Descending necrotising mediastinitis: a rare entity in children.

We present a case of descending necrotising mediastinitis (DNM) originating from a retropharyngeal abscess in a healthy early childhood patient. The patient had a history of fever, odynophagia and refusal to eat, followed by rapid deterioration of the clinical state. Cervicothoracic CT was performed, which revealed a right parapharyngeal abscess, extending to the mediastinum and occupying the retropharyngeal/visceral space, with gaseous content throughout this collection, associated with bilateral pleural effusion, aspects compatible with DNM. She started broad-spectrum antibiotic therapy and transoral drainage of the parapharyngeal and retropharyngeal collections was performed under general anaesthesia. She was admitted to the intensive care unit. The patient showed clinical, analytical and imaging improvement, having been transferred to the ear, nose and throat department, with favourable evolution. Early diagnosis of DNM by cervicothoracic CT and multidisciplinary approaches, including intensive care, broad-spectrum antibiotics and surgical intervention, are crucial to minimise the morbidity and mortality.

Retropharyngeal abscess due to Fusobacterium necrophorum complicated by progressive internal carotid artery stenosis and multiple cranial nerve palsies.

BACKGROUND: A case of retropharyngeal abscess complicated by both artery and nerve injury has rarely been reported. METHODS: A 36-year-old woman suddenly presented with right eye visual loss, dilated pupil, reduced direct light reflex, ptosis and ocular motility disorder on the side of inflammation progression, and was diagnosed with retropharyngeal abscess due to Fusobacterium necrophorum. The patient was treated only with antibiotics and, no further surgery was necessary but tracheotomy. Four months later, MRA showed right ICA occlusion and left ICA stenosis. MRI revealed continuous spread of inflammation due to the abscess from the retropharyngeal to the intracranial space. RESULTS: These severe complications would be attributed to an endothelial damage to the arterial wall and an ischemic neuropathy caused by inflammation and thrombogenesis due to Fusobacterium necrophorum. CONCLUSIONS: This case should provide a better understanding of the mechanism of vascular and cranial nerve injury due to retropharyngeal infections, and highlights the need for early antibiotic therapy and repeated vascular evaluation.

Descending necrotizing mediastinitis secondary to retropharyngeal abscess.

We report a case of descending necrotizing mediastinitis (DNM) in a 68-year-old male who presented in acute respiratory distress accompanied with anterior cervical neck swelling and pain with swallowing. Contrast enhanced computed tomography (CECT) of the neck demonstrated a large, peripherally enhancing retropharyngeal fluid and air collection that appeared to communicate with a fluid and air collection within the mediastinum. CECT of the chest demonstrated punctate foci of air and fat stranding along the anterior and superior mediastinum. Radiological evidence and the presence of necrosis on surgical debridement of the retropharyngeal abscess established the diagnosis of DNM. This case emphasizes the role of computed tomography (CT) in the diagnosis of DNM and demonstrates the utility of chest imaging in a high-risk patient who presents with a retropharyngeal abscess.

Life-threatening complication of retropharyngeal abscess in an infant: a case report.

BACKGROUND: Deep neck space infections are uncommon in infants. Retropharyngeal abscess (RPA) is a deep space neck infection that can present with subtle signs and symptoms. Delay in diagnosis can lead to life-threatening complications. Here we describe life-threatening complication of retropharyngeal abscess. CASE PRESENTATION: We report a life-threatening complication of retropharyngeal abscess in 10-month old Asian infant weighing 8.2 kg. The patient presented with fever, right-sided neck swelling, hoarseness of voice, and respiratory distress. The clinical and radiological findings were suggestive of airway obstruction complicated by retropharyngeal abscess. The patient was urgently taken to the operating room and underwent (grade 3) intubation. After stabilization, the patient underwent endoscopic trans-oral incision and drainage, during which 5 cc pus was aspirated. Antibiotics were prescribed for 2 weeks following the procedure based on the sensitivity result of the pus culture. CONCLUSION: In retropharyngeal abscess, a delay in diagnosis can result in life-threatening complications. This report highlights the importance of prompt recognition of a threatened airway and the management of retropharyngeal abscess by emergency physicians. If an emergency physician suspects RPA with airway obstructions, the airway should be immediately secured in a secure environment by otolaryngologist and an anesthesiologist.

Rare and unexpected cause for retropharyngeal abscess in an immunocompetent man: metastatic community-acquired methicillin-resistant Staphylococcus aureus infection.

Staphylococcus aureus causes clinical diseases ranging from mild skin infections to devastating conditions such as septic shock, endocarditis and osteomyelitis. S. aureus is a common cause of community-acquired bacteraemia. Prolonged bacteraemia may cause metastatic infection, manifesting as endocarditis, osteomyelitis and abscesses. A man in his 20s presented with a short-duration of fever and odynophagia. CT of the neck suggested a retropharyngeal abscess. Retropharyngeal abscesses are typically polymicrobial and caused by resident oral cavity flora. In the hospital, he developed shortness of breath and hypoxia. CT of the chest showed peripheral, subpleural nodular opacities raising suspicion for septic pulmonary emboli. Blood cultures demonstrated the growth of methicillin-resistant S. aureus The patient completely recovered with antibiotic therapy alone. This is a unique and rare presentation case of metastatic S. aureus bacteraemia, manifesting as a retropharyngeal abscess without any evidence of infective endocarditis on transoesophageal echocardiography.

Clinical features of Kawasaki disease initially mimicking retropharyngeal abscess: a retrospective analysis.

OBJECTIVE: Incomplete Kawasaki disease (IKD) initially presenting as retropharyngeal abnormality is very rare and is prone to misdiagnosis and missed diagnosis, often leading to poor prognosis. Most patients were misdiagnosed with retropharyngeal abscesses. Here, we describe and compare IKD patients initially presenting with retropharyngeal abnormalities, typical KD patients without retropharyngeal abnormalities and retropharyngeal abscess patients. METHODS: We performed a retrospective case-control study comparing IKD patients initially presenting with retropharyngeal abnormalities to both KD patients without retropharyngeal abnormalities and retropharyngeal abscess patients admitted to Shenzhen Children's Hospital between January 2016 and December 2021. RESULTS: We evaluated data from 10 IKD patients initially presenting with retropharyngeal abnormalities (Group A), 20 typical KD patients (Group B) and 16 surgical drainage confirmed retropharyngeal abscess patients (Group C). Compared to Group B, we observed that Group A was older and had a more intense inflammatory response. On the day of admission, Groups A and C had similar early clinical presentations, and there were no significant differences in any major signs or symptoms. Close observation for the development of new KD signs and symptoms and unresponsiveness to empirical antibiotic therapy after 3 days is extremely important. The CRP (p = 0.011), AST (p = 0.002) and ALT (p = 0.013) levels were significantly higher and the WBC (P = 0.040) levels were significantly lower in Group A than in Group C. Neck radiological findings, such as the presence of ring enhancement (p = 0.001) and mass effects on the airway, are also useful tools for distinguishing these two diseases. CONCLUSION: The careful observation of the signs and symptoms of this disease and the comprehensive analysis of the laboratory tests and neck radiological findings may help clinicians become aware of retropharyngeal abnormality as an atypical presentation of KD. Then, unnecessary treatments could be reduced, and the occurrence of serious complications can be avoided.

Role of steroids in conservative treatment of parapharyngeal and retropharyngeal abscess in children.

PURPOSE: To characterize the clinical features and outcomes of pediatric patients with retropharyngeal (RPA) or parapharyngeal abscesses (PPA) managed only with medical treatment and showing the importance of early symptoms and imaging studies in the diagnosis of deep neck space infections (DNIs) in children. METHODS: A retrospective analysis of all patients diagnosed with RPA and PPA between 2007 and 2017 was performed in Hospital Universitario Central de Asturias. RESULTS: 30 children were identified, with 11 RPA and 19 PPA. 23 children (76.7%) were under 5 years old, and all were treated with intravenous amoxicillin/clavulanic acid and corticosteroids. Torticollis and fever were present in all patients. The mean length of hospital stay was 7.5 days. There were no complications associated. CONCLUSION: DNIs can be treated in a conservative way, reserving the surgical drainage for cases with a complication associated (airway compromise, lack of response to antibiotic therapy, immunocompromised patients). Treatment with intravenous antibiotics and corticosteroids is a safe option, reducing the duration of symptoms and the length of hospital stay.

Retropharyngeal Abscess Presenting as Torticollis.

Retropharyngeal abscess (RPA) is a deep neck infection with life-threatening complications such as airway obliteration, necrotizing mediastinitis, and pulmonary empyema, which must be diagnosed early and treated promptly. We herein present a patient who was admitted to the emergency room with limited neck movement, torticollis, difficulty in swallowing, and a feeling that something is stuck in the throat and diagnosed with RPA. Plain lateral radiograph of the neck revealed air levels at the level of C3-C5. Computed tomography (CT) scan confirmed the diagnosis of RPA. After emergency surgery, clinical condition normalised in a short time, and at a 2-week postoperative follow-up, the retropharyngeal area was completely normal on endoscopic examination. It is important to recognise and treat RPA, which has a high mortality due to its complications. RPA should be kept in mind in the differential diagnosis of patients with neck pain and torticollis, particularly in adults. Key Words: Retropharyngeal abscess, Drainage, Trendelenburg position, Torticollis.

Acute Calcific Tendinitis of the Longus Colli: Not All Retropharyngeal Fluid is an Abscess.

OBJECTIVE: This report aimed to present a case of acute calcific tendinitis of the longus colli muscle as an uncommon cause of neck pain and dysphagia and is often misdiagnosed as a retropharyngeal abscess. METHODS: Case report and literature review. RESULTS: Acute calcific tendinitis is often misdiagnosed as a retropharyngeal abscess; however, it is distinguished from the latter based on patient history and unique radiologic findings. History, examination, and laboratory findings do not suggest an infectious etiology, and radiographic findings include a non-rim-enhancing fluid collection with or without calcifications anterior to the upper cervical spine. CONCLUSION: Unlike retropharyngeal abscess, acute calcific tendinitis is managed conservatively. When consulted for a possible retropharyngeal abscess, the otolaryngologist should avoid anchoring bias by independently obtaining a detailed history and examination and personally reviewing radiologic images to avoid unnecessary intervention.

Observation of Retropharyngeal Fluid Collection in 2 COVID-19 Positive Patients.

Our understanding of the novel coronavirus, COVID-19, is growing; yet, there remains much we do not understand, and unique presentations are abundant. One potential presentation is retropharyngeal edema, defined as fluid in the retropharyngeal space. Multiplanar imaging with computed tomography or magnetic resonance imaging is ideal for characterizing and diagnosing these fluid collections rapidly as possible life-threatening complications may develop (eg, airway obstruction and mediastinitis). Here, we discuss the presentation, imaging identification, treatment, and recovery of retropharyngeal fluid collection in 2 COVID-19 cases. The significance of this article is to suggest conservative management as a viable treatment option for retropharyngeal fluid collection, as opposed to incision and drainage, in the setting of COVID-19.

Magnetic resonance imaging accuracy before surgery in children with retropharyngeal abscesses.

AIMS: Retropharyngeal abscess (RPA) is a deep neck infection occurring in childhood. The gold standard technique for diagnosis is computerised tomography (CT) with a contrast medium. The aim of this study is to answer the question of whether magnetic resonance imaging (MRI) can be an alternative in diagnosing RPA and predicting pus drainage at surgery. METHODS: This is a retrospective study conducted at the paediatric emergency department of a tertiary level children hospital. The medical records of 31 children admitted to the Otorhinolaryngology and Paediatric ward, with a suspected diagnosis of RPA, were reviewed. The primary study outcome was the diagnostic accuracy of CT and MRI in predicting the amount of pus during surgery. RESULTS: Twenty-two patients (71%) underwent surgery. Among them, 18 had imaging before surgery. Eleven patients evaluated with CT scan underwent surgery: four had non-significant purulent drainage, three of them were reported to have a significant fluid collection (negative predictive value 66% and positive predictive value of 55%). Nine patients evaluated with MRI underwent surgery: four cases had non-significant purulent drainage, three of them showed a significant fluid collection at MRI (negative predictive value of 60%; positive predictive value of 56%). CONCLUSION: MRI and CT scans showed similar accuracy in predicting successful pus drainage during surgery; therefore, it could be a valid alternative in the diagnosis of RPA in children.

[Features of the clinic, diagnosis and treatment of parapharyngeal abscesses in children: analysis of 121 observations]. / Osobennosti kliniki, diagnostiki i lecheniya parafaringeal'nykh abstsessov u detei: analiz 121 nablyudeniya.

Parapharyngeal and retropharyngeal abscesses (PPA) in children are a rare pathology, for the diagnosis of which it is necessary to use additional instrumental examination methods. The tactics of treating patients remains a subject of discussion. OBJECTIVE: To analyze the features of the clinic, diagnosis and treatment of PPA in children. MATERIAL AND METHODS: According to the hospital database, a retrospective analysis of the medical histories of children discharged from the clinic with a diagnosis of "J39.0 Retropharyngeal and parapharyngeal abscess" was carried out in the period from 01.01.14 to 31.12.19. In all cases, the diagnosis was confirmed by computed tomography (CT) data with contrast enhancement. Complaints at the time of treatment, anamnesis and instrumental diagnosis data, clinical features of the course of the disease and the effectiveness of treatment were analyzed. RESULTS: 121 children were treated for PPA (average age 73±41 months; Me=52.5 months), which is 0.4% of all hospitalized in the otorhinolaryngological department, 0.7% of the number of emergency hospitalizations, 0.8% of the number of hospitalized children with pharyngeal diseases, and 8.3% of the number of patients with pharyngeal abscess. Abscesses were more often localized in the upper pharynx, at the level of the I-II cervical vertebrae (49.6% of all observations); abscesses were found least often in the pharyngeal space (5.8%), there was no statistically significant difference between the right-sided and left-sided location: 47.9% and 46.2%, respectively. Surgical treatment was performed in 98 (81%) patients in the presence of an abscess capsule or an abscess diameter of more than 2 cm according to CT; the remaining 23 (19%) children were treated conservatively. The opening of the abscess was performed endopharyngeal, in the case of a pronounced deep lateral location of the abscess and its proximity to large blood vessels - with access through the tonsillar niche after preliminary tonsillectomy (19.4% of those operated). CONCLUSION: The final diagnosis of parapharyngeal and retropharyngeal abscess can be established by contrast-enhanced computed tomography. Conservative treatment is indicated for a limited group of patients at the initial stages of the disease, most patients need surgical treatment.

Undiagnosed pharyngeal perforation following a penetrating neck trauma in a 5-year-old child: a proposed treatment algorithm.

External penetrating wounds of the neck leading to pharyngeal perforations are relatively uncommon. The small area of the neck contains the vital vascular, aerodigestive and nervous structures, which are difficult to access surgically. Pharyngeal perforations are challenging to treat, especially in children, as primary wound inspection may be difficult, leading to life-threatening complications like retropharyngeal abscesses, mediastinitis or airway compromise. The following is a case report of a 5-year-old girl who had a road traffic accident causing a neck laceration with a pharyngeal tear, which was only identified during emergency neck exploration in the operating room. A review of known literature and a proposed algorithm for managing penetrating neck injuries with pharyngeal injury is described.

Features associated with surgically significant abscesses on computed tomography evaluation of the neck in pediatric patients.

BACKGROUND: Neck-related chief complaints are common in the pediatric Emergency Department (ED), and although the incidence of pathology such as retropharyngeal abscesses is rare, the ability to rule out abscesses requiring surgical/procedural intervention is essential. However, there are no clear clinical guidelines regarding work-up and diagnosis in this population, possibly contributing to an excess use of potentially harmful and costly computed tomography (CT) imaging. OBJECTIVE: In this study we sought to identify historical, physical exam, and laboratory findings associated with surgically significant neck abscesses to better delineate CT neck imaging criteria. METHODS: We conducted a retrospective chart review of all patients ≤18 years presenting to a pediatric ED between 2013 and 2017 who underwent CT neck imaging. Surgically significant abscesses (SSAs) were defined as abscesses ≥2 cm, retropharyngeal abscesses (RPA), parapharyngeal abscesses (PPA), or peritonsillar abscesses (PTA). Historical factors, physical exam findings, laboratory results, demographics, and CT results were analyzed using univariate statistical analysis and regression models. RESULTS: A total of 718 patients received neck CTs and 153 SSAs were identified. In children younger than 6 years, factors associated with statistically significant increased odds of an SSA were reported throat pain (OR 1.18; 95% CI 1.05, 1.33), fussiness (OR 1.18; 1.01, 1.39), lethargy (OR 1.43; 1.07, 1.91), tonsillar enlargement (OR 1.17; 1.02, 1.34), C-reactive protein (CRP) > 10 (OR 1.22; 1.07, 1.40), and an ED visit within the preceding week (OR 1.18; 1.04, 1.33). In children older than 6 years, the factors associated with statistically significant increased odds of an SSA included current antibiotic use (OR 1.12; 1.02, 1.22) and a CRP >10 (OR 1.14; 1.03, 1.26). CONCLUSION: Some historical, physical exam, and laboratory findings are associated with SSAs, and while not definitive in isolation, may be beneficial additions to routine SSA assessment, as a supplement to clinical judgement regarding CT and observation decisions. This may potentially allow for the identification of patients requiring CT versus those who may not, and thus the opportunity to safely reduce the use of CT imaging in select patients.

Retropharyngeal Abscess in an Adult With Pneumonia During COVID-19 Outbreak.

BACKGROUND: Retropharyngeal abscesses are rarely reported in adults and occur mostly in patients with immunocompromised or as a foreign body complication. Admittedly, the treatment of retropharyngeal abscesses frequently involves surgical drainage to achieve the best results. However, when retropharyngeal abscesses occurred in a highly suspected patient with COVID-19, the managements and treatments should be caution to prevent the spread of the virus. CLINICAL PRESENTATION: On February 13, a 40-year-old male with retropharyngeal abscesses turned to our department complaining dyspnea and dysphagia. In addition, his chest CT scan shows a suspected COVID-19 infection, thus making out Multiple Disciplinary Team determine to perform percutaneous drainage and catheterization through left anterior cervical approach under the guidance of B-ultrasound. Finally, the patient recovered and was discharged from the hospital on February 27 after 14 days of isolation. There was no recurrence after half a year follow-up. CONCLUSIONS: By presenting this case, we aim at raising awareness of different surgical drainage methods and summarizing our experience in the management of retropharyngeal abscesses during the outbreak of COVID-19.

Abscés cervical profund associat a col·locació de mascareta laríngia / Absceso cervical profundo asociado a la colocación de mascarilla laríngea / Deep neck abscess associated to the placement of a laryngeal mask

INTRODUCCIÓ: Els abscessos parafaringi I retrofaringi són infeccions profundes del coll que solen associar-se a l'antecedent d'infecció de vies respiratòries altes. Ocasionalment poden ser causats per traumatismes com els que comporten algunes manipulacions mèdiques, per exemple, la col·locació de mascareta laríngia, molt utilitzada en cirurgia pediàtrica. CAS CLÍNIC: Es presenta el cas d'una nena de 6 anys amb torticoli de 8 dies d'evolució I febre de 24 hores, sense cap altra simptomatologia. La pacient havia estat intervinguda quirúrgicament sota anestèsia general amb col·locació de mascareta laríngia 36 hores abans de l'inici del quadre, sense incidències. En l'exploració, destaca una contractura cervical bilateral amb flexió del cap a la dreta, I a l'analítica es troba leucocitosi amb predomini de neutròfils I augment de la proteïna C reactiva. Es fa una ressonància magnètica cervical en què s'observa un abscés d'extensió parafaríngia I retrofaríngia, I s'indica una punció percutània ecoguiada de l'àrea abscessificada, que resulta positiva per a S. pyogenes. S'ingressa la pacient amb antibioteràpia endovenosa I s'aconsegueix la millora clínica I radiològica de l'abscés. COMENTARIS: Els abscessos cervicals profunds s'han de considerar davant de simptomatologia obstructiva I inflamatòria de la via aèria I el tracte digestiu superior, I símptomes locals o dolor al moviment cervical. El diagnòstic es basa en les troballes radiològiques, analítiques I microbiològiques, I cal instaurar antibioteràpia endovenosa empírica amb cobertura per a estafilococs, estreptococs I anaerobis. Tot I que aquests abscessos en la majoria de casos són secundaris a l'extensió d'infeccions del tracte respiratori superior, hi ha altres causes que cal considerar

INTRODUCCIÓN: Los abscesos retrofaríngeo y parafaríngeo son infecciones profundas del cuello que suelen asociarse al antecedente de infección de vías respiratorias altas. Ocasionalmente pueden ser causados por traumatismos como los que resultan de algunos procedimientos médicos, por ejemplo, la colocación de la mascarilla laríngea, muy utilizada en cirugía pediátrica. CASO CLÍNICO: Se presenta el caso de una niña de 6 años con tortícolis de 8 días de evolución y fiebre de 24 horas, sin otra sintomatología. La paciente había sido intervenida quirúrgicamente bajo anestesia general con colocación de mascarilla laríngea 36 horas antes del inicio del cuadro, sin incidencias. A la exploración, destaca una contractura cervical bilateral con flexión de la cabeza hacia la derecha, y en la analítica se encuentra leucocitosis con predominio neutrofílico y ligero aumento de proteína C reactiva. Se realiza una resonancia magnética cervical donde se observa un absceso de extensión parafaríngea y retrofaríngea, y se practica una punción percutánea ecoguiada de la zona abscesificada, que resulta positiva para S. pyogenes. La paciente ingresa con antibioterapia endovenosa y se consigue mejoría clínica y radiológica del absceso. COMENTARIO: Los abscesos cervicales profundos deben considerarse ante sintomatología obstructiva e inflamatoria de la vía aérea y del tracto digestivo superior, y síntomas locales o dolor al movimiento del cuello. El diagnóstico se basa en los hallazgos radiológicos, analíticos y microbiológicos y se debe instaurar antibioterapia endovenosa empírica con cobertura para estafilococos, estreptococos y anaerobios. Aunque en la mayoría de casos estos abscesos son secundarios a la extensión de infecciones del tracto respiratorio superior, existen otras causas que deben considerarse

INTRODUCTION: Retropharyngeal and parapharyngeal abscesses are deep neck infections that are usually associated with superior airway infections in children. However, they could also be caused by injuries secondary to medical procedures such as the placement of laryngeal masks, which are frequently used in pediatric surgery. CASE REPORT: A 6-year-old female presented to the emergency room with an 8-day history of torticollis and 24 hours of fever with no other associated symptomatology. She had undergone surgery under general anesthesia using a laryngeal mask 36 hours prior, without immediate complications. In the physical examination, the patient had bilateral cervical contracture with right bending. The blood examination showed leukocytosis with predominance of neutrophils and increase of C-reactive protein. Magnetic resonance imaging showed an abscess with parapharyngeal and retropharyngeal extension, and a percutaneous ultrasound-guided puncture of the abscessed area was performed, which resulted positive for S. pyogenes. The patient received intravenous antibiotic therapy and achieved clinical and radiological resolution of the abscess. COMMENTS: Deep neck abscesses should be considered in children with obstructive and inflammatory symptomatology of the airway and upper digestive tract and also local symptoms as neck pain. Diagnosis is based on radiological, analytical and microbiological findings and empirical intravenous antibiotics, with coverage for staphylococcus, streptococcus and anaerobics. Although in most cases these abscesses are secondary to the spread of upper respiratory tract infections, other causes should be considered