A 16-year-old black male youth presented because of low grade fever, progressive dysphagia, neck pain and weight loss for 1 month. There was no history of respiratory difficulty, and review of systems was unremarkable. He denied trauma to the mouth or pharynx. Past medical history was unremarkable except for sickle cell trait. He lived with his mother and 14-year-old brother. His mother had been treated for tuberculosis 19 years earlier.
Physical examination showed an alert teenager in no acute distress. Temperature was 36°C orally, pulse 80/min, respiration 15/min and blood pressure 102/60 mm Hg. A swelling (5 by 5 cm) of the left posterior pharyngeal region was noted. The rest of the physical examination was normal.
Laboratory data showed a white blood cell count of 12 100/mm3 (74% segmented form, 18% lymphocytes, 6% monocytes and 20% basophils), hematocrit 34.6% and platelets 562 000/mm3. Urinalysis, liver enzymes, blood urea nitrogen and creatinine were normal. Human immunodeficiency virus antibody was negative.
Roentgenographs of the neck showed a large prevertebral mass with compression of the airway, the destruction of C3 vertebral body and involvement of the anterior spinal canal. Chest roentgenograph showed normal lung fields and mild superior mediastinal widening. Computerized tomography scan of the neck showed a large retropharyngeal abscess associated with destruction of the C3 vertebral body and loss of C2-C3 intervertebral space.
Incision and drainage of the retropharyngeal abscess was performed after placement of a neck traction halo and after a tracheostomy for airway control. Purulent drainage material (60 ml) was sent for cultures.
Walid M. Abuhammour, M.D.
Basim I. Asmar, M.D.
Division of Infectious Diseases; Children's Hospital of Michigan
Department of Pediatrics; Wayne State University School of Medicine
For denouement see p. 748.
DENOUEMENT-CONTINUED FROM P. 732
Considering the positive family history for tuberculosis, clinical manifestation and radiologic finding, tuberculosis was highly suspected. An intradermal Mantoux skin test was positive with induration of 12 by 15 mm. The purulent material was positive for acid-fast bacilli and subsequently grew Mycobacterium tuberculosis susceptible to all antituberculous agents. The patient was treated with isoniazid, rifampin and pyrazinamide for 2 months and then continued to receive isoniazid and rifampin for 1 year. He improved clinically and radiologically. The halo was removed and the tracheostomy was closed. He resumed his normal activities and has been doing well since then.
The retropharyngeal space is a pocket of connective tissue that extends from the base of the skull to approximately the level of tracheal bifurcation (C6 to T2). It contains two paramedial chains of lymph nodes that receive drainage from the nasopharynx, adenoids and paranasal sinuses.1 These nodes are prominent in early childhood and atrophy at puberty. Retropharyngeal abscess can occur secondary to suppuration of the lymph nodes in the retropharyngeal space. Although infrequent it is a serious condition that may extend into the mediastinum or result in asphyxia from direct pressure or from sudden rupture.2
Retropharyngeal abscess usually follows pharyngitis or nasopharyngitis. Rarely it follows extension of vertebral osteomyelitis.3 Retropharyngeal abscess is more common in infants and older children than in adults.4 It is commonly reported in children younger than 3 years.5
Retropharyngeal abscess in children is a polymicrobial infection caused mainly by aerobic and anaerobic oral bacterial flora.6 Common symptoms include fever, swollen neck, dysphagia, drooling, muffled voice and hyperflexion of the head and neck. Anterior bulging of the posterior pharyngeal wall is usually present.
A lateral radiograph of the nasopharynx and neck is considered diagnostic if the retropharyngeal space measured from the posterior wall of the second cervical vertebrae is widened to more than twice the diameter of the cervical vertebral body.7 However, computed tomography with contrast has the ability to localize pathologic processes more accurately and to distinguish neck cellulitis from deep neck abscess, thus avoiding delay in surgical intervention.4
Skeletal tuberculosis occurs in 1 to 6% of children with untreated mycobacterial tuberculosis, and it can be the only manifestation of systemic disease.8 The vertebrae are most commonly affected.9 Thoracic and lumbar vertebrae are most commonly involved.10 Involvement of the cervical spine is rare.11 Skeletal tuberculosis is usually caused by the hematologic route early in the course of the initial infection and sometimes by lymphatic drainage from another infected focus such as tuberculosis of the pleura or kidney spreading via the periaortic lymph nodes with erosion into the spine.8 Clinical manifestation depends on the vertebrae involved and tissue planes dissected by the infection. Clinical manifestations include fever, pain, weight loss, anorexia, swelling, immobility and torticollis when the cervical spine is involved.12
Paravertebral abscess occurs in 60% of children with vertebral tuberculous osteomyelitis.13 Mycobacterial retropharyngeal abscess is usually secondary to cervical tuberculous osteomyelitis14; however, it is unusual to be the presenting feature.15
The treatment of tuberculosis spondylitis is controversial.10 Indication for surgical intervention in addition to antituberculous chemotherapy may be abscess drainage, spinal stabilization and protection of vital structures.9, 11, 16
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