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REG.NO. D032

ACUTE RETROPHARYNGEAL ABSCESS

IN AN ELDERLY ADULT


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INTRODUCTION

Retropharyngeal abscess (RPA) though anuncommon disease entity occurs usually in children

under the age of 5 years It is a surgical emergency as there is involvement of

the airway which may results in upper airwayobstruction which could lead to life threateningcondition.

B. Hartley, Cervicofacial Infection in Children, In: G. Michael, Ed., ScottsBrowns Otorhinolaryngology,Head and Neck Surgery, 7th Edition, Hodder

Arnold, London, 2008, pp. 1213-1214.


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The pathological basis for the higher prevalence inchildren is due to the loose aggregate of lymph nodes inthe prevertebral space which may become infected withresultant suppuration

Upper respiratory tract infection is the most commonpredisposing factor to RPA in children while cervical spinetuberculosis and trauma are the major aetiological factorsin adults.

O. A. Afolabi, J. O. Fadare, E. O. Oyewole and S. A. Ogah, Fish Bone Foreign BodyPresenting with an Acute Fulminating Retropharyngeal Abscess in a Resource- Challenge

Centre: A Case Report,Journal of Medical Case Reports, Vol. 5, 2011, p. 165.


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CASE REPORT

A 60 year old , elderly female, presented to our

ENT OPD with difficulty in swallowing ,

swelling in the posterior wall of oral cavity and

fever since 7 days.

She gives history of fish bone injury to the

posterior wall which occurred 5 days before the

symptoms started.


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CONTINUED

On ENT examination, Congested posterior pillar on

both side

Midline swelling in the posterior

pharyngeal wall

Increased secretions in oral

cavity.

Level 2 neck lymph nodes onleft side were enlarged with

fullness of neck on the left side


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Systemic examination : Normal

A provisional diagnosis of deep neck space

infection possibly retropharyngeal abscess was

made.


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INVESTIGATIONS

Routine investigations carried out

included complete blood count,urine routine, blood glucose,

bleeding profile, renal function test

all were within normal limits

except leukocytosis The patient had X-ray soft tissue

of the neck,it showed the reversal

of the normal cervical curvature

with a huge soft tissue mass in theretropharyngeal space with no

significant associated luminal

narrowing.


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Patient was subjected for CT

scan neck and thorax to see for

the size and extension if any to

the mediastinum

It is noted that abscess was

restricted to the

retropharyngeal space in the

midline more towards left

side,with no exentsion into the

mediastinum.


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TREATMENT

Patient was rehydrated and intravenous

antibiotics started with amoxicillin with

cavulunate,gentamycin and metronidazole

preoperatively and arranged emergency incisionand drainage under general anaesthesia


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Paient was shifted to OT and anaesthetised with

orotracheal intubation.

Then patient was placed in Rose position and the

oropharynx was exposed with Davis-Boyle gag

frame


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Operative findings were

grossly enlarged swelling in posterior pharyngeal wallwhich was tense and fluctuant

90 to 100 ml of thick pus under tension was drained

via a vertical incision.

The abscess cavity was irrigated with mixture of

warm normal saline and betadine solution.


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The pus collected from the abscess cavity was

sent for microscopy, culture and sensitivity and

Ziehl-Neelsen (ZN) staining for acid-fast bacilli

(AFB).

The specimen yielded florid pus cells, but no

bacterial growth and the ZN stain was negative

for AFB.


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POST - OP

The patient had continued with

intravenous antibiotics and

analgesics

Patient had NGT feeding for the

first two days post operative

period, started feeding around

the NGT from the 3rd day after

the surgical drainage, and the

NGT was finally removed on the6th day after surgery as oral

feeding was adequately restored.


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The general conditionof the patient isimproving and the sizeof the abscess was

monitored intraorallyusing zero degreeendoscope.

Patient was discharged

on 7th

day and advicedto take oral antibioticsand analgesics.


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CONCLUSION

The main aetiological factors of RPA in adult are

trauma induced by foreign bodies, iatrogenic,orodental infection and tuberculosis. Fish bone

injury was the responsible agent in our patient

A. Harkani, R. Hassani, T. Ziad, L. Aderdour, H. Nouri, Y. Rochdi and A. Raji,

Retropharyngeal Abscess in Adults: Five Case Reports And Review of the

Literature, The Scientific World Journal, Vol. 11, 2011, pp. 1623- 1629


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RPA may present with life threatening upper airwayobstruction.

Delay in the diagnosis of RPA is often associated

with other serious morbidities such as aspirationpneumonia, sepsis, mediastinitis, empyema anderosion of carotid artery

I. Brook, Microbiology and Management of Peritonsillar, RetropharyngealAbscess and Pharyngeal Abscesses,Journal of Oral & Maxillofacial Surgery, Vol.

62, No. 12, 2004, pp. 1545-1550.


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The diagnosis is usually made based on clinical

symptoms, signs as well as radiological features.

It is important to consider the differentialdiagnosis in a patient with suspected RPA before

initiating any treatment options , high index of

suspicion is suggested for prompt diagnosis.


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