Retropharyngeal abscess with mediastinal extension. See a little discussion
 |  These CT scans(head, neck and thorax) are from a 42 yo male patient. He presented to the emergency room with a 10 day history of pharyngitis associated with progressive dysphagia. His temperature was 38ºC and marked tenderness was noted over the entire neck |
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Marco Aurélio D'Assunção - Brazil - São Paulo
Wessel Versteeg - Netherlands - Veghel
L. A. Leitao
Maurício, Andréa e Eliana - UFMA - Brasil
Fernando e Markus-Fortaleza - Ceará - Brasil
Ana Paula Battistuzzi - Brazil - Sao Paulo
Aécio Santana - Brasil - Ceara
Felipe Amadeu
Retropharyngeal abscess occurs in infants and young children and is rare after the age of 10 years. These infections are located between the constrictors of the pharynx and the prevertebral fascia. They are secondary to pharyngitis and are due to the breakdown of retropharyngeal lymphadenitis.
The patient of this case presented with an insidious onset. Retropharyngeal abscess was suspected because of the typical clinical findings. The diagnosis of Lemierre's syndrome was suggested for this case but the entire syndrome requires septic embolization of Jugular veins besides retropharyngeal abscess and mediastinal extension. This patient also have mediatinal extension of the abscess instead of mediastinitis. The abscess was incised and drained, some material was stained( gram positive diplococcus) and the culture confirm the smear with ß-hemolytic streptococci growth. He was treated with intravenous penicillin for 10 days and recovered well.
Infants with retropharyngeal abscesses usually present with stridor and hyperextension of the neck. A lumbar puncture is the appropriate diagnostic procedure in a febrile infant who presents in opisthotonos. If the cerebrospinal fluid is normal, the possibility of a retropharyngeal abscess must be excluded. The diagnosis is made by palpating the posterior pharyngeal wall. The infant is held in the prone position for the examination so that if the abscess is ruptured during the examination, the pus flows out of the infant's mouth and is not aspirated. The abscess has a boggy fluctuant texture, and the bodies of the cervical vertebrae are not palpable. Inspection of the pharynx may not demonstrate the abscess, because the whole posterior pharyngeal wall may be displaced forward and there may be no inflammatory reaction in the mucous membrane.
The abscess can also be demonstrated by a radiograph of the lateral neck in which the posterior pharyngeal wall is displaced anteriorly or by CT of the neck. To maintain the airway, the child should be allowed to hyperextend the neck.
A tracheotomy is rarely necessary. In addition to penicillin therapy, the posterior pharyngeal wall should be incised under general endotracheal anesthesia with the patient in the Rose position. The mucous membrane at the posterior wall of the pharynx is incised vertically. The incision need only split the mucous membrane. The pus is obtained by gently spreading a hemostat in the wound toward the retropharyngeal space. No drain is necessary because the abscess cavity tends to be emptied on swallowing.
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