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Retropharyngeal Abscess Complicated RETROPHARYNGEAL ABSCESS COMPLICATED Ortega Coronel María Fernanda, Dr. Calvopiña José Dr. Mena Glennª ª Departamento de Radiología e Imagen del Hospital Eugenio Espejo Quito Ecuador _________________________________ 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 evolution with multiple subtreatments that masked the symptoms for a long time, increasing the risk of provoking severe morbidity and complications. the cervical spine, presence of air or INTRODUCTION foreign body in soft tissue. CT is useful for Retropharyngeal abscess is defined by the diagnosis of early-stage infections while infection between the posterior pharyngeal allows differentiation between cellulitis wall and the prevertebral fascia, it is an and abscess, is also useful in defining the uncommon condition, most common in vascular structures and their relationship children by extension of oropharyngeal to the infectious process defines exactly infections 1, in adults is caused by trauma like that space or spaces are involve. 7 MRI after ingestion of foreing bodies that has a higher resolution than CT and is able damage the esophagus or the trachea, to evaluate the retropharyngeal space with tracheal intubation and less frequently a series of sequences, including diffusion. untimely tooth infections.2 Many studies But this test is not used routinely for the have shown that most of these abscesses diagnosis of this condition, but has specific are polymicrobial type and dominant indications, especially when complications organisms in order of frequency: suspicion.7 streptococcus, staphylococcus and This picture hardly spontaneously resolves anaerobes.3-4 Some less common causes, being potentially lethal therefore requires such as tuberculosis.5 syphilis and vertebral intravenous antibiotics and sometimes fractures.6 Patients may present fever, surgery drainage.1 The complications are sore throat, dysphagia, dysphonia, potentially dangerous and include para- drooling, neck stiffness and sepsis. The vertebral posterior extension inspection can be a bulge in the posterior (osteomyelitis, discitis, epidural abscess) pharyngeal wall. The lateral neck lateral extension involving the carotid and radiograph is often sufficient to make the jugular vein, anterior compression, diagnosis. Typically an extension of the compromising the airway, lower extension prevertebral soft tissue in this area is seen to the mediastinum and mediastinitis in adults at the level of C2: C6 7 mm and 22 resulting in systemic dissemination sepsis.8 mm.7 Others radiological signs that can be and development, can also occur seen are the loss of the normal lordosis of dislocation axoidea atlantoaxial joint, secondary a edema and stress ligaments.9 Imaging Technologist. MATERIALS AND METHODS: X-Ray Equipment, X-Ray Fisher • Female, 54 years old, male, transferred brand. from Hospital Dr. Gustavo Dominguez 3D multislice CT scanner, Philips, (Santo Domingo de los Tsáchilas), who has Aquilion, 16 slices ®. 18 days: severe neck pain, dysphagia, RM Team, Philips, Intera, 1.5 T, odynophagia, temperature rise and channel brain. Imaging study in T1, paresthesias in all four limbs, progressing T2, and gadolinium contrast to quadriplegia. diffusion. 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 of hypopharynx whose diameter is approx AP . 2.5 cm. Moves laterally vascular structures. Fig 2, RM cervical spine (Sagittal T2): A Danger level space displayed space occupying lesion, complex liquid content, fusiform, extending from C1 to C6, with a larger diameter approx. 12 cm. The spinal cord shows diffuse thickening and increased signal relative to the level inflammatory process from C3 to C4 C6.En - C5 discopathy displayed regressive, with increased signal relative to discitis. Fig 3, cervical spine MRI (Sagittal T1): The objective of the signal change normal bone marrow in the bodies of C4, C5 and C6 intrasubstance regarding edema. Fig 4, cervical spine MRI (Sagittal STIR): In the fat suppression sequence corroborates the trabecular edema in C4, C5 and C6 and the inflammatory process at the level of the spinal cord. Fig 5, cervical spine MRI (sagittal T1 Gadolinium): After administration of paramagnetic contrast enhancement exists in the vertebral bodies C4, C5 and C6. Meningeal enhancement is also observed in the anterior aspect of the dural sac from C2 to C6 level. It objective fusiform extradural lesion extending from C2 to C4 corresponding to epidural abscess. Fig 6, brain MRI (T2 - Axial): Displayed increased signal level left and right cerebellar hemisphere and bilateral occipital. Fig 7, brain MRI (diffusion) corroborates the presence of cytotoxic edema rate in the areas described above. (Fig, 7). lesion extending from C2 to C4 RESULTS corresponding to epidural abscess (Fig.5). Displays space-occupying lesion, Displayed increased signal level left and hypodense with gas in the interior and right cerebellar hemisphere and bilateral peripheral enhancement, located at the occipital cortical level (Fig. 6). With back of the hypopharynx AP diameter is approx. 2.5 cm. Displaces laterally vascular ISCUSSION structures (Fig. 1). A space Danger level D displays space-occupying lesion of complex Optimal management retropharyngeal liquid content, fusiform, extending from C1 abscess has been subject to debate for to C6, with a larger diameter approx. 12 over a century, major advances in modern cm. (Fig. 2). The findings are consistent imaging techniques, has made possible the with retropharyngeal abscess. The spinal diagnosis of this infection in its early stages cord has diffuse thickening and increased and more exact location coupled with the signal relative to the level inflammatory widespread use of antibiotics have process from C3 to C6. C4-C5 regressive mortality changed infeccioso inherent in discopathy displayed with increased signal this process.10 relative to discitis (Fig. 2). The lateral neck radiograph and cervical CT It signal change objective normal bone is more accurate diagnostic tests for the marrow bodies C4, C5 and C6 in relation detection of this pathology. The TAC has intrasubstance edema (Fig. 3). limitations when it comes to differentiating between cellulitis and abscess but has a In the fat suppression sequence confirms the trabecular edema C4, C5 and C6 and high sensitivity to confirm proximal the inflammatory process of the spinal esophageal rupture and presence of abscess. The lateral neck radiograph is the cord level (Fig. 4). most specific test (with a reported After administration of paramagnetic sensitivity of 80%), as evidenced by contrast enhancement exists in the increased retropharyngeal space and the vertebral bodies C4, C5 and C6. Meningeal presence of gas prevertebral.3 Suspecting enhancement is also observed in the the presence of a foreign body and if any of anterior aspect of the dural sac from C2 to the above tests detect the presence of it in C6 level. It objective fusiform extradural the neck, you should perform a thorough exploration 11, using other techniques such as upper endoscopy. Several authors cite 4. Asthma BI. Bacterology of the TAC with Gallium-67 as a diagnostic retropharryngeal abscess in children. method with high sensitivity to detect this Pediatr Infect Dis. Journal 2000, 9: 586- condition and subsequent seguimiento12. 587. MRI has a higher resolution than CT and is 5. De Clercq. L. D. Chole, R.A. able to evaluate the retropharyngeal space with a series of sequences, including Retropharyngeal abscess in the adult. diffusion. But this test is not used routinely Otolaryngology-Head and Neck Surgery for the diagnosis of this condition, but has 2003, 88: 684-689. specific indications, especially when 6. Wong, Y. K. Novotny, G. M complications suspicion. retropharyngeal space. A review of In our case, the patient for 18 days receive anatomy, pathology and clinical ineffective treatments, table masking and presentation. Journal of Otolaryngology. delaying the diagnosis, reaching a rare but 2004, 7: 528-536. lethal complications associated with 7. Wholey, M. H., Bruwer, A. J., Baker, H. L. epidural abscess and subsequent mieltitis The lateral roentgenogram of the neck. occipital and cerebellar infarction probably related to septic thrombi. 8. Al-Sabah B, Bin Salleen H, Hagr A, et; retropharyngeal abscess in adults: 10-year CONCLUSION study. J Otolaryngol. 12, 2004, 33 (6 :352-5. In conclusion, like many authors, we need 9. Craig FW, Schunk JE; retropharyngeal the immediate realization of a lateral abscess in children: clinical presentation, radiograph or CT of the neck and antibiotic utility of imaging, and current prophylaxis in all patients with suspected management. Pediatrics. 2003 Jun, 111 (6 retropharyngeal abscess box, since the Pt 1) :1394-8. mechanism of production, potential 10. Jacobs TE, Invin RS, upper Severe complications and lethality of this infections, in Rippe JM, Inwin RS, eds. pathology. Intensive Care Medicine. Boston. Little, REFERENCES Brown and co. 2000, from 79 to 87. 1. Lalakea ML, Messner AH. 11. Pontell J, Har-El G. Retropharyngeal Retropharyngeal abscess management in abscess: clinical review. Ear Nose Throat J children: current practices. Otolaryngol 2005; 74: 701-4. Head Neck Surg 1999; 121: 398-405. 12.WL Chan, Fernandes VB. 2. Pintado V, Cibrian F. Retropharyngeal Retropharyngeal abscess on a Ga-67 scan: abscess in adults. Enferm Clin Microbiol a case report. Clin Nucl Med 2009, 24: 942- 2002, 13: 40-3 4. 3. Tom M.B, Rice DH. Roberson, MD. Surgical manegement of retropharyngeal space infection in children. Laryngoscope, III: Agust 2001. From 1413 to 1422. .
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