Clinical Case 1
Julian Moncada, M.D.
Josiah Han, M.D.
Our Patient
HPI
7 Year old F with hx of asthma presenting to the ED with neck pain. Pain started about 2 weeks ago after sleeping on Dad’s couch. Mom tried alternating tylenol and motrin for pain with some relief, but pain continued to persist and was taken to OSH where X-ray of the C-Spine was done and told was normal. Discharged home with instructions to follow up with orthopedics for persistent MSK pain and continue motrin use.
Presents to the ED today for worsening pain. Mother states patient woke up in the middle of the night crying in pain. Pain is located to the back of her neck with a posterior headache as well. States that the pain is worse with flexion and extension. Decreased PO intake secondary to pain. Mom also reports the patient has been tilting her head to the right for the past day. No recent falls or trauma. Denies any fevers, chills, nausea/vomiting, coughing, rhinorrhea, rashes, or known sick contacts.
History
Past Medical Hx:
None
Surgical Hx:
None
Social Hx:
No reported drug use, parents divorced
Family Hx
Maternal Aunt with lupus and multiple family members on Mother’s side w/ Rheumatoid Arthritis
Review of Systems
Constitutional: Negative for fevers, chills, activity change, fatigue
HENT: Negative for congestion, rhinorrhea, sore throat, trouble swallowing
Eyes: Negative for visual disturbance
Respiratory: Negative for apnea, coughing, choing, SOB
Gastrointestinal: Negative for abdominal pain, distention, constipation, diarrhea, N/V
GU: Negative for decreased urine volume, dysuria, vaginal pain, rashes
MSK: + posterior neck pain, negative for back pain, joint pain, extremity swelling
Skin: Negative for wounds or rashes
Vital Signs
HR: 127 bpm
BP: 117/96
RR: 24
SpO2: 99 on RA
Temp: 37.5 C/99.5 F
Physical Exam
Gen: Active, in no acute distress, tilting head to the right otherwise well appearing.
Skin: Warm, dry. No Diaphoresis, no rashes
Head: Normocephalic, atraumatic.
Neck: Head tilted towards right SCM, midline cervical tenderness over the C5-C6 area, limited ROM with flexion and extension secondary to pain
Eye: Extraocular movements are intact, normal conjunctiva, PERRL
Ears, nose, mouth and throat: TMs clear, Nose normal, Oral mucosa moist, no pharyngeal erythema or exudate, no palatal petechiae, no tonsillar enlargement
Cardiovascular: tachycardic, regular rhythm, No murmurs.
Arterial pulses: Bilateral radial, DP 2+, cap refill < 2 sec
Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal. No increased WOB.
Gastrointestinal: Soft, no abdominal tenderness to palpation, no distention, no rebound or guarding, no masses
Musculoskeletal: No tenderness, no swelling, no deformity.
Neurological: Alert and oriented appropriate for age, moving all extremities
Psychiatric: Cooperative
Labs
WBC 9.3
Hgb 10.6
Hct 30.6
MCV 87.1
Platelet 294
ESR 86
CRP 9.1
Na 135
K 3.4
Cl 82
Bicarb 28
Ca 9.0
Cr 0.35
BUN 9
Glucose 108
Gap 7
Group A Strep - negative
COVID-19 - negative
EKG
Imaging
X-ray C-spine
Findings: Normal alignment. No fractures or subluxation. Unremarkable soft tissues. Limited visualization of C1 and C2 on the open-mouth view.
Impression: Limited study. No fractures or subluxation.
CT Soft Tissue Neck (OSH 4 days prior to current presentation)
Impression:
There are no acute abnormalities.
Adenoidal hypertrophy with narrowing of the nasopharyngeal airway.
Click for diagnosis and more
Retropharyngeal Abscess
Diagnostic test: MRI Cervical Spine w/wo Contrast
Clinical Features:
Early-
Sore Throat (76%)
Fever (65%)
Dysphagia (35%)
Torticollis (37%)
Late-
Stridor
Respiratory Distress
Chest pain
Mediastinitis
Diagnostics
By Physical:
May see retropharyngeal mass on ENT exam of the pharynx
Can commonly feel fluctuance on palpation
Can lead to rupture of abscess
By imaging:
Lateral Neck Radiograph
Performed during inspiration may show: widened retropharyngeal space
CT Neck w/ IV contrast
Gold standard
Management
Airway
Should intubate before CT if severe respiratory distress/unstable
Care taken to minimize contact with abscess
Can rupture > aspiration
Antibiotics
Ampicillin/Sulbactam IV 50mg/kg/dose OR Clindamycin IV 10mg/kg/dose
Ceftriaxone 50mg/kg/dose (for penicillin allergy patients)
Consults
Consult ENT- most cases require I & D
Adjuncts
Can give Dexamethasone 0.15mg/kg-0.6mg/kg up to 10mg for inflammation and edema
Complications
Mediastinitis
Sepsis
Aspiration
Jugular Venous Thrombosis
Lemierre’s Syndrome
Anaerobic bacteria from abscess erode into the jugular vein
> septic emboli, bacteremia, sepsis
Grisel's Syndrome
Non-traumatic atlantoaxial subluxation associated with inflammatory conditions of the head/neck
Back to our patient...
MRI:
Extensive inflammatory process extending from the anterior skull base to the level of C5 including prevertebral fluid and an abscess anterior to the clivus with associated atlantoaxial subluxation
CT: Large abscess within the prevertebral soft tissues of the posterior nasopharynx.
Case Resolution
Admitted to general peds floor
Started on vanc and ancef empirically
Neurosurgery consulted - placed in aspen collar for concerns of atlantoaxial instability
ENT consulted - obtained repeat CT C-Spine w + CT head w/o
Taken to OR for I&D - switched to Unasyn IV
Discharged home
4-6 week course Unasyn through picc
4-6 week course aspen collar
References
Tintinalli, Judith E.,, et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. Eighth edition. New York: McGraw-Hill Education, 2016.
Swartz, Jordan, et al. “Retropharyngeal Abscess.” WikEM, 6 Jan. 2022, https://wikem.org/wiki/Retropharyngeal_abscess.
Rinaldo A, Mondin V, Suárez C, Genden EM, Ferlito A. Grisel’s syndrome in head and neck practice. Oral Oncol 2005;41:966-70.