Presentation
Presented to ED in shock and neutropenic. No significant past medical history. Severe throat pain and painful neck movements.
Patient Data
Left nasopharyngeal airway aid.
Unencapsulated retropharyngeal fluid collection. This elevates and narrows the supraglottic airway. General swelling of the airway mucosa but no mucosal abscess, defect or radio-opaque foreign body.
The major head and neck vessels opacify normally.
Multiple enlarged - likely reactive - in both levels IIA / IIB / III.
Infiltration of the posterior cervical fat planes. No frank extension into the mediastinum (normal CT chest not included in this study online).
Normal included intracranial structures. Normal appearance of the cervical spine (no prevertebral changes).
The patient has since been intubated, with nasogastric tube placement also. Secretions around these tubes in the airway. Right jugular central venous catheter.
Although there has been interval intra-oral drainage/decompression of the retropharyngeal collection (which is now shallower than before) there are extensive peripherally enhancing abscesses in the posterior cervical spaces on both sides. These include sites of previous abnormal - likely suppurative - nodes, but also track along the bellies of the sternocleidomastoid and levator scapulae muscles.
Although the internal jugular veins are patent, they are compressed at several points by these collections, including smaller contiguous collections in the carotid and visceral spaces (around the thyroid). There is also a partly imaged superior mediastinal collection on the right side. Possible collection extending into the right foramen and epidural space at the C5/C6 level. In addition, there is a new trace of fluid on the right floor of the mouth compatible with a further focus of abscess.
This patient underwent awake fiberoptic intubation following the initial CT, with intra-oral abscess drainage. Despite management with targeted antibiotics, there continued to be copious retropharyngeal purulent secretions leading to repeat imaging after a couple of weeks which showed the progressive extensive abscess formation in the retropharyngeal space, the floor of the mouth and superior mediastinum.
Multiple agents were cultured from systemic blood cultures and aspirated pus including E. coli, Staphylococcus epidermidis and some fungi (Arthrographis kalrae).
Case Discussion
Rapid and extensive progression of an aggressive retropharyngeal abscess.
Following a number of repeat aspirations and washouts, complemented with a course of targeted antimicrobial therapy, the patient made a complete recovery.
Knowledge of normal neck anatomy and deep neck/facial spaces is useful to anticipate where infections can track, and also guide you to important review areas with the hot neck (e.g. epidural collections).
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Thanks to Dr S Kealey for the case contribution.
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