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International Journal of Gerontology 5 (2011) 173e176

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International Journal of Gerontology

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Case Report

Cervical Epidural and Retropharyngeal Abscess Induced by a Chicken Boneq

Wei-Ting Hsu1, Yi-Shing Leu1,2,3*, Jon-Kway Huang4

1Department of Otolaryngology - Head & Neck Surgery, Mackay Memorial Hospital, 2Mackay Medicine, Nursing and Management College, Beito, 3National Defense Medical Center,4Department of Radiology, Mackay Memorial Hospital, Taipei, Taiwan

a r t i c l e i n f o

Article history:Received 18 December 2009Received in revised form7 January 2011Accepted 15 January 2011Available online 1 December 2011

Keywords:abscess,chicken bone,epidural abscess,foreign body,retropharyngeal abscess

q All contributing authors declare no conflict of int* Correspondence to: Dr Yi-Shing Leu, Department

Neck Surgery, Mackay Memorial Hospital, 92 ChungTaipei 10449, Taiwan.

E-mail address: lys@ms2.mmh.org.tw (Y.-S. Leu).

1873-9598/$ e see front matter Copyright � 2011, Tadoi:10.1016/j.ijge.2011.08.002

s u m m a r y

Retropharyngeal abscess is occasionally seen in children, but is less common in adults where it usuallyoccurs secondary to iatrogenic oropharynx trauma or a perforated foreign body in the oropharynx. Spinalepidural abscess in combination with a retropharyngeal abscess, which may cause rapid and irreversibleneurological deterioration, is not often found, as indicated by the very few reports in the literature. Herewe report a 52-year-old male with a clinical history of seizure and mental retardation since childhoodwho presented at our emergency room with severe sore throat of 1 day’s duration. A chicken bone wasremoved successfully. However, he complained of progressive dysphagia, sore throat and posterior neckpain during the following 5 days. Flexible fiber-laryngoscopy showed bulging of the retropharyngeal walland a small ulcer at the right posterior pharyngeal wall. A neck computed tomography (CT) scan showeda retropharyngeal abscess at the oropharynx and hypopharynx level. His symptoms showed partialimprovement after the administration of intravenous antibiotics. However, 2 weeks later he developedhigh fever, posterior neck pain and flaccid tetra-paresia. Emergent neck CT scan revealed a mild retro-pharyngeal abscess and epidural abscess formation between the second and third cervical vertebrae. Thepatient’s family refused drainage of the pre-vertebral and epidural pus. After receiving 2 months ofantibiotics, the patient regained the mobility of his limbsCopyright � 2011, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier

Taiwan LLC. All rights reserved.

1. Introduction

The retropharyngeal space (RPS) is a potential space boundedanteriorly by the pharyngeal muscle and its investing fascia, pos-teriorly by the alar layer of prevertebral fascia, superiorly by theskull base and extending inferiorly into the posterior mediastinumto the second thoracic vertebral level. This space contains the nodesof Rouvière which have lymphatics draining from the nasal cavity,the paranasal sinus, the nasopharynx, the oropharynx and themiddle ear. These chains of nodes atrophy after the age of 4e5years. A retropharyngeal space abscess generally results from thesuppuration or necrosis of these nodes. In children, it usually occursas a consequence of an infection of the retropharyngeal lymphnodes. In adults, it is usually caused by oropharynx trauma ofiatrogenic origin or a perforated foreign body. A non-traumaticorigin in adults is extremely rare, except in the case of immuno-compromized patients or intravenous drug abusers. Spinal epiduralabscesses linked with retropharyngeal abscesses are very rare and

erest.of Otolaryngology - Head andshan North Road, Section 2,

iwan Society of Geriatric Emergen

are often fatal1. We report such a casewith a literature review of thepossible mechanism and the outcome.

2. Case report

A 52-year-old male with a past history of seizure and mentalretardation since childhood came to our emergency room (ER)complaining of odynophagia for 1 day, after he had accidentallyswallowed a chicken bone. Physical examination showed a chickenbone lodged in the right pyriform sinus and it was removedsuccessfully by working channel laryngoscopy. However, thepatient experienced exacerbation of sore throat, dysphagia andpain in his posterior neck during the next 5 days. He visited our ear,nose and throat outpatient department (OPD) where physicalexamination revealed moderate nuchal rigidity and tendernessalong the cervical spine with marked restriction of neck motion.

Laryngoscopy showed bulging of the retropharyngeal wall anda small ulcer at the right posterior pharyngeal wall (Fig. 1). X-rayof the neck lateral view (Fig. 2A) illustrated a soft tissue swellingwith air collection at the retropharyngeal region and the maximalretropharyngeal diameter measuring 25 mm noted at the C2level. (The C4 vertebra body diameter is 20 mm). Emergent CTscan (Fig. 3) showed a retropharyngeal prevertebral soft tissue

cy & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.

Fig. 1. Laryngoscopic views showing (A) small ulcer (arrowhead) over the right posterior pharyngeal wall, near the right arytenoid; (B) retropharyngeal wall bulging (＊).

W.-T. Hsu et al.174

prominence with air collection from the oropharynx to thehypopharynx, which was highly suggestive of a retropharyngealabscess. The patient was admitted for further management.Laboratory findings did not show leukocytosis (white blood cellcount was 8700/mL), but a high C-reactive protein (CRP) level of25.60 mg/dL was found. The blood culture yielded no pathogens.Antibiotic treatment with Augmentin, gentamicin and metroni-dazole was administered intravenously for 4 days. Consequently,his symptoms improved and the antibiotics were changed to oralforms. The CRP level decreased (18.7 mg/dL) and a follow-up necklateral view (Fig. 2B) showed remission of the soft tissue swelling(measuring 17 mm at C2 level) without air collection at the ret-ropharyngeal region.

Eleven days after being discharged, the patient presented to ourER a third time with high fever, progressive neck pain and odyno-phagia. Laboratory findings did not show leukocytosis (white cellcount 9200/mL), but a high CRP level of 23.58 mg/dL was detectedagain. The neck X-ray lateral view showed widening of the retro-pharyngeal space, raising concern that infection might be present.A neck CT scan (Fig. 4) revealed a retropharyngeal abscess at thelevel of the oropharynx and the hypopharynx with an epidural

Fig. 2. (A) Soft tissue swelling with air collection (arrow) at the retropharyngeal region and(C4 vertebra body diameter is 20 mm: the straight line). (B) Remission of the soft tissue sweltissue swelling noted, but increase in the enhancement of retropharyngeal soft tissue was

abscess at the upper cervical level (C2e3 level). The patientdeveloped air hunger and subsequent flaccid tetraparesia a dayafter admission. Tracheal intubation was performed because ofairway obstruction. A chest CT scan revealed a consolidation withair bronchogram finding at the right lower lung andmoderate rightside pleural effusion.

Two sets of blood culture yielded a-hemolytic Streptococcusspecies (Viridans group streptococci). We consulted the neurologicsurgeon for emergency surgical intervention, but the patient’sfamily refused. Antibiotic treatment with Unasyn, gentamicin andthen oral Ceftibuten was administrated. The patient regained themobility of his limbs. Before discharging from the hospital, he stillhad paresia of the left leg. The infection was under control and theCRP level decreased to 1.01 mg/dL. His odynophagia and neckswelling improved and fever resolved. However, he was unable towean off the tracheal tube while in hospital and he was discharged,against medical advice, under the use of T-piece (40% O2).

Three days later the patient was re-admitted as a result ofurosepsis. While in hospital he removed his tracheal tube himself.Neither dyspnea nor desaturation was noted after extubation. Arepeat chest X-ray was negative for lung collapse or pneumonia.

the maximal retropharyngeal diameter measured 25 mm at the C2 (dotted line) levelling (17 mm at C2 level) without air collection at the retropharyngeal region. (C) No softfound.

Fig. 3. Neck computed tomography scan showing prominence of the retropharyngeal prevertebral soft tissue with air collection from the oropharynx to the hypopharynx. (A)Axialview; (B) sagittal view.

Epidural and Retropharyngeal Abscess 175

Because of his stable clinical condition, he was discharged andfollowed up at the outpatient department.

3. Discussion

Delayed treatment of retropharyngeal abscess (RPA) can causecervical spinal epidural abscesses, which require urgent treatment.In adult RPA, the most serious and life-threatening complication isairway obstruction. Mediastinal and pleural involvement occurfrequently, resulting in suppurative mediastinitis, pyropneumo-thorax, and pericarditis. The other complications are epiduralabscess and sepsis.

Epidural extension of a retropharyngeal abscess is an extremelyserious, but very rare, condition. Although the incidence is rare, it isoften fatal1e4. It has been well documented that infections of thevertebral body are caused by many different mechanisms5. Spinalepidural abscesses occur most commonly from hematogenous

Fig. 4. Computed tomography scan showing discitis (arrow) and epidural abscess formatioprevertebral soft tissue with air collection from the oropharynx to the hypopharynx is sug

spread. Regional trauma from an ingested foreign body is the causein 59% of patients with a retropharyngeal abscess6. Only a smallnumber of retained foreign bodies (such as fish bones, wire, meatbones, and chicken bones) can perforate the upper digestive tractlumen, and an even smaller fraction can migrate extraluminally7,8.Progression of epidural abscess may cause discitis and subse-quently of cervical osteomyelitis.

The bacteriology of retropharyngeal abscess is often poly-microbial. Gram-positive organisms and anaerobes are often thepredominating pathogens. Among the aerobic organisms strepto-cocci (especially Streptococcus viridans and a-hemolytic strepto-cocci) and staphylococci are found, particularly in abscesses amongdrug users. Most abscesses of odontogenic origin involve anaerobicpathogens, and species of Bacteroides (Bacteroides melaninogenicus)and Peptostreptococcus are commonly isolated9,10.

It should not be forgotten that, even though rare, one of thecauses of spinal compression and neurological deterioration is an

n at the upper cervical level (C2-C3) (arrowhead). Prominence of the retropharyngealgestive of a retropharyngeal abscess. (A) Axial view; (B) sagittal view.

W.-T. Hsu et al.176

epidural spinal abscess11. The use of gadolinium-enhancedmagnetic resonance imaging (MRI) for radiographic diagnosis hasseveral advantages in clinical practice. In addition to its ability todepict soft tissues, MRI is superior in identifying alternativepathologies, including intramedullary, extramedullary intradural,epidural and extraspinal lesions. Unless contraindicated,gadolinium-enhanced MRI is the investigation of choice fordetecting spinal epidural abscesses12. However our patient did notreceive MRI, because the previous CT examination had alreadydemonstrated the RPA with discitis and epidural abscess, and hehad experienced prolonged intubation with unstable vital signs. Inaddition, his family refused surgery and signed “do not resuscitate”consent during the initial management at ER. Instead of furtherMRIexamination, we followed up his condition through clinical symp-toms, neck lateral X-ray and hemogram with CRP level.

According to the literature, since the era of Taylor and Kennedy13

in 1923 and Dandy14 in 1926, urgent surgical decompression hasbeen the treatment of choice for spinal epidural abscess, and thishas been confirmed in numerous series to date. Drainage of thepurulent collection allows immediate decompression of neuralelements and accesses the most voluminous sample fromwhich toculture an organism. Typically, appropriate intravenous antibioticsare to be administered for 4 to 6 weeks. Some clinicians lengthenthe duration by continuing with oral antibiotics12. Our patientreceived conservative treatment solely because his family refusedsurgical intervention. The short duration of intravenous antibiotics(14 days) also prolonged his clinical course and hospitalization.

Since the reports early in the 20th century, outcomes for spinalepidural abscess have dramatically improved. In Dandy’s 1926report14, mortality reached 81%. Baker et al15, aided by improve-ments in diagnosis and antibiotics, reported 18% in 1975, and Curryet al12 in 2005 reported around 16%. More than half of all patientswith spinal epidural abscess are left with neurologic dysfunctionand more than one-third are unable to ambulate independently.Therapy for spinal epidural abscess therefore focuses on threegoals: preservation of normal neurologic function, prevention ofworsening of existing neurologic deficits, and optimization ofopportunities for improvement and return of function. For patientswith deficits, conservative therapy results in further deteriorationor delayed surgery nearly half of the time12.

Our patient presented with a retropharyngeal abscess on thefifth day even after successful removal of a chicken bone within 24hours of ingestion. Complications including respiratory distress and

paresis of the four limbs occurred 16 days later. Progression of theretropharyngeal abscess caused epidural abscess and discitis. Inthis case, there were no dental procedures, dental infection, priorbite wounds, or any other predisposing factors such as diabetes,hypertension, or immunocompromized status. After administra-tion of antibiotics, the patient regained the mobility of his limbs.The essential cause of this problem lies in the need for early diag-nosis, because only timely treatment can prevent or reducepermanent neurologic deficits.

In our opinion, the most important step when managing RPA isto diagnose and identify the etiological agent early. If antibiotictherapy is not effective, or neurologic deficit occurs, surgicaltreatment is necessary.

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