CASE 13
By: Dr. Sattam Lingawi and Dr. Alaa Al-Turkustani
HISTORY: 61-year-old female with neck pain and radiculopathy.
What are your findings?
What is the differential diagnosis?
FINDINGS:
Fig 1: Lateral plain radiograph of the cervical spine demonstrating prevertebral soft tissue swelling with air lucency within.
Fig 2 & 3: Sagittal CT scan of the cervical spine in bone and soft tissue windows respectively demonstrating narrowing of the C4/5 intervertebral disc space with prevertebral soft tissue swelling with loculated fluid collection.
Fig 4: Sagittal T2, Fig 5: Sagittal T1, Fig 6: Sagittal T1 with contrast & Fig 7: Axial T1 with contrast of the cervical spine demonstrating significant large fluid collection in the anterior prevertebral soft tissues extending from the C3 to C5. There is in addition posterior protrusion of the epidural collection with compression on the cord. The cord edema extends from the lower medulla oblongata down to T3 level inferiorly. Significant enhancement within the vertebral bodies of C3, C4 and C5 is detected. Associated diskitis with osteomyelitis is present with epidural abscess both anteriorly and posteriorly. Significant extension of the inflammatory changes to the prevertebral soft tissues anteriorly is seen.
DIFFERENTIAL DIAGNOSIS:
Discitis and osteomyelitis.
Metastasis.
DIAGNOSIS:
Discitis and osteomyelitis with prevertebral and epidural abscesses and spinal cord compression.
PEARLS AND DISCUSSION:
Retropharyngeal abscess is a potentially life-threatening infection involving the retropharyngeal space which requires prompt diagnosis and aggressive therapy.
Four-Step Interpretive Approach to Retropharyngeal Space Collection on Multiplanar Imaging
| Step | Retropharyngeal Edema | Suppurative Retropharyngeal Node | Retropharyngeal Abscess |
|---|---|---|---|
| Fluid distribution | Fills the retropharyngeal space from side to side | Unilateral | Fills the retropharyngeal space from side to side |
| Configuration and mass effect | Axial images show ovoid, rectangular, or "bow-tie" configuration; sagittal images show diffuse configuration with tapered inferior and superior margins; mild mass effect | Rounded or ovoid configuration; mass effect varies | Rounded or ovoid configuration; moderate-to-marked mass effect |
| Thick enhancing wall | No | Can have an enhancing wall | Most have an enhancing wall |
| Ancillary findings | Neck infection adjacent to the retropharyngeal space or suppurative retropharyngeal node; internal jugular vein thrombosis; focal calcification anterior to C1–C2; other inflammatory signs of radiotherapy | Primary infectious source such as otitis media or tonsillitis; retropharyngeal edema is a common associated finding | Primary infectious source such as otitis media or tonsillitis; presence of a foreign body in traumatic causes; complications in the airway, mediastinum, or vessels |
FURTHER READING:
Jenny K. Hoang and Barton F. Branstetter IV. Multiplanar CT and MRI of Collections in the Retropharyngeal Space: Is It an Abscess? AJR 2011; 196: W426–W432
Yongdong Wang*, Nina Sigh and John Mernagh. Retropharyngeal Abscess: Its Evolution and Imaging Assessment. OMICS J Radiology 2013, 2:5
Erin Frankie Capps, MD and James J. Kinsella, MD, Emergency Imaging Assessmentof Acute, Nontraumatic Conditions of the Head and Neck. RadioGraphics 2010; 30:1335–1352
