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Tuberculous retropharyngeal abscess.

Abstract

Chronic retropharyngeal abscess caused by tuberculosis is rare. It should be suspected in a person who presents with a destructive lesion of the vertebra and a retropharyngeal mass. Early diagnosis and treatment are necessary to prevent the serious complications of the disease. We present the case of a patient who came to our clinic with collapse of the C5-C6 vertebrae and retropharyngeal abscess. We were able to avoid any complications by initiating early surgical drainage and antituberculous therapy.

Introduction

Tuberculosis is a relatively common disease in developing countries, and it has varied presentations and numerous complications. One of the many presentations is tuberculosis of the spine, or Pott's disease. This clinical entity is rare, but it should be strongly suspected in a patient who presents with a destructive lesion of the vertebra and a retropharyngeal mass that extends across the midline. (1) Early diagnosis is essential in order to avoid the onset or progression of the neurologic sequelae of Pott's disease.

In this article, we describe a case of cervical spine tuberculosis with retropharyngeal abscess in a patient in whom early diagnosis and intervention prevented the serious complications associated with Pott's disease.

Case report

A 64-year-old man presented with neck pain of 6 months' duration. The pain was intermittent, but its frequency and duration had gradually increased. The patient also noticed a swelling on the left side of his neck over the previous 15 days. The swelling had also gradually increased to the point that it involved the upper part of his chest. He also complained of dysphagia and breathlessness over the previous few days. On the morning of his presentation, the patient complained of generalized weakness, and he was unable to walk. When questioned further, he gave a history of a recent onset of constipation and difficulty urinating. He had no personal history of cough, fever, night sweats, intravenous drug abuse, or head and neck trauma. He had no family history of, or known exposure to, tuberculosis.

On physical examination, the patient exhibited torticollis to the left. The diffuse swelling on the left side of the neck extended to the left side of the chest, to the second intercostal space. Palpation of the

neck revealed tenderness over the spinous process of C1-C5 and paraspinous muscle spasm. The lungs were clear on auscultation. Fiberoptic endoscopy detected a midline bulge in the posterior pharyngeal wall. The laryngopharynx was edematous. Both vocal folds were normal and moved equally with phonation and respiration.

A lateral cervical spine x-ray revealed partial destruction of the C5-C6 vertebrae (figure, A). Findings on the chest x-ray were unremarkable. Magnetic resonance imaging (MRI) revealed a decrease in vertebral body height, irregular margins, and a decrease in intravertebral disk space at C5-C6 (figure, B). A hyperintense prevertebral collection extended vertically from C2 to C5 and laterally to intermuscular and subcutaneous planes on the left side.

[FIGURES A-B OMITTED]

A tentative diagnosis of retropharyngeal abscess was made. Because a difficult intubation was anticipated, a tracheotomy was performed and the neck was explored under general anesthesia. A large pocket of pus was present behind the stemocleidomastoid muscle medial to the internal jugular vein. The pus was drained and sent for microbiologic examination. On an acid-fast smear, the tuberculous bacilli were identified. A diagnosis of Pott's disease was established, and the patient was started on antituberculous therapy. He improved rapidly over the next few days. His neck stiffness decreased, and he was able to eat comfortably.

Discussion

Retropharyngeal abscess can be either acute or chronic:

* Acute retropharyngeal abscess is commonly seen in children younger than 5 years. It is a result of suppuration of retropharyngeal lymph nodes secondary to infection in the adenoids, nasopharynx, posterior pharyngeal wall, sinuses, and tonsils. In adults, it may arise as a result of a direct infection caused by some penetrating injury or foreign body.

* Chronic retropharyngeal abscess is usually seen in adults. It is caused by a tuberculous infection of the cervical spine, as pus spreads directly through the anterior longitudinal ligament. Retropharyngeal tuberculous abscess is a rare presentation of tuberculosis, even in a patient with extensive pulmonary tuberculosis. (2) It has been reported that 1% of all patients hospitalized with tuberculosis have skeletal tuberculosis, (3) with only 7% of these having involvement of the cervical spine. (4) When skeletal tuberculosis occurs, it affects the lumbar, thoracic, and cervical vertebrae in decreasing order of frequency. This supports the theory that infection in Pott's disease originates in the pelvic organs and disseminates hematogenously via Batson's plexus to involve more superior areas of the spine in a watershed fashion. (5) This explains why only the most anterior portion of the spine is involved and why Pott's disease is rare in the cervical area.

Patients with Pott's disease present with restricted movements of the neck and pain at the back of the neck. As the abscess expands, it may bulge anteriorly into the airway and cause respiratory obstruction, or it may compress the spinal cord and lead to weakness of the extremities. It may also cause paraplegia. As mentioned, a delay in diagnosis and treatment can increase the risk of complications, including a spontaneous rupture of the abscess that can lead to tracheobronchial aspiration or stridor secondary to laryngeal edema. Early diagnosis is also essential in order to prevent the onset or progression of the neurologic sequelae of Pott's disease. (1)

Clinical suspicion for Pott's disease should be high for any patient who presents with a destructive lesion of the spine. Radiographically, the most common finding is an osteolytic lesion with widening of the retropharyngeal soft-tissue space. Treatment includes incision and drainage of the abscess under antibiotic and antituberculous treatment cover.

The incidence of chronic retropharyngeal abscess is on the rise as a result of the resurgence of tuberculosis secondary to human immunodeficiency virus infection. A proper history and careful examination are important for making an early diagnosis.

References

(1.) Neal SL, Kearns M J, Seelig JM, Jefferey HP. Manifestations of Pott's disease in the head and neck. Laryngoscope 1986;96: 494-6.

(2.) Melchior Diaz MA, Doningo Carrasco C, Monge Jogra R, et al. Tuberculous retropharyngeal abscess in an HIV patient: Report of a case. Acta Otorhinolaryngol Esp 1993;44:467.

(3.) Morton W, Dodge HJ. The present status of skeletal tuberculosis. A statement of the Subcommittee on Surgery and the Committee on Therapy. Am Rev Respir Dis 1963;88:272.

(4.) Fang D, Leong JC, Fang HS. Tuberculosis of the upper cervical spine. J Bone Joint Surg 1983;65(B):47-50.

(5.) Hsu LC, Yau AC. The Cervical Spine" Philadelphia: J.B. Lippincott; 1983:336-43.

M. Panduranga Kamath, MS; Kiran M. Bhojwani, MS; Surendra U. Kamath, MS; Chakrapani Mahabala, MD; Salil Agarwal, MBBS

From the Department of Otolaryngology-Head and Neck Surgery, Kasturba Medical College, Mangalore, Karnataka State, India.

Reprint requests: Dr. M. Panduranga Kamath, Upstairs, Panduranga Ganapaya and Sons, Opposite the Taj Mahal Cafe, Car St., Mangalore 575001, Karnataka State, India. Phone: 91-984-514-7529; fax: 91-824-242-8379; e-maih kamathmp@yahoo.co.in
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Author:Agarwal, Salil
Publication:Ear, Nose and Throat Journal
Date:Apr 1, 2007
Words:1163
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