Giant Retropharyngeal Abscess in a Nigerian Adult Following Fish Bone Throat Injury

doi:10.4236/ijohns.2013.26056

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International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 271-275

Published Online November 2013 (http://www.scirp.org/journal/ijohns)

http://dx.doi.org/10.4236/ijohns.2013.26056

Open Access IJOHNS

Giant R etropha ryngeal Abscess in a Nigerian Adult

Following Fish Bone Throat Injury

Stanley B. Amutta1*, Daniel Aliyu1, Mohammed Abdullahi1, Mohammed Danfulani2,

Yunusa A. Mufutau3

1ENT Department, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

2Radiology Department, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

3Psychiatry Department, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Email: *[email protected]

Received August 26, 2013; revised September 25, 2013; accepted October 6, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Retropharyngeal abscess (RPA) is an uncommon disease entity that typically occurs in children under 5 years of age,

which has the potential to cause upper airway obstruction. Upper respiratory tract infection is the most common predis-

posing factor to RPA in children while cervical spine tuberculosis and trauma are the major aetiological factors in the

adult. We report a case of a 21-year-old Nigerian farmer with giant retropharyngeal abscess following fish bone throat

injury causing life-threatening upper airway obstruction. The patient responded well to emergency tracheostomy, intra-

oral surgical drainage and empirical antibiotic therapy. We highlight the diagnostic and therapeutic challenges of man-

aging such a patient.

Keywords: Giant Retropharyngeal Abscess; Fish Bone; Tracheostomy; Antibiotic; Intra-Oral Drainage

1. Introduction

Retropharyngeal abscess (RPA) though an uncommon

disease entity occurs usually in children under the age of

5 years [1-3]. However, recent findings indicate that

adults could also be involved [4,5]. The involvement of

the airway results in upper airway obstruction which

could lead to life threatening condition thus, it is a surgi-

cal emergency. The pathological basis for the higher

prevalence in children is due to the loose aggregate of

lymph nodes in the prevertebral space which may be-

come infected with resultant suppuration. These lymph

nodes are not usually present in adults because they at-

rophy while the child grows; hence retropharyngeal ab-

scess is not a common disorder among adults. Upper

respiratory tract infection is the most common predis-

posing factor to RPA in children [3-6] while cervical

spine tuberculosis and trauma are the major aetiological

factors in adults [3-5,7]. Other factors reported among

adults include diabetes mellitus [4] and human immuno-

deficiency virus (HIV) infection [7,8].

In a retrospective study in Ibadan, Nigeria [9], thirty

cases of retropharyngeal abscess were reported compris-

ing of 25 children and 5 adults. In that study, adult pa-

tients presented early while the children presented late. A

recent study from north central Nigeria reported RPA

due to fish bone but in a child [5]. We report a case of

giant retropharyngeal abscess in a 21-year-old subsis-

tence adult Nigerian farmer following fish bone throat

injury while highlighting the diagnostic and therapeutic

challenges of managing this type of patient.

2. Case Report

A 21-year-old subsistence farmer, presented at the Emer-

gency department of our hospital with 10-day history of

progressive sore throat, persistent low grade fever, neck

pain, dyspnoea, odynophagia and voice changes. There

was an antecedent history of fish bone impaction in the

throat two weeks prior to the onset of symptoms however;

the patient did not seek medical intervention. He was

unable to take both fluid and solid diet at presentation.

There was associated hoarseness and inability to sit or

stand without support. There was no history suggestive

of recurrent tonsillitis, dental infection, chronic cough,

night sweats or contact with a patient with pulmonary

tuberculosis and was not a known diabetic.

*Corresponding author.

S. B. AMUTTA ET AL.

272

Examination revealed an acutely ill-looking young

man in painful and respiratory distress, was dehydrated,

in stridor, with inaudible hoarse voice, limitation of neck

movement and also had trismus. He was not pale and

there was no significant peripheral lymphadenopathy.

There was no impairment in the mental state. Vital signs

were blood pressure of 90/60 mmHg, pulse rate of 96/

minute, respiratory rate of 30/minute and temperature

was 37.4˚C.

Ear and nasal examinations were essentially normal.

There was moderate trismus and poor oral hygiene, but

there was no evidence of dental infection. Examination

of the posterior pharyngeal wall was difficult due to

trismus and neck pain. There was remarkable decreased

air entry in both lung fields with wide spread transmitted

sounds. Heart sounds were I and II were essentially nor-

mal. Abdominal and central nervous system examina-

tions were normal and there was no cervical spine ten-

derness or gibbous deformity.

A provisional diagnosis of upper airway obstruction

secondary to deep neck space infection possibly secon-

dary to retropharyngeal abscess was made to rule out

peritonsillar and parapharyngeal abscesses. The patient

had X-ray of the neck with a conventional X-ray machine

Silhouette VR GE 2007 using automatic processor,

Colenta 2007 model 2226680/MS18s serial number

48202HL6, with inherent filtration of 0.6 mmAL and

additional filtration of 1.0 mmAL. The X-ray soft tissue

neck lateral view showed the reversal of the normal cer-

vical curvature with a huge soft tissue mass in the retro-

trachael space displacing the trachea anteriorly with sig-

nificant associated luminal narrowing. This soft tissue

mass measured about 65 mm at its widest point at the

level of 4th cervical vertebra (C4). The anteroposterior

view also showed huge soft tissue mass around its mid

portion. No areas of calcifications or lucencies were

demonstrated within the soft tissue mass. Overall, fea-

tures of the X-ray of the neck were those of a huge

retropharyngeal mass lesion, presumably retropharyngeal

abscess. These radiological features further supported the

provisional diagnosis of RPA (Figure 1). The soft tissue,

bony framework of the chest, lung fields and heart ap-

peared normal on Chest X-ray. Patient could not do

computerized tomography (CT) scanning due to financial

constraints.

Other laboratory studies showed packed cell volume of

40%, random blood sugar 6.4 mmol/L, serum electro-

lytes, urea and creatinine were within normal limits.

Screening for HIV I and II using ELISA (enzyme linked

immunoabsorbent assay) was non-reactive. White blood

cell count was elevated and demonstrated neutrophilia

while the erythrocyte sedimentation rate (ESR) was 15

mm/hr Westergreen.

Patient was rehydrated and intravenous cefuroxime 1

Figure 1. Lateral view, soft tissue X-ray of the neck showing

grossly increased prevertebral soft tissue shadow delineated

by white arrows.

gram 12-hourly, metronidazole 500 mg 8-hourly; para-

cetamol 300 mg 8-hourly and diclofenac sodium 50 mg

8-hourly were administered. Emergency tracheostomy

was done under local anaesthesia infiltration with 2%

xylocaine 1:200,000 adrenaline to relieve the life threat-

ening upper airway obstruction and the procedure con-

tinued with administration of general anaesthesia via the

tracheostomy tube. He was then placed in Rose position

and the oropharynx was exposed with Davis-Boyle gag

frame.

Operative findings were grossly enlarged posterior

pharyngeal wall which was tense and fluctuant and 500

mls of thick pus under tension was drained via a vertical

incision. The abscess cavity was irrigated with warm

normal saline and a feeding nasogastric tube (NGT) was

passed. The specimen 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.

Post operatively the patient had intravenous cefu-

roxime, metronidazole, paracetamol and diclofenac so-

dium for 72 hours, and this was changed to oral cefu-

roxime and metronidazole which were administered via

the NGT for further 7-days. He had NGT feeding for the

first five days post operative period, started feeding

around the NGT from the 6th day after the surgical

drainage, and the NGT was finally removed on the 16th

day after surgery as oral feeding was adequately restored.

He was decanulated on the 8th post operative day when

post operative lateral radiograph of the neck showed only

straightening of the cervical spine with significant reduc-

tion of the retrotrachael space, and reversal of the nar-

rowed airways in comparison with the previous examina-

tion (Figures 1 and 2). The retrotrachael space at the

Open Access IJOHNS

S. B. AMUTTA ET AL. 273

Figure 2. Lateral view, post operative soft tissue X-ray of

the neck with nasogastric tube in situ and resolution of the

increased prevertebral soft tissue shadow.

level of C4 was reduced to about 20 mm (Figure 2) and

no recurrence on follow-up visit.

3. Discussion

The retropharyngeal space is one of the deep neck spaces

with the skull base as the superior border, the inferior and

the posterior limits are the superior mediastinum and the

prevertebral fascia respectively while the posterior bor-

der of the pretrachael fascia forms the anterior border.

Laterally, it is bounded by the carotid sheath and it con-

tains lymph nodes [10]. RPA may present with life

threatening upper airway obstruction, as it was in our

index patient [1-5,9]. Delay in the diagnosis of RPA is

often associated with other serious morbidities such as

aspiration pneumonia, sepsis, mediastinitis, empyema

and erosion of carotid artery [4,6,11]. The diagnosis is

usually made based on clinical symptoms, signs as well

as radiological features. However, these symptoms and

signs are non-specific to retropharyngeal abscess [6]. In

adults RPA may present with fever, sore throat, odyno-

phagia, dysphagia, drooling, and dyspnoea and muffled

voice. Signs of the disease include limitation of neck

movement, torticolis, cervical tenderness, bulging poste-

rior oropharyngeal wall, increased prevertebral soft tissue

shadow on plain lateral neck X-ray and contrast en-

hanced CT scanning may demonstrate the extent of the

abscess [1,2]. Our patient presented with most of these

clinical and plain X-ray features of RPA. The grossly

increased prevertebral soft tissue shadow was the indica-

tor for the provisional diagnosis of RPA in this index

case. The use of X-ray for this purpose is limited and

controversial because of its inability to differentiate in-

flammatory oedema from abscess.

It was not possible to delineate the extent of the ab-

scess or involvement of other deep neck spaces before

the surgical drainage. Contrast enhanced CT scanning

would have made this possible, [1-4,6] but it was not

done to avoid further delay of the worsening severe up-

per airway obstruction and besides, the patient could not

afford to pay for the CT scan at presentation which costs

₦20000.00 (about $130.00) as he was not covered by any

health insurance because he was not in federal civil ser-

vice as this is the main agent providing health insurance

cover for Nigerians. Furthermore, in a resource limited

society with prevalent poverty, clinical history, physical

examinations and X-ray findings still form the basis for

the diagnosis of RPA [5] as in this case report.

It is important to consider the differential diagnosis in

a patient with suspected RPA before initiating any treat-

ment options. Congenital cystic lesions like infected

branchial cleft cyst, thyroglossal duct cyst and cervical

thymic cyst may mimic or be the source of a deep neck

abscess [12]. Incision and drainage make definitive exci-

sion of these cysts cumbersome. Additionally, malignant

head and neck cancers, and lymphoma may metastasize

to cervical lymph node and present with deep neck space

infection or abscess [12]. Therefore, high index of suspi-

cion is suggested for prompt diagnosis. Epiglottitis, sia-

loadenitis and infected laryngocele have been implicated

in the development of deep neck abscesses [13]. Calcific

retropharyngeal tendinitis and RPA [14] have similar

clinical features. Contrast enhanced CT scan features of

calcific retropharyngeal tendinitis includes increased

prevertebral soft tissue mass with calcification and it

does not require surgical drainage as it responds very

well to non-steroidal anti-inflammatory drugs and steroid

[14].

Treatment of RPA includes rehydration, intravenous

antibiotic and surgical drainage under general anaesthe-

sia administered by an experienced anaesthetist [1,2,12,

15,16]. Provision of adequate airway is a priority in a

patient with RPA and life threatening upper airway ob-

struction; hence, the patient in this report had emergency

tracheostomy under local anaesthesia before the surgical

drainage of the abscess. This is in agreement with other

reports [3,15]. In addition, tracheostomy may be used in

the absence of upper airway obstruction to prevent acci-

dental rupture of the abscess during intubation by an in-

experienced anaesthetist [3] and in addition, compro-

mised airways resulting from post operative oedema is

another indication for routine tracheostomy in these pa-

tients.

The surgical approaches for drainage of RPA are tran-

soral, transcervical, transnasal endoscopic or combined

approach [15]. The transoral approach is usually recom-

mended for acute RPA and those located medially [15].

This approach yields good result and avoids a neck inci-

sion and the subsequent scar [15] however it requires

administration of general anaesthesia.

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S. B. AMUTTA ET AL.

274

Trans-nasal endoscopic guided needle aspiration is

suitable for very small and unilocular abscesses [15-17].

It has the advantage of avoiding general anaesthesia and

probable injury to local structures such as blood vessels

and nerves [17], although repeated aspirations may be

required to achieve complete resolution. Additionally, it

is not appropriate for large abscesses with potential for

airways obstruction [17]. Cold RPA from tuberculosis is

drained by external transcervical approach to prevent

dissemination of the infection into the gastrointestinal

tract. Besides, large or recurrent acute RPA that extend

behind carotid artery can be safely approach by the trans-

cervical route [17] to limit bleeding. Disadvantages are

neck scar and injury to surrounding structures.

The main aetiological factors of RPA in adult are

trauma induced by foreign bodies, iatrogenic, orodental

infection and tuberculosis [3,4,6-8]. Fish bone injury was

the responsible agent in our index patient. It is important

to note that the patient did not seek medical help until

complications set in thus compelling him to come to the

hospital. Ignorance coupled with poverty and poor access

to specialist otolaryngologic service was some of the

reasons that hindered the patient from seeking medical

care early. In contrast to this, adults with RPA in another

report from Western Nigeria presented early [9]. The

high level of awareness, better economic environment

and exposure to western education in western region of

Nigeria may be the explanation for this difference.

Clinical conditions associated with impaired immunity

such as tuberculosis, diabetes mellitus and infection with

HIV which are relatively common in developing coun-

tries are sometimes associated with RPA [18-21]. The

patient in this report did not have destructive lesion of

the cervical vertebra and Ziehl-Neelsen staining of the

specimen smear for acid-fast bacilli was negative while

random blood sugar value was within normal range and

he was non-reactive to HIV I and II viruses.

The organisms frequently encountered in RPA are po-

lymicrobial including aerobes (group A β-haemolytic

streptococcus, staphylococcus aureus and haemophilus

influenza), anaerobes (gram negative cocci and bacter-

oides) [11,22]. The specimen from our patient yielded no

bacterial growth. This could be due to prior antibiotic

therapy from rural patent medicine shops which is a

common practice by our patients though inappropriate

culture technique and media for the isolation of anaer-

obes could be responsible.

The retropharyngeal abscess was described as giant

because it measured 65 mm in diameter and this so far

the biggest reported from our sub-region. However, we

could not verify if larger size has been reported else-

where. In an earlier report Ozbek et al., [3] reported a

giant RPA which was 61 mm in transverse diameter but

this is smaller than that reported in the present case.

The prognosis for patients with RPA is very good es-

pecially with early diagnosis and appropriate intervention.

However, with late presentation, delayed diagnosis and

in the presence of significant co-morbidities such as im-

munosuppression, HIV, tuberculosis, diabetes mellitus,

head and neck malignancies the prognosis may be poor.

Ridder et al. [12] reported 6 (2.6%) mortality among 234

cases over an 8-year period and the deaths were due to

sepsis and multiple organ failure. Overall, the patient in

this report responded very well to the tracheostomy, in-

tra-oral drainage and the broad spectrum antibiotics. He

was decanulated on the 8th day post surgical drainage and

was discharged home after achieving full recovery and

no recurrence on follow-up visit.

4. Conclusion

The prognosis of giant retropharyngeal abscess is good

with tracheostomy, surgical drainage and medical inter-

vention as seen in this case report.

REFERENCES

[1] B. Hartley, “Cervicofacial Infection in Children,” In: G.

Michael, Ed., Scott’s Browns Otorhinolaryngology, Head

and Neck Surgery, 7th Edition, Hodder Arnold, London,

2008, pp. 1213-1214.

http://dx.doi.org/10.1201/b15118-107

[2] L. W. Tom and I. N. Jacobs, “Diseases of the Oral Cavity,

Oropharynx, and Nasopharynx,” In: B. James, Ed.,

Ballenger’s Otorhinolaryngology, Head and Neck Sur-

gery, 16th Edition, BC Decker Inc., Hamilton, 2003, pp.

1039-1040.

[3] C. Ozbek, S. Dagli, E. E. U. Tuna, O. Ciffci and C. Oz-

dem, “Giant Retropharyngeal Abscess in an Adult as a

Complication of Acute Tonsillitis: Case Report,” Ear

Nose Throat Journal, Vol. 88, No. 11, 2009, p. E20.

[4] S. B. Sharma and P. Hong, “Ingestion and Pharyngeal

Trauma Causing Secondary Retropharyngeal Abscess in

Five Adult Patients,” Case Report in Emergency Medi-

cine, Vol. 2012, 2012, Article ID: 943090.

[5] O. A. Afolabi, J. O. Fadare, E. O. Oyewole and S. A.

Ogah, “Fish Bone Foreign Body Presenting with an Acute

Fulminating Retropharyngeal Abscess in a Resource-

Challenge Centre: A Case Report,” Journal of Medical

Case Reports, Vol. 5, 2011, p. 165.

http://dx.doi.org/10.1186/1752-1947-5-165

[6] 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. http://dx.doi.org/10.1100/2011/915163

[7] E. Mevio, P. Calabro, F. De Paoli, A. Maccabruni and G.

Michelone, “Unusual Extracranial Complications of Otitis

Media in a Young HIV Patient: Retropharyngeal and

Mouret’s Abscess,” Revue de Laryngologie-Otologie-

Rhinologie, Vol. 119, No. 3, 1998, pp. 199-201.

[8] R. Meyer, S. Argarwal and I. Singh, “Tuberculous Retro-

Open Access IJOHNS

S. B. AMUTTA ET AL.

Open Access IJOHNS

275

pharyngeal Abscess in an HIV Patient,” Hong Kong Medi-

cal Journal, Vol. 12, No.6, 2006, pp. 483-485.

[9] O. G. Nwaorgu, P. A. Onakoya, J. A. Fasunla and T. S.

Ibekwe, “Retropharyngeal Abscess: A Clinical Experi-

ence at the University College Hospital Ibadan,” Nigeria

Journal of Medicine, Vol. 14, No. 4, 2005, pp. 415-418.

[10] C. R. Jennings, “Surgical Anatomy of the Neck,” In: G.

Michael, Ed., Scott’s Browns Otorhinolaryngology, Head

and Neck Surgery, 7th Edition, Vol. II, Hodder Arnold,

London, 2008, pp. 1744-1745.

http://dx.doi.org/10.1201/b15118-153

[11] I. Brook, “Microbiology and Management of Peritonsillar,

Retropharyngeal Abscess and Pharyngeal Abscesses,”

Journal of Oral & Maxillofacial Surgery, Vol. 62, No. 12,

2004, pp. 1545-1550.

http://dx.doi.org/10.1016/j.joms.2003.12.043

[12] G. J. Ridder, K. Technau-Ihling, A. Sander and C. C.

Boedeker, “Spectrum and Management of Deep Neck

Space Infections: An 8-Year Experience of 234 Cases,”

Otolaryngology—Head and Neck Surgery, Vol. 133, No.

5, 2005, pp. 709-714.

http://dx.doi.org/10.1016/j.otohns.2005.07.001

[13] J. Stalfors, A. Adielsson, A. Ebenfelt, G. Nethander and T.

Westin, “Deep Neck Space Infections Remain a Surgical

Challenge. A Study of 72 Patients,” Acta Otolaryngology,

Vol. 124, No. 10, 2004, pp. 119-1196.

http://dx.doi.org/10.1080/00016480410017864

[14] K. Terao, T. Kusunoki, K. Mori. K. Murata and K. Doi,

“A Case of Calcific Retropharyngeal Tendinitis: The Sig-

nificance of Early Diagnosis,” Ear, Nose and Throat

Journal, Vol. 92, No. 2, 2013, pp. 74-83.

[15] P. J. Schuller, M. Cohen, J. Greve, C. Plettenberg, J.

Chereath, M. Wagemann, et al., “Surgical Management

of Retropharyngeal Abscess,” Acta Oto-Laryngologica,

Vol. 129, No. 11, 2009, pp. 1274-1279.

http://dx.doi.org/10.3109/00016480802642088

[16] D. K. C. Wong, C. Brown, N. Mills, P. Spielmann and M.

Neeff, “To Drain or Not to Drain-Management of Pediat-

ric Deep Neck Abscesses: A Case Conrol Study,” Inter-

national Journal Pediatric Otorhinolaryngology, Vol. 76,

No. 12, 2012, pp. 1810-1813.

http://dx.doi.org/10.1016/j.ijporl.2012.09.006

[17] K. Chang, Y. Chen, S. Hao and S. Chen, “Ultrasound-

Guided Closed Drainage for Abscesses of the Head and

Neck,” Otolaryngology—Head and Neck Surgery, Vol.

132, No. 1, 2004, pp. 119-124.

http://dx.doi.org/10.1016/j.otohns.2004.08.004

[18] M. P. Kamath, K. M. Bhojwani, S. U. Kamath, C. Maha-

bala and S. Argawal, “Tuberculous Retropharyngeal Ab-

scess,” Ear Nose Throat Journal, Vol. 86, No. 4, 2007, pp.

236-237.

[19] H. A. Soub, “Retropharyngeal Abscess Associated with

Tuberculosis of Cervical Spine,” Tubercle and Lung Dis-

ease, Vol. 77, No. 6, 1996, pp. 563-565.

http://dx.doi.org/10.1016/S0962-8479(96)90057-X

[20] A. Christoforidou, S. Metallidis, P. Kollaras, A. Agathange-

lidis, P. Nikolaidia, V. Vital and K. Markou, “Tubercu-

lous Retropharyngeal Abscess as a Cause of Oropharyn-

geal Dysphagia,” American Journal of Otolaryngology-

Head and Neck Medicine and Surgery, Vol. 33, No. 2,

2012, pp. 272-274.

[21] C. Patil, R. Kharat, P. Deshmukh, S. Singhal and B.

D’Souza, “Tuberculous Retropharyngeal Abscess without

Cervical Spine TB,” Asian Pacific Journal of Tropical

Medicine, Vol. 4, No. 3, 2011, pp. 251-252.

http://dx.doi.org/10.1016/S1995-7645(11)60080-1

[22] H. S. Sharma, D. S. Kurl and M. Hamza, “Retropharyn-

geal Abscess: Recent Trend,” Auris Nasus Larynx, Vol.

25, No. 4, 1998, pp. 403-406.

http://dx.doi.org/10.1016/S0385-8146(98)00007-8