retropharyngeal abscess complicated · it is a concise review of retropharyngeal abscess, we report...

RETROPHARYNGEAL ABSCESS COMPLICATED

Ortega Coronel María Fernanda, Dr. Calvopiña JoséDr. Mena Glennªª Departamento de Radiología e Imagen del Hospital Eugenio Espejo Quito Ecuador

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Revista de la Federación Ecuatoriana de Sociedades de Radiología, Ecuador 2011 N° 4, Pag, 9 -11.

ABSTRACT

It is a concise review of retropharyngeal abscess, we report a case of long and torpid evolutionwith multiple subtreatments that masked the symptoms for a long time, increasing the risk ofprovoking severe morbidity and complications.

INTRODUCTION

Retropharyngeal abscess is defined by theinfection between the posterior pharyngealwall and the prevertebral fascia, it is anuncommon condition, most common inchildren by extension of oropharyngealinfections 1, in adults is caused by traumaafter ingestion of foreing bodies thatdamage the esophagus or the trachea,tracheal intubation and less frequentlyuntimely tooth infections.2 Many studieshave shown that most of these abscessesare polymicrobial type and dominantorganisms in order of frequency:streptococcus, staphylococcus andanaerobes.3-4 Some less common causes,such as tuberculosis.5 syphilis and vertebralfractures.6 Patients may present fever,sore throat, dysphagia, dysphonia,drooling, neck stiffness and sepsis. Theinspection can be a bulge in the posteriorpharyngeal wall. The lateral neckradiograph is often sufficient to make thediagnosis. Typically an extension of theprevertebral soft tissue in this area is seenin adults at the level of C2: C6 7 mm and 22mm.7 Others radiological signs that can beseen are the loss of the normal lordosis of

the cervical spine, presence of air orforeign body in soft tissue. CT is useful fordiagnosis of early-stage infections whileallows differentiation between cellulitisand abscess, is also useful in defining thevascular structures and their relationshipto the infectious process defines exactlylike that space or spaces are involve. 7 MRIhas a higher resolution than CT and is ableto evaluate the retropharyngeal space witha series of sequences, including diffusion.But this test is not used routinely for thediagnosis of this condition, but has specificindications, especially when complicationssuspicion.7

This picture hardly spontaneously resolvesbeing potentially lethal therefore requiresintravenous antibiotics and sometimessurgery drainage.1 The complications arepotentially dangerous and include para-vertebral posterior extension(osteomyelitis, discitis, epidural abscess)lateral extension involving the carotid andjugular vein, anterior compression,compromising the airway, lower extensionto the mediastinum and mediastinitisresulting in systemic dissemination sepsis.8

and development, can also occur

dislocation axoidea atlantoaxial joint, secondary a edema and stress ligaments.9

MATERIALS AND METHODS:

• Female, 54 years old, male, transferredfrom Hospital Dr. Gustavo Dominguez(Santo Domingo de los Tsáchilas), who has18 days: severe neck pain, dysphagia,odynophagia, temperature rise andparesthesias in all four limbs, progressingto quadriplegia.

Imaging Technologist.

X-Ray Equipment, X-Ray Fisherbrand.

3D multislice CT scanner, Philips,Aquilion, 16 slices ®.

RM Team, Philips, Intera, 1.5 T,channel brain. Imaging study in T1,T2, and gadolinium contrastdiffusion.

Clinical Lab.

IMAGES

Figure 1, contrasted CT Cervical (axial C3 - C4 - C5): Displayed space occupying lesion,hypodense with gas in the interior and peripheral enhancement, located at the rear ofhypopharynx whose diameter is approx AP . 2.5 cm. Moves laterally vascular structures.

Fig 2, RM cervical spine (Sagittal T2): A Danger level spacedisplayed space occupying lesion, complex liquid content,fusiform, extending from C1 to C6, with a larger diameterapprox. 12 cm. The spinal cord shows diffuse thickening andincreased signal relative to the level inflammatory process fromC3 to C4 C6.En - C5 discopathy displayed regressive, withincreased signal relative to discitis.








Clinical Lab.

IMAGES










Clinical Lab.

IMAGES



Fig 3, cervical spine MRI (Sagittal T1): The objective of the signalchange normal bone marrow in the bodies of C4, C5 and C6intrasubstance regarding edema.

Fig 4, cervical spine MRI (Sagittal STIR): In the fat suppressionsequence corroborates the trabecular edema in C4, C5 and C6and the inflammatory process at the level of the spinal cord.

Fig 5, cervical spine MRI (sagittal T1 Gadolinium): Afteradministration of paramagnetic contrast enhancement exists in thevertebral bodies C4, C5 and C6. Meningeal enhancement is alsoobserved in the anterior aspect of the dural sac from C2 to C6level. It objective fusiform extradural lesion extending from C2 toC4 corresponding to epidural abscess.

Fig 6, brain MRI (T2 - Axial): Displayedincreased signal level left and rightcerebellar hemisphere and bilateraloccipital.









Fig 7, brain MRI (diffusion)corroborates the presence of cytotoxicedema rate in the areas describedabove. (Fig, 7).

RESULTS

Displays space-occupying lesion,hypodense with gas in the interior andperipheral enhancement, located at theback of the hypopharynx AP diameter isapprox. 2.5 cm. Displaces laterally vascularstructures (Fig. 1). A space Danger leveldisplays space-occupying lesion of complexliquid content, fusiform, extending from C1to C6, with a larger diameter approx. 12cm. (Fig. 2). The findings are consistentwith retropharyngeal abscess. The spinalcord has diffuse thickening and increasedsignal relative to the level inflammatoryprocess from C3 to C6. C4-C5 regressivediscopathy displayed with increased signalrelative to discitis (Fig. 2).

It signal change objective normal bonemarrow bodies C4, C5 and C6 in relationintrasubstance edema (Fig. 3).

In the fat suppression sequence confirmsthe trabecular edema C4, C5 and C6 andthe inflammatory process of the spinalcord level (Fig. 4).

After administration of paramagneticcontrast enhancement exists in thevertebral bodies C4, C5 and C6. Meningealenhancement is also observed in theanterior aspect of the dural sac from C2 toC6 level. It objective fusiform extradural

lesion extending from C2 to C4corresponding to epidural abscess (Fig.5).

Displayed increased signal level left andright cerebellar hemisphere and bilateraloccipital cortical level (Fig. 6). With

DISCUSSION

Optimal management retropharyngealabscess has been subject to debate forover a century, major advances in modernimaging techniques, has made possible thediagnosis of this infection in its early stagesand more exact location coupled with thewidespread use of antibiotics havemortality changed infeccioso inherent inthis process.10

The lateral neck radiograph and cervical CTis more accurate diagnostic tests for thedetection of this pathology. The TAC haslimitations when it comes to differentiatingbetween cellulitis and abscess but has ahigh sensitivity to confirm proximalesophageal rupture and presence ofabscess. The lateral neck radiograph is themost specific test (with a reportedsensitivity of 80%), as evidenced byincreased retropharyngeal space and thepresence of gas prevertebral.3 Suspectingthe presence of a foreign body and if any ofthe above tests detect the presence of it inthe neck, you should perform a thoroughexploration 11, using other techniques such

as upper endoscopy. Several authors citethe TAC with Gallium-67 as a diagnosticmethod with high sensitivity to detect thiscondition and subsequent seguimiento12.MRI has a higher resolution than CT and isable to evaluate the retropharyngeal spacewith a series of sequences, includingdiffusion. But this test is not used routinelyfor the diagnosis of this condition, but hasspecific indications, especially whencomplications suspicion.

In our case, the patient for 18 days receiveineffective treatments, table masking anddelaying the diagnosis, reaching a rare butlethal complications associated withepidural abscess and subsequent mieltitisoccipital and cerebellar infarction probablyrelated to septic thrombi.

CONCLUSION

In conclusion, like many authors, we needthe immediate realization of a lateralradiograph or CT of the neck and antibioticprophylaxis in all patients with suspectedretropharyngeal abscess box, since themechanism of production, potentialcomplications and lethality of thispathology.

REFERENCES

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4. Asthma BI. Bacterology ofretropharryngeal abscess in children.Pediatr Infect Dis. Journal 2000, 9: 586-587.

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7. Wholey, M. H., Bruwer, A. J., Baker, H. L.The lateral roentgenogram of the neck.

8. Al-Sabah B, Bin Salleen H, Hagr A, et;retropharyngeal abscess in adults: 10-yearstudy. J Otolaryngol. 12, 2004, 33 (6 :352-5.

9. Craig FW, Schunk JE; retropharyngealabscess in children: clinical presentation,utility of imaging, and currentmanagement. Pediatrics. 2003 Jun, 111 (6Pt 1) :1394-8.

10. Jacobs TE, Invin RS, upper Severeinfections, in Rippe JM, Inwin RS, eds.Intensive Care Medicine. Boston. Little,Brown and co. 2000, from 79 to 87.

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12.WL Chan, Fernandes VB.Retropharyngeal abscess on a Ga-67 scan:a case report. Clin Nucl Med 2009, 24: 942-4.

retropharyngeal abscess complicated · it is a concise review of retropharyngeal abscess, we report...

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