Factors affecting perforation of the esophagus in patients with deep neck infection.

BACKGROUND: Deep neck infection (DNI) is a serious disease that can lead to severe morbidity, including esophageal perforation, and mortality. However, no previous study has explored the risk factors associated with esophageal perforation in patients with DNI. This study investigated these factors. METHODS: Between September 2015 and September 2021, 521 patients with DNI were studied. Relevant clinical variables and deep neck spaces were assessed. RESULTS: In a multivariate analysis, involvement of the retropharyngeal space (OR 5.449, 95% CI 1.603-18.51, p = 0.006) and the presence of mediastinitis (OR 218.8, 95% CI 55.98-855.3, p < 0.001) were independent risk factors associated with esophageal perforation in patients with DNI. There were no differences in pathogens between 32 patients with and 489 patients without esophageal perforation (all p > 0.05). CONCLUSION: Involvement of the retropharyngeal space and the presence of mediastinitis were independent risk factors associated with esophageal perforation in patients with DNI. There were no differences in pathogens between the groups with and without esophageal perforation in DNI.

Factors affecting patients with concurrent deep neck infection and aspiration pneumonia.

BACKGROUND: Deep neck infection (DNI) is a life-threatening condition of the deep neck spaces with potential to obstruct the airway. Aspiration pneumonia (AP), which results from aspiration of colonized oropharyngeal or upper gastrointestinal contents, is a respiratory infection that affects the lungs, wherein the air sacs are filled with purulent fluid. The cooccurrence of these two diseases can cause severe damage to the respiratory system, leading to morbidity and mortality. However, the risk factors for concurrent DNI and AP have not yet been investigated. This study aimed to address this issue. METHODS: A total of 561 DNI patients were enrolled in this study between June 2016 and December 2021. Among these patients, 26 had concurrent DNI and AP at the time of diagnosis. Relevant clinical variables were assessed. RESULTS: In the univariate analysis, age > 60 years (OR = 3.593, 95% CI: 1.534-8.414, p = 0.002), C-reactive protein (OR = 1.005, 95% CI: 1.001-1.008, p = 0.003), involvement of ≥3 spaces (OR = 4.969, 95% CI: 2.051-12.03, p < 0.001), and retropharyngeal space involvement (OR = 4.546, 95% CI: 1.878-11.00, p < 0.001) were significant risk factors for concurrent DNI and AP. In the multivariate analysis, age > 60 years (OR = 2.766, 95% CI: 1.142-6.696, p = 0.024) and retropharyngeal space involvement (OR = 3.006, 95% CI: 1.175-7.693, p = 0.021) were independent risk factors for concurrent DNI and AP. The group with concurrent DNI and AP had longer hospital stays (p < 0.001) and lower rates of incision and drainage (I&D) open surgery (p = 0.020) than the group with DNI alone. There were no significant differences in pathogens (p > 0.05) between the groups. CONCLUSIONS: Both DNI and AP can independently compromise the airway, and the concurrence of these two conditions makes airway protection more difficult. Age > 60 years and retropharyngeal space involvement were independent risk factors for the concurrence of DNI and AP. The group with concurrent DNI and AP had longer hospital stays and lower rates of I&D open surgery than the group with DNI alone. There were no differences in DNI pathogens according to concurrent AP status.

An anatomical study of the pharyngeal plexus: Application to avoiding postoperative dysphagia following anterior approaches to the cervical spine.

We aimed to localize the pharyngeal branches of the pharyngeal plexus to preclude postoperative complications such as dysphagia resulting from injury to those branches. Cranial nerves IX and X and the sympathetic trunk were dissected on 10 sides in the necks of embalmed adult cadavers of European descent to identify the pharyngeal branches so that anatomical landmarks could be identified and injury thereby avoided. In all sides, the pharyngeal branches originated from the glossopharyngeal and vagus nerves and the superior cervical ganglion and entered the posterior pharyngeal wall at the C2-C4 levels within 10 mm medial to the greater horn of the hyoid bone. All pharyngeal branches were anterior to the alar fascia. Based on our anatomical study, vagus nerve branches to the pharyngeal muscles enter at the C3/C4 vertebral levels. Such knowledge might help decrease or allow surgeons to predict which patients are more likely to develop dysphagia after cervical spine surgery.

Anatomical and histological study of the alar fascia.

INTRODUCTION: The alar fascia remains one of the most variably described fascial structure in the human body. Much disagreement persists in the literature and mainstream anatomical texts about its anatomy, function, and clinical significance. It is generally described as a coronally oriented fascial sheet separating the retropharyngeal space anteriorly from the danger space posteriorly. The current study aimed to confirm the presence of the alar fascia and delineate its anatomical characteristics, connections, and potential function through gross dissection and microscopic analysis. Possible clinical and surgical implications are considered. METHODS: Twelve (12) cadaveric necks were dissected and examined histologically. Smooth muscle (αSMA), nerve (S100 protein), and myosin proteins were identified immunohistologically to characterize the composition and possible functions of the alar fascia. RESULTS: The alar fascia was found in all specimens spanning between the carotid sheaths. Morphologically, it was not a delamination or derivative of the prevertebral fascia. It extended from the base of the skull to the upper thoracic level (T2) where it fused with the visceral fascia. No midsagittal connection was found between the alar and visceral fasciae. Immunohistochemically, the alar fascia was positive in focal areas for αSMA and S100 proteins but negative for fast and slow myosin. CONCLUSION: The alar fascia is an independent and constant coronal fascial layer between the carotid sheaths. It contains neurovasculature and may limit the spread of retropharyngeal infections into the thorax as well as facilitate normal physiological functions of the cervical viscera.

Minimally invasive approach for retrieval of retropharyngeal foreign body.

Ingested fish bone at times can migrate extraluminally into the surrounding soft tissue, leading to complications. Conventionally, these migrated fish bones are retrieved by open procedures, which could add to the morbidity. We successfully retrieved one such foreign body by a minimally invasive transcervical approach in a 64-year-old female patient. The method offered an easy identification of the foreign body with minimal soft-tissue dissection, which ultimately aided in the early post-operative recovery. This is the first report of a minimally invasive approach to explore the retropharyngeal space, and we propose the technique even for sampling retropharyngeal lymph node.

Early stages of development of the alar fascia (human specimens at 6-12 weeks of development).

In recent years, there has been much discussion concerning the cervical fasciae. The aim of this study is to confirm and to describe the development of the alar fascia as well as its relationship with nearby structures. Histological preparations of 25 human embryos (6-8 weeks of development) and 25 human fetuses (9-12 weeks of development) were studied bilaterally using a conventional optical microscope. Our study confirms the existence of the alar fascia and permits three stages to be established during its development. The initial stage (1st), corresponding to the 6th week of development (Carnegie stages 18-19), is characterized by the beginning of the alar fascia primordium in the retroesophageal space at the level of C7-T1. In the formation stage (2nd), corresponding to the 7th and 8th weeks of development (Carnegie stages 20-23), the alar fascia primordium grows upwards and reaches the level of C2-C3. In the maturation stage (3rd), beginning in the 9th week of development, the visceral, alar and prevertebral fasciae can be identified. The alar fascia divides the retrovisceral space (retropharyngeal and retroesophageal) into two spaces: one anterior (between the alar fascia and the visceral fascia and extending from C1 to T1, named retropharyngeal or retroesophageal space according to the level) and the other posterior (between the alar fascia and the prevertebral fascia, named danger space). We suggest that this latter space be named the retroalar space. This study suggests that alar fascia development is related to mechanical factors and that the alar fascia permits the sliding of the pharynx and the oesophagus during swallowing.

Kissing Carotids: A Rare Anatomical Aberration with Clinical Significance.

Kissing Carotids is a term given for an anatomical variation in which bilateral internal carotid arteries are medially placed in the retropharyngeal space and are juxtaposed to each other. Though this condition is asymptomatic it can lead to abrupt catastrophic bleeding during oral surgical procedures and tracheal intubation. This variation can be diagnosed with a contrast enhanced computed tomography and can alert the surgical team. We present here a case of 55 year old asymptomatic female diagnosed with bilateral retropharyngeal internal carotid artery aberration. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-024-04654-3.

A Comparison of Transoral Versus Transcervical Surgical Approaches to Retropharyngeal Lymphadenectomy: A Scoping Review.

IMPORTANCE: A gap in knowledge exists concerning the functional outcomes and complications when comparing various surgical approaches for retropharyngeal lymph node (RPLN) metastases. OBJECTIVE: To explore perioperative outcomes, functional outcomes, and complications associated in the treatment of RPLN metastases. DESIGN: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) protocol was used to conduct a scoping review of the PubMed and Scopus databases. REVIEW METHODS: We systematically searched 2 databases from inception to January 2023 for articles examining the treatment approaches and postoperative outcomes in the retropharyngeal space. We included English records about surgical approaches, complications, functional outcomes for patients >18 years old with retropharyngeal lymphadenopathy. RESULTS: One-hundred ninety-nine articles were identified, of which 17 were included in the analysis. Three studies assessed RPLN dissection in the postradiation setting. We identified limited knowledge about functional outcomes and complications following surgery for retropharyngeal lymphadenopathy. Overall, acute postoperative dysphagia was documented in 35/170 patients (20.5%). However, the assessment of dysphagia was limited, and not described in the majority of studies. The overall rate of postoperative neuropathy and hematoma were 4.1% and 4.7%, respectively. No postoperative hematomas were documented in the transcervical approach. CONCLUSION: Our findings underscore the need for further research on postoperative outcomes following RPLN dissection. We recommend further studies focusing on objective swallow assessments and long-term outcomes of either surgical approaches.

Superior Parathyroid Masquerading as Retropharyngeal Lymph Node.

Introduction: Ectopic parathyroid glands have been reported with an incidence of 2-22%. Undescended parathyroid glands, defined as glands situated above the carotid bifurcation or > 1 cm cranial to the superior pole of the thyroid gland, comprise 2-7% of all ectopic parathyroid glands. We report a case of incidentally discovered parathyroid gland located in the retropharyngeal space at the level of the oropharynx. Case Presentation: The patient in this report was a 60-year-old female with squamous cell carcinoma of the tonsil T2N0M0 with MRI showing a hyperintense ovoid structure, medial to the carotids at the level of the oropharynx, corresponding to the location of the lateral group of retropharyngeal lymph nodes. Patient underwent transoral ultrasonic radical tonsillectomy along with a retropharyngeal lymph node dissection by the transcervical route. Postoperative histopathology revealed the retropharyngeal node sampled to be a normal parathyroid gland. Discussion: "High" undescended parathyroid gland as reported here along with 4 other cases of infratemporal fossa parathyroid glands reported previously, can be the cause for recurrent missed adenomas. Being extracervical in location, these are likely to be missed if the skull base has not been included in the preoperative Tc-99 sestamibi scan and also during bilateral neck exploration.

A rare case of retropharyngeal liposarcoma: a rare location of a rare diagnosis.

We report a case of retropharyngeal liposarcoma in a 53-year-old female, who had complaints of neck swelling accompanied with dysphagia, orthopnea and dysphonia. Clinical examination revealed huge multinodular swelling in front of neck with bilateral extension, more prominent on left side and moving with deglutition. The diagnosis of retropharyngeal liposarcoma was established following CT scan, MRI and incisional biopsy. Surgical excision of mass along with near total thyroidectomy was performed. Postoperative hospital stay was uneventful. She remained well in follow-up period of 1 year as well. In conclusion, retropharyngeal liposarcoma is a rare tumor. A review of the literature explores the reasons behind the late presentation as well as the difficulties in diagnosis and treatment of this rare tumor.

Cardiac arrest with retropharyngeal hematoma caused by minor facial injuries from a ground level fall.

Background: Traumatic retropharyngeal hematoma followed by airway obstruction is extremely rare. In this report, we show unique images from two cases of out-of-hospital cardiac arrest due to airway obstruction caused by massive retropharyngeal hematoma after a minor facial injury. Case presentation: Case 1: A 78-year-old man was transferred to our emergency department due to cardiac arrest. He presented with respiratory insufficiency after a ground level fall. His neck was swollen, and the attending physician performed an emergent cricothyroidotomy to secure his airway and administered intravenous adrenaline. Computed tomography revealed a massive retropharyngeal hematoma and severe hypoxic encephalopathy. Despite a temporary return of spontaneous circulation (ROSC), the patient died on the admission day.Case 2: A 68-year-old woman presented with dyspnea, prompting her family to call an ambulance. On the way to the hospital, the ambulance crew determined the patient was in cardiac arrest. The patient's history revealed a ground level fall in which she hit her face. Computed tomography revealed a massive retropharyngeal hematoma compressing her upper airway. Although ROSC was obtained, the patient died on the 12th day of hospitalization due to hypoxic encephalopathy.Extension views of cervical spine images identified angular instability without cervical bone fracture in both cases, suggesting that possible injuries of the anterior longitudinal ligament contributed to the retropharyngeal hematoma. Conclusions: Patients presenting with asphyxia after a simple ground level fall accompanied by minor facial injuries should be assessed by emergency physicians for the possibility of a retropharyngeal hematoma. In both cases presented here, unique images indicate possible injuries of the anterior longitudinal ligament.

Synovial sarcoma in the prevertebral space can mimic malignant neurogenic neoplasm: Case report and literature review.

Synovial sarcoma, a rare malignant neoplasm with a poor prognosis, accounts for approximately 5%-10% of all primary soft-tissue malignancies worldwide. Typically affecting adolescents and young adults, it primarily manifests near the joints of the lower extremities. This study aimed to demonstrate that this tumor can also affect the prevertebral space. A 32-year-old male patient presented at our outpatient clinic with a 2-month history of upper limb numbness and a 1-month complaint of palpable neck mass. Imaging studies revealed a bulky, lobulated, and heterogeneous mass exhibiting heterogeneous enhancement. Furthermore, the mass caused expansion of the neuroforamen in the neck, initially suggesting a diagnosis of malignant schwannoma. However, a histopathologic examination suggested synovial sarcoma. The article provided a comprehensive review of the clinical, pathological, and radiological features of this condition. Additionally, it explored current treatment options and prognoses by referencing relevant literature.

Successful Surgical Excision of Retropharyngeal Plexiform Neurofibroma in a Non-neurofibromatosis Adult Male.

Plexiform neurofibromas are benign tumors that arise from neuronal cells and are commonly associated with neurofibromatosis type 1 (NF1) patients. However, the occurrence of plexiform neurofibromas in the pharyngeal region is extremely rare. In this particular case, we report the successful diagnosis of a retropharyngeal plexiform neurofibroma in an adult male patient without a history of neurofibromatosis. The diagnosis was made using magnetic resonance imaging (MRI) and confirmed by a biopsy. Following the diagnosis, the tumor was surgically excised, resulting in a successful removal of the neurofibroma.

Incomplete Kawasaki Disease Presenting as Retropharyngeal Abscess: A Case Report and Review of the Literature.

Kawasaki disease (KD) is a cryptic and self-limiting vasculitis predominantly seen in children, often posing a diagnostic challenge due to its varied clinical presentations. Among these, the emergence of deep neck infections, particularly retropharyngeal abscesses, stands out as an extremely rare manifestation. Herein, we present a case of a 10-year-old girl who was hospitalized for fever, neck pain, swollen cervical lymph nodes, and increased inflammation markers. Although anti-infective treatment was initiated, her condition remained unchanged. A cervical computed tomography scan revealed an abscess in the retropharyngeal space. Remarkably, on the third day post-admission, the patient developed symptoms synonymous with KD, such as conjunctival redness, reddened lips, and a strawberry tongue. Subsequent treatment with high-dose intravenous immunoglobulins (IVIG) and oral aspirin led to swift symptom relief, including complete abscess resolution verified by a follow-up neck magnetic resonance imaging. This unique co-presentation of KD and a retropharyngeal abscess, possibly linked to infections like Streptococcus or Staphylococcus aureus, underscores the importance of quick diagnosis and KD management, especially when conventional treatments prove ineffective.

Fulminant Retropharyngeal Edema Associated with SARS-COV-2 (+) Diagnosis in an Adult.

SARS-COV-2 can cause retropharyngeal edema for which literature on optimal management is sparse. Prompt identification and treatment of the condition is vital to successful recovery. This report presents such a case and offers support for conservative management in treatment of retropharyngeal edema.

Langerhans' cell histiocytosis of the retropharynx: first reported case.

Langerhans' cell histiocytosis (LCH) is a rare condition characterised by histiocyte proliferation leading to destructive granulomatous lesions. It may occur anywhere in the body but extraosseous manifestations affecting the head and neck are particularly uncommon. Here, we present the first reported case of a mass arising in the retropharyngeal space caused by LCH. The patient was a 33-year-old man with various symptoms which are presented. Although rare, LCH can affect a variety of tissues in the head and neck. Clinicians need to be cognisant of its inclusion in the differential diagnoses for similar cases in their practice, in particular because of potential difficulties in diagnosis.

A Rare Case of Retropharyngeal Abscess in a 3 Month Old Male Infant: Case Report and Review of Literature.

Retropharyngeal abscess (RPA) is a rare, potentially fatal condition found more frequently in young children usually who were having a history of Upper respiratory infection. RPA is an acute suppurative infection of the retropharyngeal space. In view of scarce literature availability and atypical presentation in infants, it poses a definitive diagnostic dilemma to the clinicians. Here, we are reporting a three-month-old male infant presented with feeding difficulty, obstructive sleep apnea and intermittent inspiratory stridor. Child was managed in a pediatric ICU with a multidisciplinary approach which involved pediatrician, otorhinolaryngologist pediatric anesthesiologist, microbiologist, and radiologist. With the recent advances, early radio imaging have a vital role in diagnosing the condition and also helps in planning of surgery. Prompt diagnosis and surgical management with appropriate antimicrobial therapy for this condition is imperative to prevent complications such as airway obstruction and mediastinitis. Timely surgical intervention, preferably intraoral transpharyngeal approach, to drain the abscess is recommended.

Different surgical approaches in retropharyngeal lymph nodes dissection in head and neck cancer: A systematic review.

OBJECTIVE: To perform a systematic review of studies analyzing different surgical approaches in the treatment of retropharyngeal lymph node (RPLN) metastases. METHODS: The study was performed according to the PRISMA guidelines. RESULTS: Twenty-one studies were included in the review, for a total of 481 patients (median age: 55.8 years; male: n = 279/393, 70.1%). The success rate by type of approach was 100% (n = 233/233), 93.5% (n = 29/31), 95.7% (n = 67/70), 100% (n = 14/14), 100% (n = 82/82), and 100% (n = 51/51) in the transcervical, endoscopic-assisted transcervical, TORS, transoral, maxillary swing and transmandibular cohorts, respectively. The complication rate by type of approach was 11.2% (n = 26/233), 48.4% (n = 15/31), 48.6% (n = 34/70), 14.3% (n = 2/14), 6.1% (n = 5/82) in the transcervical, endoscopic-assisted transcervical, TORS, transoral and maxillary swing cohorts, respectively. Oncological outcomes were reported by 17 studies (n = 404/481; 84%). Overall, after a median follow-up of 28 months (n = 339/481; IQR 23-40.5), no evidence of disease (NED) was found in 238 patients (58.9%), recurrence at the RPLNs in 14 (3.5%), local recurrence in 22 (5.4%), regional recurrence in 23 (5.7%), locoregional recurrence in 16 (4%), distant metastases in 42 (10.4%), death from disease in 36 (8.9%), death from other cause in 23 (5.7%), and death from unspecified cause in 26 (6.4%). CONCLUSIONS: Further prospective randomized controlled trials are needed to provide direct comparison between different approaches for RPLNs dissection.

Ganglioneuroblastoma in the Retropharyngeal Space: A Case Report and Literature Review.

Ganglioneuroblastoma is a rare peripheral neuroblastic tumor located anywhere in the sympathetic nervous system but rarely in the retropharyngeal space. Diagnosis can often be difficult based on imaging alone. We describe one case of a child presenting with snoring. The lesion was located in the rare retropharyngeal space, and its histology finally revealed ganglioneuroblastoma. Therefore, clinicians should be aware of pediatric patients with respiratory symptoms indicating cervical ganglioneuroblastoma. To make a definite diagnosis as soon as possible, a core needle biopsy or even immunohistochemistry may need to be performed before surgery.

Migrated and Impacted Foreign Body of Retropharyngeal Space: A Case Report.

Foreign body upper aerodigestive tract is a common presentation but foreign body migrating into retropharyngeal space is not only uncommon, but its management also differs and is challenging too. Here we present a case of a foreign body migrating into the retropharyngeal space which was removed intraorally. A 28- year old male patient presented with complaints of pain while swallowing following consumption of sausage and pork two days earlier to the onset of symptoms. X-Ray Neck AP and lateral view were done which revealed a thin metallic foreign body at the level of the T4 vertebra. Upper gastrointestinal endoscopy and rigid esophagoscopy were done in which a foreign body was not visualized in the esophageal lumen. NCCT neck was done which gave precise location and was removed intraorally with the patient in Rose position. A repeat x-ray was done on the 5th day which revealed no foreign body, the patient was discharged on the 7th day. Although the upper aerodigestive tract foreign body is common, foreign body migrating to the posterior pharyngeal wall or into the retropharyngeal space is not common and it is difficult to remove a migrated foreign body many cases requiring open procedures, thoracoscopy, thoracotomy.