Retropharyngeal abscess in adults: five case reports and review of the literature

An uncommon cause of retropharyngeal abscess in adults: Cervical pyogenic spondylodiscitis

INTRODUCTION AND IMPORTANCE

Retropharyngeal abscess (RPA) represents a rare and life-threatening condition, particularly uncommon in the adult population. The simultaneous occurrence of RPA, and cervical spondylodiscitis is an exceedingly infrequent situation.

CASE PRESENTATION

we reported the case of a 67-year-old male who presented to our department with complaints of sore throat, restricted neck range of motion, as well as numbness and weakness in the right arm persisting for two weeks. Cervical computed tomography identified a retropharyngeal abscess measuring 15 cm in height around C3 to D3. Subsequent cervical magnetic resonance imaging disclosed revealed infectious spondylodiscitis at C5-C6-C7 and partially collected epiduritis from C5 to C7. The abscess was promptly drained by the transoral way. Following the procedures, the patient was discharged with a cervical collar and a prescribed course of antibiotics.

CLINICAL DISCUSSION

Cervical retropharyngeal abscesses complicating spondylodiscitis is very rare. The clinical symptoms are variable and nonspecific. Given the potentially life-threatening nature of this condition, its management represents a real challenge.

CONCLUSION

The management of such complex cases necessitates a multidisciplinary approach involving otolaryngologists, neurosurgeons, and infectious disease specialists to mitigate the risk of complications and prevent any potential delays in treatment.

Effective surgical drainage of a massive retropharyngeal abscess via an incision in the posterior wall of the oropharynx under local anesthesia

INTRODUCTION

A retropharyngeal abscess is a deep neck infection, uncommon in adults but more prevalent in children. This report details a rare case of a huge retropharyngeal abscess in an adult female, effectively managed by an incision in the posterior oropharyngeal wall under local anesthesia.

CASE PRESENTATION

A 76-year-old woman with hypertension, diabetes, ischemic heart disease, and total thyroidectomy presented with sudden neck swelling, dyspnea, stridor, and dysphagia. Examination and imaging revealed a large retropharyngeal abscess. The abscess was drained through an incision in the posterior wall of the oropharynx using a local anesthetic, yielding immediate symptom relief. Cultures identified Streptococcus and Staphylococcus aureus, leading to adjusted antibiotics. The patient showed significant improvement, with resolution of respiratory distress and reduced inflammation.

DISCUSSION

The retropharyngeal space, containing lymph nodes and connective tissue, extends from the skull base to the superior mediastinum, communicating with the carotid sheath and parapharyngeal space. Effective management of a critically ill, immunocompromised patient with a resistant retropharyngeal abscess was achieved using an intraoral approach and intravenous antibiotics. This method avoids general anesthesia and minimizes postoperative complications. CT scans are essential for assessing disease extent and planning surgery. Our case highlights the successful treatment of a large abscess with minimal risks.

CONCLUSION

Drainage of retropharyngeal abscesses via the intraoral approach under local anesthesia can be considered a valuable method for high-risk patients who are not candidates for general anesthesia. Additionally, we presented a rare case of an exceptionally large retropharyngeal abscess.

A Difficult Differential Diagnosis in New Neck Masses: Retropharyngeal Abscess or Malignancy?

Retropharyngeal abscesses (RPAs) are rare in the adult population and rarer without an inciting event or comorbidity such as recent oral surgery, neck infection, or pharyngeal trauma. The definitive treatment is incision and drainage of the abscess. Clinical researchers have recently questioned whether invasive surgical intervention is necessary and posed the question of what role antibiotics play in management. Sequelae of RPAs are severe and include rupture of the abscess, erosion of the carotid artery, thrombophlebitis, and most seriously, airway compromise. We present a case where an atypical presentation of an RPA caused a disagreement among specialists, and the debate of whether the described case represented an abscess or malignancy caused a delay in diagnosis and treatment for the patient. Only after invasive and emergent surgical intervention was a final diagnosis able to be made. This case demonstrates the need for more research and official guidance on the management of new neck masses to hasten diagnosis and prevent devastating outcomes.

S, J. Shah N. Use of Navigation System in the Management of Deep Neck Space Infection-A Case Report

Deep neck space infections are an ENT (Ear, Nose, Throat) emergency. Navigation system (NS) can be utilized to assist in locating the exact site of pathology and avoiding iatrogenic injury especially in paediatric patients. This manuscript explores the importance of NS in managing retro pharyngeal abscess (RPA) in an 11 month old baby.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04406-9.

A Diagnostic Dilemma of Prevertebral Abscess Versus Food Bolus on Lateral Neck X-Ray: A Case Report

In this case, a 76-year-old female presenting with globus sensation post-oral intake demonstrated radiographical evidence of mottled radiolucency and prevertebral widening on a lateral neck X-ray at the inferior C4/cricoid cartilage, leading to concern for a prevertebral abscess. A decision was made to proceed with an urgent gastrointestinal endoscopy, and a food bolus was identified and removed, leading to a full remission of the patients' symptoms. In this case, an appropriate diagnosis was achieved by combining multiple investigations, which highlights to clinicians that taking investigations in isolation, with the aforementioned lateral neck X-ray being the primary example, could lead to potential misdiagnosis and mismanagement of patients.

Spontaneous retropharyngeal abscess presenting as delirium in a frail older woman: a case-based review

INTRODUCTION

Retropharyngeal abscess (RPA) is an uncommon infection in older people, which usually presents with localized upper airway symptoms.

CASE PRESENTATION

We present a case of RPA in a 69-year-old frail woman with co-morbidities, who presented atypically with delirium. She initially complained of general symptoms of malaise, body aches and general decline. Her symptoms progressed to hypoactive delirium before she started to localize her complaints to the upper airway. The delirium presentation of RPA is not commonly reported in the literature. Co-morbidities and frailty are likely to be the underlying risk factors for delirium presentation in this case. Most of the RPA cases reported in older people in the literature presented typically with localized symptoms, however these cases had lower burden of morbidities and reported no frailty. In our case report, poor mouth hygiene and dental caries were thought to be the source of infection. Early intervention with antibiotic treatment for total of four weeks resulted in a full recovery.

CONCLUSION

RPA may present with delirium in older people with frailty and co-morbidities. Poor oral hygiene and dental caries, if left untreated, may progress into serious deep space neck infection.

A case of blindness caused by Lemierre's syndrome

Key Clinical Message

We describe a patient who lost her vision because of Lemierre's syndrome. Ophthalmologic complications of Lemierre's syndrome are rare, and very few cases have been reported. Clinicians need to recognize that it is a serious condition that can lead to blindness in some cases.

Abstract

Lemierre's syndrome is a systemic septic embolism resulting from thrombophlebitis of the internal jugular vein. We report a case of blindness caused by Lemierre's syndrome, despite prompt diagnosis and early treatment. A 36-year-old woman was transported to our hospital. She presented with fever, facial swelling, and right visual acuity deterioration. Contrast-enhanced computed tomography revealed a retropharyngeal abscess and right internal jugular vein thrombosis. Blood culture revealed Fusobacterium necrophorum, suggesting Lemierre's syndrome. The patient had septic shock and disseminated intravascular coagulation. We diagnosed her visual impairment as orbital-apex syndrome due to spread of inflammation. After 6 weeks of antimicrobial drug treatments, her general condition had improved, and the retropharyngeal abscess had disappeared. On Day 49 of her illness, she was transferred to a rehabilitation hospital, but her visual acuity was not restored. Clinicians should be aware that Lemierre's syndrome can, although rarely, cause blindness.

Deep Neck Infection: A Case of Retropharyngeal Abscess

The incidence of retropharyngeal abscesses has been decreasing since the introduction of antibiotic therapy, and it is currently a rare diagnosis in adults, although there are some recent cases in the literature. Given its seriousness, if not treated promptly, the infection can progress rapidly and its complications can be fatal, making it a serious health problem. A 79-year-old woman presented at her primary care center with complaints of persistent odynophagia for about two weeks and rapidly progressive dysphagia in five days, initially for solids and later for solids and liquids. On observation, she had difficulty swallowing saliva and presented a painful mass in the bilateral anterior submental and anterior cervical region. Due to the rapid progression of symptoms and the findings of the physical examination, the patient was referred to the emergency department for a suspected abscess or cervical mass. In the emergency department, a cervical CT scan was performed, which revealed a retropharyngeal abscess measuring approximately 7 x 6 x 4 cm, involving the right carotid artery and internal jugular vein, with compression of the internal jugular vein. The patient was admitted to the otorhinolaryngology department, where intravenous antibiotic therapy with third-generation cephalosporin and clindamycin was initiated. She underwent exploration in the operating room to determine the cause of the abscess and transoral drainage of the already spontaneously draining abscess. After completing antibiotic therapy, a follow-up CT scan showed complete resolution of the abscess without suggestive masses of neoplasm or foreign bodies, therefore, the cause of the abscess has not been identified.  The most frequent cause of retropharyngeal abscess in adults is dental septic foci and another commonly described cause is the ingestion of foreign bodies such as fish bones or chicken bones. Early diagnosis of this condition is crucial, as delays in treatment initiation can lead to the progression of infection into the deep cervical spaces, resulting in serious complications such as mediastinitis, pericarditis, jugular vein thrombosis, sepsis, laryngeal edema, conditions with a high degree of morbidity and mortality. Therefore, it is important for any doctor to be aware of warning signs and symptoms in patients who present such symptoms, especially primary care doctors, who are the first gateway to health services and to whom patients often turn first. This case report shows the importance of suspicion and subsequent referral for timely diagnosis and treatment.

Life-threatening complication of retropharyngeal abscess in an infant: a case report

BACKGROUND

Deep neck space infections are uncommon in infants. Retropharyngeal abscess (RPA) is a deep space neck infection that can present with subtle signs and symptoms. Delay in diagnosis can lead to life-threatening complications. Here we describe life-threatening complication of retropharyngeal abscess.

CASE PRESENTATION

We report a life-threatening complication of retropharyngeal abscess in 10-month old Asian infant weighing 8.2 kg. The patient presented with fever, right-sided neck swelling, hoarseness of voice, and respiratory distress. The clinical and radiological findings were suggestive of airway obstruction complicated by retropharyngeal abscess. The patient was urgently taken to the operating room and underwent (grade 3) intubation. After stabilization, the patient underwent endoscopic trans-oral incision and drainage, during which 5 cc pus was aspirated. Antibiotics were prescribed for 2 weeks following the procedure based on the sensitivity result of the pus culture.

CONCLUSION

In retropharyngeal abscess, a delay in diagnosis can result in life-threatening complications. This report highlights the importance of prompt recognition of a threatened airway and the management of retropharyngeal abscess by emergency physicians. If an emergency physician suspects RPA with airway obstructions, the airway should be immediately secured in a secure environment by otolaryngologist and an anesthesiologist.

The assessment and management of deep neck space infections in adults: A systematic review and qualitative evidence synthesis

OBJECTIVES

To summarise current practices in the diagnosis and management of deep neck space infections (DNSIs). To inform future studies in developing a framework in the management of DNSIs.

DESIGN

This review was registered on PROSPERO (CRD42021226449) and reported in line with PRISMA guidelines. All studies from 2000 that reported the investigation or management of DNSI were included. The search was limited to English language only. Databases searched included AMED, Embase, Medline and HMIC. Quantitative analysis was undertaken with descriptive statistics and frequency synthesis with two independent reviewers. A qualitative narrative synthesis was conducted using a thematic analysis approach.

SETTING

Secondary or tertiary care centres that undertook management of DNSIs.

PARTICIPANTS

All adult patients with a DNSI.

MAIN OUTCOME MEASURES

The role of imaging, radiologically guided aspiration and surgical drainage in DNSIs.

RESULTS

Sixty studies were reviewed. Thirty-one studies reported on imaging modality, 51 studies reported treatment modality. Aside from a single randomised controlled trial, all other studies were observational (n = 25) or case series (n = 36). Computer tomography (CT) was used to diagnose DNSI in 78% of patients. The mean percentage of management with open surgical drainage was 81% and 29.4% for radiologically guided aspiration, respectively. Qualitative analysis identified seven major themes on DNSI.

CONCLUSIONS

There are limited methodologically rigorous studies investigating DNSIs. CT imaging was the most used imaging modality. Surgical drainage was commonest treatment choice. Areas of further research on epidemiology, reporting guidelines and management are required.

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.

A Case of Deep Neck Abscess with Viral Pneumonia in the Covid Era

The coronavirus disease 2019 (COVID-19) pandemic has generated many challenges for physicians, including multiple post-covid long-term effects that are still being studied. We report a case of patient who developed a retropharyngeal abscess with a concomitant viral pneumonia resembling Covid and its management.

Disparate Presentations of Retropharyngeal Abscess: An Experience From a Tertiary Care Centre

To discuss the varied presentations, diagnosis, and prompt management of retropharyngeal abscess for academic importance. A retrospective study was conducted in the Department of Otorhinolaryngology and Head and Neck Surgery in Belagavi district of Karnataka. Six cases of varied age group with diagnosis of retropharyngeal abscess were studied during two-year period from January 2019 to January 2021. Thorough assessment of all cases was done which included symptoms at the time of presentation, clinical examination findings, imaging studies and laboratory results, medical and surgical interventions. Six patients (4 males, 2 females) were diagnosed as having Retropharyngeal abscess. Youngest age of presentation was 2 month infant. The most common symptoms at presentation included fever and odynophagia seen in all six patients. The clinical examination revealed bulge in posterior pharyngeal wall in all cases, cervical lymphadenopathy in one case, drooling of saliva in three and stridor in one patient, diffuse neck swelling in two ptatients, and trismus in two patients. Contrast Enhanced Computerized Tomographic (CECT) scanning was performed in five patients and one patient underwent Magnetic Resonance Imaging (MRI). The abscess was surgically drained in all patients and received intravenous antibiotics after which there was significant improvement. Retropharyngeal space infection if left untreated, they carry the potential to cause life-threatening complications and death. Although with availability of broad-spectrum antibiotics, the mortality rate is low, appropriate and successful management requires a thorough understanding of the anatomy of the neck, knowledge of usual causative organisms and appropriate medical and surgical management.

Streptococcus equi subsp. equi in Retropharyngeal Abscess: Case Report and Review of Literature

Retropharyngeal abscesses (RPAs) represent the group of deep space infections of the neck. Although RPA is a well-known condition, some aspects of it still may be challenging. Localization, symptoms, and etiology may confuse even the most experienced physicians. S. equi subspecies are zoonotic agents and cause multiple diseases in diverse animals. Infections in humans are rare. This report presents an extremely rare case of retropharyngeal abscess in a 12-year-old girl caused by an infection of Streptococcus equi subsp. equi.

Retropharyngeal Abscess in a Fourteen-Month-Old Child Presenting with Dysphagia and Obstructive Sleep Apnea: A Case Report

Retropharyngeal abscess is a relatively uncommon midline deep neck space infection that extends from the base of the skull to the posterior mediastinum, situated between the buccopharyngeal and alar fascias. In this case report, we present a 14-month-old previously healthy female patient who had a high-grade fever for 7 days, associated with neck stiffness and restriction of neck movements to the right side. Her parents noticed decreased oral intake associated with dysphagia, muffled quality of voice, and obstructive sleep apnea. However, the patient had no clinical signs of mechanical obstruction on examination. A contrast-enhanced computed tomography scan of the neck showed a large retropharyngeal septated fluid collection measuring 8 × 3 × 6 cm, which was categorized as a large retropharyngeal abscess that was complicated by descending mediastinitis. The patient was taken immediately to the operation theater for incision and drainage under general anesthesia, after which she was started on intravenous antibiotics.

Retropharyngeal abscess- An unusual complication in a COVID-19 patient

The coronavirus disease 2019 (COVID-19) pandemic has generated many challenges for physicians, including multiple long-term effects that are still being studied. We report a CASE of patient who developed a retropharyngeal abscess post-COVID19 infection.

We report a CASE of a female who was diagnosed with COVID19 pneumonia and hospitalized for a week at an outside institute. Approximately 3 weeks post discharge she developed neck pain, dysphagia, voice change and odynophagia for which she went to an outside emergency department. A soft tissue neck CT was performed and was concerning for retropharyngeal abscess. The patient was then transferred to our institution. On arrival, a CT scan of the neck and nasopharyngoscopy were performed and biopsies of the epiglottis and right inferior tonsillar pole were taken. Biopsies of the epiglottis and tonsil showed acute inflammation, spongiosis, edema and marked dilation of the lymphatics. Her clinical course was complicated by persistent infection requiring multiple washouts, hyperglycemia, tube feed intolerance, dysphagia and deconditioning. A multi-disciplinary approach was instituted for appropriate management.

This case report highlights the necessity for close follow up after recovery from COVID-19 infection, particularly in patients with multiple comorbidities.

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.

Two cases of tuberculous retropharyngeal abscess in adults

Retropharyngeal abscess (RPA) is an acute or chronic deep neck tissue infection. Tuberculous RPA is chronic and extremely rare in adults. A 20-year-old female patient visited the local hospital due to cough and sputum. The sputum smear was positive for acid-fast staining, and lung computed tomography (CT) indicated pulmonary tuberculosis (TB). The patient received the standard regimen of isoniazid+rifampicin+pyrazinamide+ethambutol (HRZE) for 6 months. After HRZE, pulmonary symptoms improved, but some pharyngeal discomfort remained. In another case, a 25-year-old male patient was admitted to our hospital because of a mass on the left side of his neck. Lymph node TB was considered after a puncture biopsy. Lung CT showed no obvious abnormality. After HRZE for 5 months, the mass had progressively enlarged. Both patients underwent B-ultrasonography-guided puncture, and Xpert® MTB/RIF of the abscess was positive and rifampin-sensitive. Tuberculous RPA was diagnosed and treated with isoniazid+rifampicin (HR) for 12 months. After combination anti-TB therapy and surgical drainage, both patients fully recovered. Tuberculous RPA is rare in adults; because of pharyngeal symptoms or progressive enlargement of a neck mass with anti-TB treatment, clinicians need to suspect tuberculous RPA in adults, which is treated with anti-TB therapy and surgery.

Life threatening abscess in the visceral space with penicillin and metronidazole resistant Prevotella Denticola following use of a laryngeal mask airway: case report

Background

Laryngeal mask airways (LMA) are commonly used for airway management. Complications with this device are rare. However, when they do occur, there is a high risk for respiratory problems, necessitating early diagnosis and treatment. We present the first case of a life-threatening abscess spreading in the visceral space caused by a penicillin and metronidazole resistant Prevotella Denticola after the use of an LMA.

Case presentation

A female patient was admitted to our day care centre for bunion surgery. A single use LMA size 3 (Solus®, intersurgical, Wokingham, Berkshire, United Kingdom) was successfully inserted. After surgery, the patient complained of a sore throat and amoxicillin was prescribed by the general practitioner. Three days after surgery the patient was admitted to the Intensive Care Unit (ICU) for obstructive breathing, due to an abscess in the visceral space. Retropharyngeal and certainly parapharyngeal abscesses in adults are already rare. This case however, is unique because it is the first case of abscess spreading into the visceral space after the use of an LMA. Amoxicillin/clavulanate and vancomycin were started. The abscess was incised 5 days later and microbiology showed 3 positive cultures of the anaerobe Prevotella denticola, resistant for penicillin and metronidazole, but sensitive for amoxicillin/clavulanate. The patient fully recovered.

Conclusion

LMA’s are easy to use and are established, safe tools to support ventilation of the airway. In this case, the authors hypothesise a small wound in the lateral pharyngeal wall probably created an opening into the visceral space causing infection with Prevotella denticola, supporting the idea that the pharyngeal mucosal space must be part of the visceral space. Additionally, early recognition and treatment of an LMA induced abscess is necessary to prevent evolution of complications leading to airway obstruction.

Neisseria Cinerea Bacteremia Secondary to a Retropharyngeal Abscess

Neisseria cinerea is a commensal bacteria of the human oropharynx, not thought to be pathogenic, and is rarely associated with serious infections, including bacteremia. Case reports involving invasive N. cinerea infections are uncommon in the literature. Retropharyngeal abscesses are unusual in adults, and are usually attributable to local trauma.Based on a review of the literature, Neisseria cinerea bacteremia secondary to a retropharyngeal abscess has not been described. We present a unique case of an elderly female without clear predisposing factors for a retropharyngeal abscess, who presented with a N. cinerea bacteremia and was found to have an asymptomatic retropharyngeal abscess.

Acute Retropharyngeal Calcific Tendonitis as a Rare Cause of Odynophagia and Neck Pain

Retropharyngeal calcific tendonitis (RCT) is an aseptic inflammatory process of the superior oblique tendons of the longus colli muscle caused by the deposition of calcium hydroxyapatite crystals. We reported a 23-year-old woman who presented with a sudden onset of neck pain with odynophagia after waking up from sleep. Physical examination showed paracervical point tenderness with limited neck movement in all directions. Prior to surgery, further imaging was requested to aid in diagnosis, which in turn revealed RCT. It is important to be aware that RCT presentation may mimic other severe conditions such as retropharyngeal space abscess or meningitis.

Airway Management with Dexmedetomidine and High-Flow Nasal Cannula in a Patient with Deep Neck Infection

Retropharyngeal deep neck infection sometimes necessitates securing of the airway and surgery for drainage. Airway management in patients with deep neck infection is challenging for anesthesiologists. A 56-year-old woman diagnosed with deep neck infection was admitted for incision and drainage. In the first operation for incision and drainage, indirect videolaryngoscope was utilized to confirm the airway before tracheal intubation, and the patient was intubated successfully. In the second operation for wound closure, dexmedetomidine administration and high-flow nasal cannulation were used during monitored anesthesia care throughout a subsequent procedure. The outcome in the present case suggests that indirect videolaryngoscope, dexmedetomidine, and high-flow nasal cannula can facilitate effective management during surgery in patients with retropharyngeal deep neck space infection.

[Retropharyngeal abscess: case study of 5 cases and literature review]

Nous rapportons 5 cas d´abcès rétropharyngés que nous avons corrélé avec la littérature. Il y avait des enfants ainsi que des adultes. Le corps étranger à type d´arête de poisson a été l´étiologie la plus dominante. La dysphagie accompagnée de douleur, la fièvre et le torticolis ont été les symptômes fréquents. L´abcès rétropharyngé siégeait beaucoup plus en région oropharyngée et hypopharyngée. L´imagerie notamment la tomodensitométrie nous a permis d´avoir des informations précises chez les 3 patients qui en ont bénéficié. L´obstruction des voies aéro-digestives a été retrouvé chez la plupart de nos patients. Seulement 4 patients ont bénéficié d´une incision drainage. Tous les patients ont bénéficié d´un traitement médical. Nous avons enregistré le décès de l´enfant de 2 ans dans un tableau de choc septique à J5 post-opératoire. Nous avons constaté la rareté de cette affection dans notre contexte mais engageant le pronostic vital si le diagnostic et le traitement retardent.

Retropharyngeal abscess in a post-lung transplant cystic fibrosis patient with prior cervical fusion: a case study

BACKGROUND

Cystic fibrosis (CF) is a chronic, genetic, incurable disease that affects primarily the respiratory and gastrointestinal systems. End-stage lung disease is the leading cause of death in people with CF, and lung transplant is required to preserve life. Anti-rejection medications are necessary post-transplant; however, these medications lower immune response and increase susceptibility to bacterial infections. Complications from infections post lung-transplant account for approximately 30% of CF-related deaths. Retropharyngeal abscess (RPA) is a rare deep neck infection that occurs most commonly in children. This is the case of a 45-year-old Caucasian male with CF who developed a retropharyngeal abscess post wisdom teeth extraction that seeded into hardware from a previous cervical disc fusion.

CASE PRESENTATION

The patient presented to the emergency department with severe neck and shoulder pain, limited range of motion in his arm and neck, and dysphonia. He reported feeling pain for 10 days and suspected the pain was caused by a weightlifting injury. The patient reported low-grade fever 5 days prior, which responded to acetaminophen. He was afebrile upon admission and in no respiratory distress. Diagnostic labs revealed WBC 22,000/uL and CRP 211 mg/L. The CT scan showed a large abscess in the retropharyngeal space between C2-C7. The immediate concern was airway obstruction and need for possible intubation or tracheostomy. The patient was transferred to ENT service with neurosurgery and transplant consults. The RPA was drained and lavaged. The cervical hardware was discovered to be infected and was removed. The source of the RPA infection was determined to be from the patient's wisdom teeth extraction 6 months prior to RPA. The patient received 8 weeks of intravenous ceftriaxone for Streptococcus pneumoniae bacteremia and underwent revision of his cervical fusion 3 months after hardware removal.

CONCLUSIONS

Clinicians should consider prophylactic antimicrobial therapy for immunocompromised patients when they are at increased risk for transient bacteremia such as following invasive procedures (e.g., tooth extraction). Prophylactic antimicrobial therapy could prevent potentially life-threatening infections such as RPA in immunocompromised patients.

18F-fluorodeoxyglucose positron emission tomography/computed tomography findings in descending necrotizing mediastinitis and cervical vertebral osteomyelitis in a cancer patient: A case report

RATIONALE

A deep neck infection (DNI) with descending necrotizing mediastinitis (DNM) has great clinical importance because of its high morbidity and mortality, particularly when associated with predisposing underlying disease. With the expanding clinical use of F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT), it may be necessary to perform FDG PET/CT for immediate diagnosis and treatment of DNM. To the best of our knowledge, this is the first case report of DNI with DNM diagnosed based on FDG PET/CT findings.

PATIENT CONCERNS

A 65-year-old man who underwent chemotherapy for stage IV lung cancer complained of sore throat, fever, and mild pain in the right upper arm for 4 days before admission.

DIAGNOSES

FDG PET/CT revealed retropharyngeal abscess with acute osteomyelitis of the vertebral bodies of C4 and C5 and DNM. In blood and sputum cultures, Klebsiella pneumoniae was isolated. DNI with DNM was diagnosed based on contrast-enhanced neck and chest CT.

INTERVENTIONS AND OUTCOME

Because of his underlying condition, antibiotic therapy with ceftriaxone and ciprofloxacin was started. There was initial improvement, but the patient died after 2 weeks from sepsis and multiorgan failure.

LESSONS

The findings of DNI with DNM on FDG PET/CT were as follows: as an acute infection, DNM showed more severe uptake relative to the average maximum standardized uptake value of brown fat or physiologic muscle; showed the prevertebral uptake pattern rather than the paravertebral uptake pattern of brown fat; and showed continuous patterns of hypermetabolic lesions from the retropharyngeal/parapharyngeal space to the thoracic prevertebral space.

Diagnosis, and Treatment of Cervical Epidural Abscess and/or Cervical Vertebral Osteomyelitis with or without Retropharyngeal Abscess; A Review

Background:

Every year approximately 19.6 patients/100,000 per year are admitted to hospitals with spinal epidural abscesses (CSEA), 7.4/100,000 have vertebral osteomyelitis (VO)/100,000/year, while 4.1/100.000 children/year have cervical retropharyngeal abscesses (RPA) (i.e., data insufficient for adults).

Methods:

Here we evaluated 11 individual case studies, 6 multiple patient series, and looked at 9 general review articles focusing on CSEA, and/or VO, with/without RPA.

Results:

Of the 11 case studies involving 15 patients, 14 had cervical spinal epidural abscesses (CSEA: 10 CSEA/ VO/RPA, 2 CSEA/VO, 1 CSEA/TSEA, 1 CSEA/ TSEA/LSEA), 13 had cervical osteomyelitis (VO: 11 VO/CSEA, 2 VO/RPA), and 12 had cervical retropharyngeal abscesses (RPA: 10 RPA/CSEA/VO, 2 RPA/VO alone). When patients were treated surgically, they required 12 anterior, and 2 posterior approaches; 1 patient required no surgery. In the 6 larger cervical series involving 355 patients, 4 series involved CSEA (3 CSEA, 1 CSEA/VO), and 2 seires had cervical VO. Primary surgery was performed in 298 patients, while 57 were initially managed medically; 24 of these latter patients failed non-surgical therapy, and required delayed cervical surgery. Notably, all 17 clinical studies advocated early surgery where clinically appropriate for varying combinations of CSEA and/or VO with or without RPA. The 8 final articles reviewed all-levels of SEA and or VO, while also providing additional unique information regarding RPA.

Conclusion:

We analyzed 11 case studies and 6 multiple case series regarding the diagnosis and treatment of combinations of cervical CSEA, and/or VO with or without RPA. We also reviewed 8 articles on the evaluation/ management of all-level SEAs and/or VOs, along with the unique features of RPAs.

Retropharyngeal Abscess. Clinical Review of Twenty-five Years

INTRODUCTION

Retropharyngeal abscess is a serious condition. Its rare occurrence, thus sharing symptoms with other processes, make it a diagnostic challenge for the clinician. Therefore, it is critical to make an early diagnosis to prevent delaying treatment and avoid complications.

OBJECTIVES

To gain knowledge of the epidemiology, pathogenesis, clinical manifestations, the most commonly implicated microorganisms, the type of treatment used, morbidity and mortality of retropharyngeal abscesses at a tertiary institution over the last 25 years.

METHODS

A retrospective study was conducted by reviewing medical records of all patients diagnosed with retropharyngeal abscess in a single centre between 1 January 1990 and 31 February 2016. Thirty-three patients were included in our study. Data such as personal history, present illness, diagnoses and treatment procedures were collected from the medical records.

RESULTS

The incidence during the years of study was 0.2 cases/100 000 inhabitants/year. Personal medical histories most often associated were alcoholism, smoking, diabetes and obesity. The most common aetiology found was impaction of a foreign body (especially fishbone). The most common presenting symptoms were odynophagia and neck pain accompanied by fever. Preventive tracheotomy was performed in the initial management of the patient in 9 cases (27%). The most frequent complication was descending necrotizing mediastinitis. Surgical drainage of the abscess was required in 27 patients (82%), especially with external approaches (17 cases). Two patients had sequelae: paralysis of unilateral vocal cord and Horner's syndrome. No mortality was observed in the patients of the study.

CONCLUSION

Retropharyngeal abscesses must be considered medical-surgical emergencies as they are likely to produce serious complications. We must pay attention to the warning symptoms such as odynophagia and cervical pain, associated or otherwise with dyspnoea, stridor, trismus, and neck stiffness. Advances in diagnostic and therapeutic procedures together with advances in critical care have been a key factor in improving the prognosis and mortality of these patients.

Wisdom Tooth's Revenge: Retropharyngeal Abscess and Mediastinitis after Molar Tooth Extraction

Retropharyngeal abscess is potentially associated with high morbidity and mortality as a result of its direct anatomical connection with the mediastinum. Therefore, knowledge of the relevant anatomy is essential for recognizing the presence and extent of disease in a timely manner. In this case report, we aim to review the pertinent anatomy and patterns of spread of infection from a full blown deep neck space infection to result in mediastinitis and empyema.

Tuberculous retropharyngeal abscess with Pott disease and tuberculous abscess of the chest wall: A case report

RATIONALE

Tuberculous retropharyngeal abscess is rare, but it can be fatal if not treated appropriately. It usually occurs secondary to tuberculosis of the cervical spine. Moreover, tuberculous abscess involving the chest wall is relatively rare in skeletal tuberculosis. Although the optimal treatment is controversial, most clinicians suggest a combination of sufficient antituberculous medication and complete resection to prevent recurrence and increase therapeutic efficacy. Herein, we present an unusual case of retropharyngeal abscess with cervical Pott disease and tuberculous abscess of the chest wall.

PATIENT CONCERNS

The patient was a 27-year-old Indonesian woman who had neck pain, dysphagia, and odynophagia, but no neurological deficit. Examination of the oral cavity showed anterior displacement of the posterior pharyngeal wall. The mass over the right anterior chest wall measured approximately 5 × 4 cm in size.

DIAGNOSES

Radiography and computed tomography findings were suggestive of retropharyngeal abscess extending to the cervical spine and chest wall abscess.

INTERVENTIONS

She was admitted to the hospital for treatment. Drainage of the retropharyngeal and chest wall abscesses with debridement of the chest wall was performed.

OUTCOMES

No complications occurred after early surgical treatment and administration of antituberculous medication. The patient recovered well and went back to her own country after discharge.

LESSONS

Tuberculous retropharyngeal abscess with Pott disease and tuberculous abscess of the chest wall are both complicated diagnoses that physicians have to consider in similar patient presentations.

Tubercular Retropharyngeal Abscess in Association with Aberrant Retropharyngeal Internal Carotid Arteries - A Rare Entity: Imaging Diagnosis and a Word of Caution

Retropharyngeal (RP) abscess is rarely encountered in adults. Still rare is an abscess of tubercular etiology especially without involvement of the underlying cervical spine. We present a case of an immunocompetent woman with a tubercular RP abscess diagnosed on contrast-enhanced cervical computed tomography and confirmed on cytology. Another interesting feature was an aberrant RP course of the internal carotid arteries in this patient. This case report stresses the importance of imaging in establishing an unexpected diagnosis of an RP abscess, suggesting its likely cause, and also in demonstrating the aberration in regional vascular anatomy, and warns the clinician of life-threatening hemorrhagic complication in the event of any diagnostic or therapeutic intervention.

Acute progressive neurological decline in an elderly man

The patient was an 88-year-old man referred to a physical therapist by his primary care physician for a 1-week history of severe neck pain of insidious onset. Based upon the history and physical examination, the physical therapist concluded that the patient's neck pain was mechanical in nature. Initial physical therapist intervention included cervical taping, cervical collar use and instruction in home exercise. At his follow-up visit 4 days after his initial physical therapy visit, the patient reported no improvement. The patient's son, who accompanied him to this visit, also reported that his father had a recent onset of fever and mild confusion. The case was discussed with the patient's physician and it was recommended that the patient report to the emergency department. Evaluation in the emergency department revealed that the patient was febrile with diminished oxygen saturation and an elevated white blood cell count. Chest radiographs were consistent with pneumonia and blood cultures were positive for methicillin-resistant Staphylococcus aureus. The patient was hospitalized and over the next 6 days, his condition progressively declined and quadriplegia below the C4 myotomal level developed. Magnetic resonance imaging of the cervical spine revealed severe cervical central canal stenosis with extensive signal abnormality in the cervical cord, as well as diffuse oedema in the perivertebral soft tissues that was consistent with a retropharyngeal abscess. Despite medical management, the patient subsequently succumbed to the complications of pneumonia and quadriplegia.

Pharyngeal Emergencies

Pharyngeal emergencies, which can be subdivided into traumatic versus nontraumatic, are a common cause of Emergency Department visits. Patients often present to Emergency Department with a wide variety of pharyngeal symptoms, for which computed tomography imaging has become the first line imaging modality. Familiarity with these conditions enables a radiologist to make a prompt diagnosis, assess the extent of disease, and evaluate for potential complications. In this chapter, we present a brief overview of nontraumatic pharyngeal emergencies based on anatomic subdivisions (nasopharynx, oropharynx, and hypopharynx), discuss their etiologies, clinical presentations, computed tomography imaging findings, and management options. We will also discuss differential diagnoses based on imaging findings.

Retropharyngeal abscess after chemotherapy

Chemotherapy increases susceptibility to infection due to the effect on cell-mediated and humoral immunity. Retropharyngeal abscess is a serious head and neck infection that rapidly progresses from toxicity, whether the patient is neutropenic or not. The risk should be carefully assessed with any chemotherapeutic agent, especially docetaxel.

Life-threatening parapharyngeal and retropharyngeal abscess in an infant

Severe extensive deep neck abscess in an infant is uncommon. We share the case of a previously well 4-month old infant who was referred for a 4-day history of fever, lethargy and left lateral neck swelling. Contrast-enhanced CT scan revealed a large 5.3×8 cm collection involving the left parapharyngeal and retropharyngeal space, causing significant airway narrowing. 40 mL of frank pus was drained via intraoral incision and drainage with the aid of endoscope, and undesirable complications from an external approach were averted. The infant was extubated 48 hours postsurgery and was discharged home well after completion of 1 week of intravenous antibiotics. The child was discharged well from our follow-up at 1 month review. We discuss the pathophysiology of deep neck space abscesses, its incidence in the paediatric population and the various management options.

Quincke's disease

Marijuana smoke can cause thermal injury, and since legalization and increased use of marijuana in our society, differentiating, diagnosing, and managing this condition have become mandatory. A case of a 28-year-old male with Quincke's disease secondary to marijuana inhalation is presented.

A Rare and Severe Complication Following Thyroid Fine Needle Aspiration: Retropharyngeal Cellulitis

INTRODUCTION

Fine needle aspiration (FNA) is the most accurate and cost-effective method for evaluating thyroid nodules. We have reported a rare complication related to the procedure: severe retropharyngeal cellulitis.

CASE PRESENTATION

A thirty-five-year-old female was admitted to hospital with hoarseness, laryngeal stridor and dyspnea without fever that emerged about 3 days after a first diagnostic FNA. After the procedure, the patient felt her voice became hoarse and 1 day before presentation began to have dyspnea, without fever. It had become difficult for her to swallow solids, and she felt as if food was sticking in her throat. In the emergency room, hematochemical tests and CT scan of the neck/mediastinum had been performed. This showed leukocytosis with neutrophilia and a severe cellulitis framework with involvement of the laterocervical neck area and in particular, the invasion of the retropharynx and the upper part of the mediastinum. The patient was admitted in hospital for an anti-inflammatory therapy with cortisone and antibiotic therapy.

CONCLUSIONS

For the first time to our knowledge, we have reported a severe retropharyngeal and upper mediastinum cellulitis, probably due to the FNA procedure in an immunocompetent young woman.

Schematic interpretation of lateral neck radiographs of adults in the emergency department: a pictorial review

The lateral neck radiograph is widely utilized for the evaluation of common neck conditions in the emergency department. The anatomy of the neck is complex and it can be difficult to differentiate between soft tissue structures on a lateral radiograph. We suggest a schematic pattern of interpreting the lateral neck radiograph with case images of various pathologies that can present in the emergency setting.

Parapharyngeal abscess following use of a laryngeal mask airway during open revision septorhinoplasty

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Laryngeal mask airways have a high rate of success and low rate of complications.

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Parapharyngeal abscesses have not been recently published following LMA use.

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We report a parapharyngeal abscess after uncomplicated LMA use following atraumatic insertion.

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Pressure necrosis from over-inflation is thought to have perforated the pyriform fossa.

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The perforation created a communication into the parapharyngeal space causing infection.

Introduction

A laryngeal mask airway (LMA) is an established safe tool to support the airway during surgery under general anesthetic. It is commonly used both in North America and abroad. Complications with this device are rare.

Presentation of case

A 50-year old female developed a parapharyngeal neck abscess following an uneventful septorhinoplasty during use of an LMA Classic. The patient had symptoms of pain and difficulty swallowing. CT revealed extensive soft tissue edema and swelling in the right and posterior neck involving the right parapharyngeal space, right parotid space, minimal involvement of the right submandibular space, and extending across the retropharyngeal space. The abscess was incised and drained with an open approach, combined with laryngoscopy to evaluate the site of the infection at the right pyriform fossa. The patient fully recovered following discharge.

Discussion

Despite the rare incidence of LMA injuries, early recognition of parapharyngeal neck abscesses can initiate early treatment and prevention of spread to retropharyngeal space where airway obstruction and emergent complications may occur.

Conclusion

Laryngeal mask airways have a high rate of success and low rate of complications. In this reported case, pressure necrosis from over-inflation of the LMA is thought to have perforated the right pyriform fossa. The perforation created a communication into the parapharyngeal space causing infection. We report this case to highlight the importance of identifying possible complications associated with a routine method of airway management during shared airway surgeries.

Retropharyngeal abscess as a rare presentation of pulmonary tuberculosis

A tubercular retropharyngeal abscess is rare in immunocompetent adults. In the case of a tubercular retropharyngeal abscess, it is usually due to cervical spine tuberculosis and is seen mostly in children. A 19-year-old female patient presented to our Medicine Outpatient Department (OPD) at All India Institute of Medical Sciences (AIIMS) with odynophagia and neck pain for two months, without any other constitutional symptoms. On evaluation, she was diagnosed with tubercular retropharyngeal abscess along with pulmonary tuberculosis, without involvement of the cervical spine. This patient was successfully treated by antituberculosis drug therapy alone, without any need for surgical drainage.

Emergency evaluation and management of the sore throat

Although sore throat is a very common complaint in the emergency department and is often associated with benign conditions, such as pharyngitis, it can be the early onset of something much more serious and even life threatening. A thorough history and examination are vital to the correct diagnosis but a high index of suspicion must be maintained to diagnose less common but serious pathology, such as epiglottitis and retropharyngeal abscess. Airway management is paramount to survival, and aggressive means should be taken early when epiglottitis is considered.

Ingestion and pharyngeal trauma causing secondary retropharyngeal abscess in five adult patients

Retropharyngeal abscess most commonly occurs in children. When present in adults the clinical features may not be typical, and associated immunosuppression or local trauma can be part of the presentation. We present a case series of five adult patients who developed foreign body ingestion trauma associated retropharyngeal abscess. The unusual pearls of each case, along with their outcomes, are discussed. Pertinent information for the emergency medicine physician regarding retropharyngeal abscess is presented as well.