SAEM Clinical Image Series: Worsening Sore Throat

Computed tomography neck

A 40-year-old male presented to the emergency department (ED) complaining of a sore throat for one week. The patient had presented ten days earlier following a stab wound to the anterior neck that violated the platysma. There was no vascular injury noted on the computed tomography angiography (CTA) but there was extensive soft tissue damage with emphysema extending into the retropharyngeal space. The patient underwent a flexible laryngoscopy by ENT, which showed no airway injury. He was observed in the intensive care unit for two days, then discharged. Following discharge, the patient had progressive sore throat and odynophagia, so he re-presented to the ED.

Physical Exam

General: Non-toxic, afebrile, with normal vital signs

HEENT: Mild fullness to the right posterior oropharynx, healing wound to the left anterior neck with diffuse tenderness to palpation

Pulmonary: Clear lung sounds bilaterally, no respiratory distress

Labs

WBC: 24.7 cells/uL with bandemia

Case Question: What is the diagnosis and initial management of this condition?

Retropharyngeal abscess (RPA)

Initial management includes an assessment of airway stability, intravenous antibiotics, and emergent ENT consult.

Case Question: What are the most common presenting symptoms for this condition?

Sore throat, fever, odynophagia, and neck pain

It is common for symptoms to present out of proportion to physical examination.

Case Discussion

Given the patient’s degree of leukocytosis with clinical symptoms, the patient underwent a CTA scan that revealed a large, 16 cm x 4.5 cm multiloculated RPA that extended into the mediastinum and exerted mass-effect on the esophagus and hypopharynx. The patient was started on intravenous antibiotic therapy and taken emergently to the operating room by the ENT service for surgical drainage and tracheostomy. The hospital course was complicated by a second washout for concern of persistent pharyngeal perforation. Subsequently, he had no residual leak, was decannulated, and discharged with oral antibiotics and outpatient ENT follow-up.

Take-Home Points

Retropharyngeal abscess is an infection of the deep space of the neck. It requires prompt diagnosis by emergency physicians because of the potential for airway compromise.
It can be difficult to diagnose by physical examination alone [1]. Almost half of reported cases presented with only subtle findings on an oropharyngeal exam [2]. Symptoms out of proportion to physical examination should prompt a broader work-up with diagnostic imaging [3].
RPA is less common in adults. Known risk factors include an immunosuppressed state, direct extension of an infection from an adjacent focus, and trauma often from an impacted food bolus or fish bone/chicken bone causing injury to the posterior pharyngeal wall [4].

References

Tannebaum R.D. Adult retropharyngeal abscess: a case report and review of the literature. J Emerg Med. 1996;14:147–158. PMID: 8740744
Harkani A., Hassani R., Ziad T., Aderdour L., Nouri H., Rochdi Y. Retropharyngeal abscess in adults: five case reports and review of the literature. Sci World J. 2011;11:1623–1629. PMCID: PMC3201680
Wetmore RF, Mahboubi S, Soyupak SK. Computed tomography in the evaluation of pediatric neck infections. Otolaryngol Head Neck Surg. 1998 Dec;119(6):624-7. PMID: 9852537
Sharma S.B., Hong P. Ingestion and Pharyngeal Trauma Causing Secondary Retropharyngeal Abscess in Five Adult Patients. Case Rep Emerg Med. 2012;2012:943090. PMCID: PMC3542898

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2020 SAEM Annual Meeting | Copyrighted by SAEM 2020 – all rights reserved. View other cases from this series on ALiEM.

Author information

Victoria Silver, DO

Emergency Medicine/Internal Medicine Resident
Louisiana State University - New Orleans

The post SAEM Clinical Image Series: Worsening Sore Throat appeared first on ALiEM.

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