift after decompression; therefore, frequent accuracy checks and limited head manipulation are essential. Thin-slice CT navigation protocols may increase radiation exposure, which should be balanced against the morbidity of incomplete drainage, repeat surgery, or external approaches.ConclusionsCT-based neuronavigation-assisted transoral drainage is a safe, precise, minimally invasive option for selected complex pediatric RPAs-particularly skull-base-directed, deep, multiloculated, or mucosally distant collections without obvious bulging.