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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01015-0
10.1016/j.ijscr.2024.110234
110234
Case Report
Effective surgical drainage of a massive retropharyngeal abscess via an incision in the posterior wall of the oropharynx under local anesthesia
Azar Adel a
Alkheder Ahmad alkhederahmed@gmail.com
ab⁎
Alsodi Zeina c
Ayob Humam a
a Department of Otorhinolaryngology, Al Mouwasat University Hospital, Faculty of Medicine, Damascus University, Damascus, Syria
b Faculty of Medicine, Syrian Private University, Damascus, Syria
c Faculty of Medicine, Damascus University, Damascus, Syria
⁎ Corresponding author at: Al Mazzah, Damascus, Syria. alkhederahmed@gmail.com
03 9 2024
10 2024
03 9 2024
123 1102345 8 2024
24 8 2024
31 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

A retropharyngeal abscess is a deep neck infection, uncommon in adults but more prevalent in children. This report details a rare case of a huge retropharyngeal abscess in an adult female, effectively managed by an incision in the posterior oropharyngeal wall under local anesthesia.

Case presentation

A 76-year-old woman with hypertension, diabetes, ischemic heart disease, and total thyroidectomy presented with sudden neck swelling, dyspnea, stridor, and dysphagia. Examination and imaging revealed a large retropharyngeal abscess. The abscess was drained through an incision in the posterior wall of the oropharynx using a local anesthetic, yielding immediate symptom relief. Cultures identified Streptococcus and Staphylococcus aureus, leading to adjusted antibiotics. The patient showed significant improvement, with resolution of respiratory distress and reduced inflammation.

Discussion

The retropharyngeal space, containing lymph nodes and connective tissue, extends from the skull base to the superior mediastinum, communicating with the carotid sheath and parapharyngeal space. Effective management of a critically ill, immunocompromised patient with a resistant retropharyngeal abscess was achieved using an intraoral approach and intravenous antibiotics. This method avoids general anesthesia and minimizes postoperative complications. CT scans are essential for assessing disease extent and planning surgery. Our case highlights the successful treatment of a large abscess with minimal risks.

Conclusion

Drainage of retropharyngeal abscesses via the intraoral approach under local anesthesia can be considered a valuable method for high-risk patients who are not candidates for general anesthesia. Additionally, we presented a rare case of an exceptionally large retropharyngeal abscess.

Highlights

• We presented a rare case of an exceptionally large retropharyngeal abscess.

• The intraoral approach under local anesthesia effectively managed a massive retropharyngeal abscess in a high-risk adult patient.

• The procedure minimized postoperative complications and avoided the risks associated with general anesthesia.

• Timely intervention led to immediate improvement in respiratory distress, voice, and inflammatory markers.

• Cultures identified Streptococcus and Staphylococcus aureus, prompting adjusted antibiotics despite initial resistance.

Keywords

Retropharyngeal abscess
Parapharyngeal abscess
Massive
Huge
Surgical drainage
Local anesthesia
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pmc1 Introduction

A retropharyngeal abscess is a deep neck infection, uncommon in adults but more prevalent in children due to the greater number of retropharyngeal lymph nodes [1]. In adults, these abscesses can arise from local trauma like swallowing a foreign object such as a fishbone, from medical procedures like laryngoscopy, endotracheal intubation, or the placement of feeding tubes, or due to certain diseases [1,2]. Early diagnosis and treatment, often involving surgical drainage, are crucial for optimal outcomes, although the timing of surgery is still debated [1,2]. Diagnosing retropharyngeal abscesses is challenging because of their rarity and variable clinical presentations. Symptoms typically include sore throat, neck stiffness, fever, and difficulty swallowing or painful swallowing, with respiratory distress and stridor being less common [3]. During physical examination, a retropharyngeal or parapharyngeal swelling might be noted. However, trismus in adults and non-cooperation in children can complicate intraoral visualization [3]. Conditions like pharyngotonsillitis, peritonsillar cellulitis or abscess, parapharyngeal cellulitis or abscess, and occasionally complicated otitis media can be associated with these abscesses [3,4]. Initial management focuses on relieving symptoms, particularly ensuring adequate oxygen and securing the airway in severe cases. Most cases are not critical and can be managed with supportive care, including antipyretics, analgesics, and intravenous antibiotics. Surgical incision and drainage are reserved for persistent or large abscesses [4,5]. Due to the infrequency of retropharyngeal abscesses in adults, diagnosis can be delayed, and adults may not always display the typical symptoms seen in children [5]. CT and MRI studies revealed an average abscess volume of 9.4 cm3 ranging between 1.3 and 31.2 cm3 with a mean section area of 3.7 cm2 [6,7].

This report details a rare case of a huge retropharyngeal abscess in an adult female, effectively managed by an incision in the posterior oropharyngeal wall under local anesthesia.

This work is also reported in line with SCARE criteria which helped to improve the transparency and quality of this case report [10].

2 Case presentation

A 76-year-old woman with a medical history of hypertension, diabetes mellitus, Ischaemic heart disease, and total thyroidectomy presented to the ENT emergency department with a complaint of swelling on the right side of the neck, which appeared suddenly 15 days ago and gradually increased. The swelling extended to the left side of the neck after two days, accompanied by neck pain. Three days ago, the patient developed progressively worsening dyspnea with stridor, choking, and difficulty swallowing liquids and solids, as well as difficulty speaking, without other associated head and neck symptoms. The patient had a fever and weight loss for a month but no history of dental interventions or upper respiratory tract infections. Clinical examination revealed a firm, painful swelling on the right side of the neck with local fever, and a firm, non-painful swelling on the left side of the neck without local inflammatory signs. Examination of the pharynx showed a bulge in the posterior wall of the oropharynx, almost touching the base of the tongue (Fig. 1), along with dry mouth.Fig. 1 Clinical examination of the oral cavity: The posterior wall of the oral pharynx is seen to protrude forward, coming into contact with the base of the tongue and the palatopharyngeal arch.

Fig. 1

Ultrasound imaging of the neck revealed a collection of turbid fluid with a distinct wall on the left side of the neck, posterior to the major vessels, compressing them and the esophagus, along with lymphadenopathy on both sides, the largest on the right side. CT imaging showed a large abscess mass posterior the pharynx and lateral to it on both sides, measuring approximately (3.20 × 6.05 × 9.20 cm), with an area and volume of approximately 19 cm2 and 90 cm3, respectively. With lymphadenopathy on both sides (Fig. 2). Laboratory tests indicated elevated inflammatory markers.Fig. 2 Computed tomography of the head and neck, sagittal and axial plane, shows a huge abscess posteriorly and laterally to the pharynx.

Fig. 2

The abscess was drained through an incision in the posterior wall of the oropharynx using a local anesthetic spray. The patient was positioned in a trendelenburg position with continuous suction of secretions, closely monitoring for aspiration, for 30 min until the gag reflex was returned, a large amount of pus was drained (Fig. 3), resulting in immediate improvement in respiratory distress and voice. A sample was taken for culture and sensitivity testing, and a 16 French nasogastric tube was inserted to assist with feeding and to apply pressure on the abscess cavity. No irrigation was performed because of the need to huge amount to cleanse the cavity and to avoid a potential spread of infection promoted by the dissection of planes by pressure. Bacterial culture results showed the growth of Streptococcus and Staphylococcus aureus, and antibiotics were adjusted (Linezolid, Clindamycin, and Meropenem) accordingly as the organisms were resistant to empirical antibiotics (Ceftriaxone and Clindamycin). The drainage incision was monitored daily with gentle massage of the posterior pharyngeal wall.Fig. 3 View during drainage of an abscess through an incision in the posterior wall of the oropharynx.

Fig. 3

The patient showed significant clinical improvement the next day, with complete resolution of respiratory distress. Gradually improvement with regression of the posterior pharyngeal wall bulge and a decrease in inflammatory markers until day 12 (Fig. 4). However, on day 12, the patient developed a pulmonary embolism and subsequently died.Fig. 4 shows the daily follow-up of the patient, indicating a gradual improvement. By day 12, there is an almost complete regression of the posterior oropharyngeal wall protrusion, along with the cessation of pus discharge. D = day.

Fig. 4

3 Discussion

Retropharyngeal space, which contains lymph nodes and connective tissue, is confined by the skull base and superior mediastinum. It communicates with carotid sheath and para pharyngeal space reaches the diaphragm through danger space. Throughout 8 -year experience, 234 patients with deep neck infections were elected with only 15 patients of retropharyngeal abscess (6.4 %). An incision and drainage was performed in 83 % of the cases mostly through a transcervical approach and under general anesthesia. Sepsis and multiorgan failure were responsible for death in 6 patients (2.6 %).The mean and standard deviation of hospital stay was 13.1 ∓ 9.6 (ranged between 2 and 72 days) [11]. Another study had gathered 210 patients with deep neck infections and one third of the population had an associated systemic disorder. During 18 years; retropharyngeal abscess was occured only to 25 patients (12 %). All patients were treated with incision and drainage. Aspiration pneumonia resulted in 1 death and no major vessel rapture was occurred [12]. According to the site and extension of the infection; upper retropharyngeal space can be managed through transpalatal approach to better view the region or through endoscopic transnasal route to yield a short hospitalisation time and a very low morbidity which are essential in elderly patients. However, such an approach requires comprehensive anatomical knowledge and surgical expertise to avoid disastrous and uncontrollable bleeding from internal carotid artery. Another impingement to approach is the skull base osteomyelitis which can be addressed via infratemporal or infralabyrinthine techniques [[13], [14], [15]]. Several studies favored an intraoral approach whenever accessible due to the simplicity of the technique and providing a rapid recovery and shorter hospital stay in addition to avoid marginal nerve transection which reflects in lower costs and morbidities. Moreover it is at least as effective as the classical external approach with no significant difference as regard to postoperative complications [[13], [14], [15]]. Clinical picture and radiological assessment suggested the most appropriate approach to manage a critical-ill patient and a tough situation (comorbidities and immuno-compromised patient and resistant organisms to empirical medications) with an effective and safe procedure presumed to reserve a compromised resolution in an exceptional situation. Although there is no correlation between organisms and the severity of clinical course, successful treatment can be delayed in a disastrous and urgent case [8]. Endoscopic sinus surgery, transpalatal, transoral, transcervical, infratemporal and even translabyrinthine has been approached to treat retropharyngeal abscess according to the site and extension of the infection with caution being taken to he vital structures [9]. An intraoral approach and intravenous antibiotics, gentle pressure and daily care was able to eradicate a fatal dead space infection around the cervical spine with a good outcome and no complications. The intraoral approach under local anastasia minimizes postoperative wound care with no dressings or scar formation, it has the advantage of avoiding general anesthesia and intraoperative risks like abscess rupture during endotracheal intubation or neural and vascular injuries related to the external technique. In addition, it can be performed in distant areas where experienced surgeons are not available. Potential complications need to be taken into account are secondary infection, recurrence, pulmonary aspiration, alteration of anatomic structures, chronic dysphagia, fistula formation and lastly a rare case reported haemorrhage due to injury to a large retropharyngeal vessel and cardiac arrest due to plugging of the glottis and trachea with mucus. Therefore caution should be exerted if retro-laterally location of the abscess or free pus is diagnosed [7]. Simultaneously, the general condition and any associated systemic disorders of the patient should be controlled and prepared for potential transcervical approach under general anesthesia, prominently when there is no improvement after 48 h with the existence of multiple spaces and lateral extention to large vessels requiring a combined intraoral and external approach [16]. CT scan is mandatory in such a situation to evaluate the extent of a disease, detect vital structures, predict the amount of purulence and avoid cervical spine injury especially when the intraoral approach is to be introduced. The length of hospital stay and follow-up were similar between studies with mean of 9 days (range between 6 and 15 days) without any recurrence after 6 mothes. Another study included 39 children showed the mean hospital stay of 8 days (ranged between 2 and 18 days) with no deaths or treatment failures. A third study of 17 adults and 8 children revealed mean hospital stay of 5.3 vs 6.7 days respectively with 100 % cure for both groups. A fourth study gathered 11 patients aged between 1 and 68 years old showed mean of 17.5 days (6–33 days) and experienced one recurrence after 1 year. A study of210 cases showed 205 casesabscess-related hospital stay of 9.5 days resulted in 1 death because of aspiration pneumonia. Finally an 8-year experience of 234 cases showedthat mean and standard deviation of hospital stay was 13.1 + −9.6 (ranged between 2 and 72 days) [7,11,12,15,17,18]. In our case, we display effective management in a critical situation with an enormous abscess size and minimal operative risks and complications. 12 sequential days was depicted to follow the clinical course of the case.

4 Conclusion

This case report highlights the successful management of a rare and extensive retropharyngeal abscess in an adult female with significant comorbidities. The intraoral approach under local anesthesia proved to be an effective and safe procedure, minimizing postoperative complications and avoiding the risks associated with general anesthesia. Despite the patient's complex medical history and the presence of antibiotic-resistant organisms, the timely intervention led to a rapid improvement in symptoms and a reduction in inflammatory markers. However, the development of a pulmonary embolism on day 12 underscores the importance of vigilant postoperative monitoring and management of potential complications. This case underscores the need for prompt diagnosis and tailored treatment strategies in managing deep neck infections, particularly in high-risk patients. Further studies are warranted to establish standardized protocols for the management of retropharyngeal abscesses in adults.

Consent of patient

Written informed consent was obtained from legal guardian for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

Ethics clearance was not necessary since the University waives ethics approval for publication of case reports involving no patients' images, and the case report is not containing any personal information.

Funding

N/A. We received no funding in any form.

Author contribution

Ahmad Alkheder and Adel Azar: Validation, Writing – review & editing, Visualization, Methodology, Software, Writing – original draft, Formal analysis. Zeina Alsodi: Validation, Writing – review & editing, Visualization, Methodology, Software, Writing – original draft, Formal analysis. Humam Ayob: Supervision, Writing – review & editing, Project administration.

Guarantor

The corresponding author takes the full responsibility of the work.

Research registration number

This case report is not a first time of reporting, new device or surgical technique. So I would not need a Research Registry Unique identifying number (UIN).

Conflict of interest statement

The Authors disclose no conflicts.

Data availability

All data are available from the corresponding author on reasonable request. The case has not been presented at a conference or regional meeting.
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References

1 Arora S. Sharma J.K. Pippal S.K. Yadav A. Najmi M. Singhal D. Retropharyngeal abscess following a gun shot injury Braz. J. Otorhinolaryngol. 75 6 2009 909 10.1016/s1808-8694(15)30559-0 20209297
2 Marques P.M. Spratley J.E. Leal L.M. Cardoso E. Santos M. Parapharyngeal abscess in children: five year retrospective study Braz. J. Otorhinolaryngol. 75 6 2009 826 830 10.1016/s1808-8694(15)30544-9 20209282
3 Page N.C. Bauer E.M. Lieu J.E. Clinical features and treatment of retropharyngeal abscess in children Otolaryngol. Head Neck Surg. 138 3 2008 300 306 10.1016/j.otohns.2007.11.033 18312875
4 Lander L. Lu S. Shah R.K. Pediatric retropharyngeal abscesses: a national perspective Int. J. Pediatr. Otorhinolaryngol. 72 12 2008 1837 1843 10.1016/j.ijporl.2008.09.001 18926577
5 Seyhan T. Ertas N.M. Borman H. Necrotizing fasciitis of the chest wall with a retropharyngeal abscess: case report and literature review Ann. Plast. Surg. 61 5 2008 544 548 10.1097/SAP.0b013e31816d81ff 18948783
6 Johnston D. Schmidt R. Barth P. Parapharyngeal and retropharyngeal infections in children: argument for a trial of medical therapy and intraoral drainage for medical treatment failures Int. J. Pediatr. Otorhinolaryngol. 73 5 2009 761 765 10.1016/j.ijporl.2009.02.007 19297031
7 Schuler P.J. Cohnen M. Greve J. Surgical management of retropharyngeal abscesses Acta Otolaryngol. 129 11 2009 1274 1279 10.3109/00016480802642088 19863324
8 Elsherif A.M. Park A.H. Alder S.C. Smith M.E. Muntz H.R. Grimmer F. Indicators of a more complicated clinical course for pediatric patients with retropharyngeal abscess Int. J. Pediatr. Otorhinolaryngol. 74 2 2010 198 201 10.1016/j.ijporl.2009.11.010 19963280
9 Nicolai P. Lombardi D. Berlucchi M. Farina D. Zanetti D. Drainage of retro-parapharyngeal abscess: an additional indication for endoscopic sinus surgery Eur. Arch. Otorhinolaryngol. 262 9 2005 722 730 10.1007/s00405-004-0890-1 15668811
10 Sohrabi C. Mathew G. Maria N. Kerwan A. Franchi T. Agha R.A. The SCARE 2023 guideline: updating consensus surgical case report (SCARE) guidelines Int. J. Surg. Lond. Engl. 109 5 2023 1136
11 Ridder G.J. Technau-Ihling K. Sander A. Boedeker C.C. Spectrum and management of deep neck space infections: an 8-year experience of 234 cases Otolaryngol. Head Neck Surg. 133 5 2005 709 714 10.1016/j.otohns.2005.07.001 16274797
12 Parhiscar A. Har-El G. Deep neck abscess: a retrospective review of 210 cases Ann. Otol. Rhinol. Laryngol. 110 11 2001 1051 1054 10.1177/000348940111001111 11713917
13 Ardehali M.M. Jafari M. Hagh A.B. Submandibular space abscess: a clinical trial for testing a new technique Otolaryngol. Head Neck Surg. 146 5 2012 716 718 10.1177/0194599811434381 22267495
14 Maroun C.A. Zalzal H.G. Mustafa A.A. Carr M. Transoral versus Transcervical drainage of pharyngeal abscesses in children: post-operative complications Ann. Otol. Rhinol. Laryngol. 130 9 2021 1052 1056 10.1177/0003489421990161 33562999
15 Benaixa J.P. González-Pérez J.M. Rodríguez Sola M. Moreno Luna R. Rando I. Esteban F. Tratamiento de los abscesos perifaríngeos mediante punción-aspiración y drenaje por vía intraoral [treatment of peripharyngeal abscesses by means of intra-oral puncture-aspiration and drainage] Acta Otorrinolaringol. Esp. 58 3 2007 105 109 10.1016/s2173-5735(07)70313-7 17371693
16 Choi S.S. Vezina L.G. Grundfast K.M. Relative incidence and alternative approaches for surgical drainage of different types of deep neck abscesses in children Arch. Otolaryngol. Head Neck Surg. 123 12 1997 1271 1275 10.1001/archotol.1997.01900120015002 9413352
17 Harkani A. Hassani R. Ziad T. Retropharyngeal abscess in adults: five case reports and review of the literature ScientificWorldJournal 11 2011 1623 1629 10.1100/2011/915163 22125422
18 Grisaru-Soen G. Komisar O. Aizenstein O. Soudack M. Schwartz D. Paret G. Retropharyngeal and parapharyngeal abscess in children--epidemiology, clinical features and treatment Int. J. Pediatr. Otorhinolaryngol. 74 9 2010 1016 1020 10.1016/j.ijporl.2010.05.030 20598378
