|Year : 2021 | Volume
| Issue : 4 | Page : 39-42
Giant Tuberculous Retropharyngeal Abscess with Associated Neurological Manifestations in Cervical Pott's Disease
Batuk Diyora, Gagan Dhall, Mehool Patel, Nilesh More, Subhasish Dey, Mazharkhan Mulla
Department of Neurosurgery, LTMG Hospital, Mumbai, Maharashtra, India
|Date of Submission||20-Feb-2021|
|Date of Acceptance||06-Oct-2021|
|Date of Web Publication||24-Dec-2021|
Department of Neurosurgery, Second Floor, College Building, LTMG Hospital, Sion, Mumbai - 400 022, Maharashtra
Source of Support: None, Conflict of Interest: None
Retropharyngeal abscess is a relatively uncommon pathology that predominantly occurs in the pediatric age group. Tuberculous retropharyngeal abscess (TBRPA) is relatively rare. TBRPA in a 13-year-old female child was reported. She presented with neck pain, restricted neck movements, right upper limb weakness, dysphagia, odynophagia, and weight loss. Radiological imaging showed upper cervical spine tuberculosis with a giant retropharyngeal abscess. She underwent drainage of pus and stabilization of the upper cervical spine. Subsequently, she received antituberculous therapy for 18 months. Postsurgery, her clinical symptoms improved. At a 1-year follow-up, there was no evidence of recurrence of the tuberculous lesion.
Keywords: Dysphagia, Pott's disease, tuberculosis, tuberculous retropharyngeal abscess
|How to cite this article:|
Diyora B, Dhall G, Patel M, More N, Dey S, Mulla M. Giant Tuberculous Retropharyngeal Abscess with Associated Neurological Manifestations in Cervical Pott's Disease. J Spinal Surg 2021;8:39-42
|How to cite this URL:|
Diyora B, Dhall G, Patel M, More N, Dey S, Mulla M. Giant Tuberculous Retropharyngeal Abscess with Associated Neurological Manifestations in Cervical Pott's Disease. J Spinal Surg [serial online] 2021 [cited 2022 Jan 21];8:39-42. Available from: http://www.jossworld.org/text.asp?2021/8/4/39/333609
| Introduction|| |
A retropharyngeal abscess is a relatively uncommon pathology that predominantly occurs in pediatric age. It occurs due to Gram-positive, Gram-negative, or respiratory anaerobic bacterial infection. Infections usually spread from the tonsils, throat, sinuses, adenoids, vertebral spine, or nose to the retropharyngeal space. In acute retropharyngeal abscess cases, these bacterial infections are usually acquired following a penetrating injury by a foreign body, for example, fishbone or during endotracheal intubation or specific endoscopic procedures. However, rarely, a chronic retropharyngeal abscess may occur secondary to cervical tuberculous osteomyelitis (cervical Pott's disease) when there is the contiguous spread of infection from the cervical spine to the throat on both sides of the midline. Due to the nonspecificity of its symptoms, the diagnosis of a retropharyngeal abscess may prove to be complicated. It should suspect the diagnosis in patients with a retropharyngeal mass and a destructive lesion of the vertebral column. We present a case of the giant retropharyngeal abscess with underlying cervical Pott's disease in a young child and describe management.
| Case Report|| |
A 13-year-old female child presented to us with complaints of neck pain and stiffness for 3 months. She had experienced weight loss and malaise for 2 months. She also had dysphagia and odynophagia for 15 days. On physical examination, the vitals were normal. However, the patient looked cachectic and ill. On the oropharyngeal examination, the posterior pharyngeal wall was noted to be anteriorly displaced. Her neck movements were painful and restricted in all directions. Neurological examination revealed muscle power in the right upper limb was graded 3 out of 5 on the Medical Research Council Scale for muscle strength. Muscle power was normal in the rest of the limbs. She had exaggerated deep tendon reflexes in both upper and lower limbs without ankle/patellar clonus. The Babinski reflex was also positive on both sides. She did not have any sensory deficits. Her erythrocyte sedimentation rate (ESR) was 45 mm/h and a C-reactive protein (CRP) of 50 mg/L.
The screening tests for HIV-1 and HIV-2 yielded negative results. Other hematological and biochemical parameters were normal. Cervical spine radiography on lateral view revealed the increased distance between the trachea and anterior border of the cervical vertebrae, suggesting a retropharyngeal lesion. [Figure 1] shows increase in the size of the retropharyngeal due to a large retropharyngeal collection. Her cervical spine magnetic resonance imaging (MRI) showed spondylodiscitis involving the C3 vertebral body and adjacent epidural collection compressing on the thecal sac of the spinal cord. MRI also showed a giant prevertebral retropharyngeal collection which was hypointense on T1-weighted images and hyperintense on T2-weighted images. Multiloculated collection was enhancing on contrast administration [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e. Her neck computed tomography (CT) scan with bone window showed severe destruction of the C3 vertebral body, moderate collapse, Grade I retrolisthesis of C2 over C3, and reduction of C2-C3 disc space with prevertebral and postvertebral collection [Figure 3]a, [Figure 3]b, [Figure 3]c.
|Figure 1: X-ray cervical spine lateral view (a) significant widening of retropharyngeal space extending from skull base to T1 vertebral level and AP view, (b) displaced trachea toward left side|
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|Figure 2: Magnetic resonance imaging (MRI) of the cervical spine showed spondylodiscitis involving C3 vertebral body along with adjacent epidural collection compressing on the thecal sac of spinal cord. MRI also showed significant prevertebral retropharyngeal collection which was hypointense on T1-weighted images (a), and hyperintense of T2-weighted images (b), and inhomogeneous enhancing on contrast administration (c), MRI of the cervical spine in axial view showing giant retropharyngeal collection compressing the aerodigestive tract (d and e)|
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|Figure 3: Computed tomography scan cervical spine sagittal (a) coronal, (b) and axial (c) view showing destruction of C3 vertebral body. Sagittal (a) and axial (c) view also showing large retropharyngeal and epidural collection|
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The severe compression of the upper cervical spinal cord with the destruction of the C3 vertebral body, neurological deficits, and aerodigestive tract compression with associated dysphagia decided to surgically drain the abscess, decompress the spinal cord, and stabilize the upper cervical spine. The patient underwent endotracheal intubation with the help of a video laryngoscope and general anesthesia administered. Through the right retromandibular approach, retropharyngeal pus collection of about 150 ml drained out, C2-C3 and C3-C4 discectomy, and C3 corpectomy performed, and C2-C4 vertebral bodies internally fixed with the help of bone-filled self-expanding titanium cage which attached with plates and screws. A ZiehlNeelsen smear on the pus obtained from the drainage of retropharyngeal abscess revealed acid-fast bacilli, and subsequent mycobacterial culture LowensteinJensen medium showed Mycobacterium tuberculosis after 4 weeks of inoculation. Based on these findings, a diagnosis of the tuberculous retropharyngeal abscess (TBRPA) with Pott's disease was established, and she was kept on antituberculous medication. She was discharged after a week as she did not have any complaints or residual neurological deficits. However, she presented again after 3 weeks with a collection at the operative site. Repeat cervical spine radiography showed a widening of the retropharyngeal space with titanium implants in situ [Figure 4]a. She underwent ultrasound-guided aspiration of about 70 ml of reddish-brown fluid. After 1 month, a follow-up radiograph showed no recollection evidence with titanium implants in place [Figure 4]b. The patient kept on antitubercular polychemotherapy for the next 18 months. At a 1-year follow-up, she was utterly asymptomatic without any neurological deficit. The follow-up MRI revealed no residual or recurrent disease [Figure 5]a, [Figure 5]b, [Figure 5]c.
|Figure 4: X-ray cervical spine lateral view showing cage plate construct in situ with retropharyngeal collection after 4 weeks of surgery (a), follow-up X-ray cervical spine after 2 weeks of needle aspiration (b)|
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|Figure 5: Follow-up magnetic resonance imaging 1 year after surgery showing no evidence of recurrence of lesion on T1 sagittal weighted image (a), T2 sagittal weighted image (b) and T2 axial weighted images (c)|
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| Discussion|| |
The retropharyngeal space extends from the skull base to the posterosuperior mediastinum. It communicates with the lateral pharyngeal space. Abscesses of retropharyngeal space can either be acute or chronic. Acute pyogenic retropharyngeal abscesses are more common overall and usually seen in children <5 years old. They are caused by infection of retropharyngeal lymph nodes that drain the infected lymph from the nose, ear, and throat following their illness by various bacteria. Chronic retropharyngeal abscesses are caused by tuberculous infection and commonly seen in adults and rarely in children. TBRPA may occur due to (1) direct spread of infection from tuberculous cervical spondylitis (Pott's disease) through pus which erodes into retropharyngeal space on both sides of midline, as in our case, (2) tuberculous infection of persisting retropharyngeal lymph nodes draining lymph from infected foci, and (3) hematogenous spread of tubercle bacilli from pulmonary or extrapulmonary tuberculous foci to retropharyngeal space.,,
A patient with TBRPA usually presents with dysphagia, odynophagia, neck pain, and neck stiffness, often associated with reduced neck mobility. A retropharyngeal abscess with a hypodense area of ≥2.5 cm2 on CT scan is considered large, and it may present with dyspnea, stridor, neck rigidity, dysphonia, external neck swelling, trismus, and torticollis. The classic tuberculosis symptoms such as fever, night sweats, and cachexia are usually not found in TBRPA cases. The most common symptoms of cervical Pott's disease are neck pain and diminished neck mobility. If a large enough epidural or retropharyngeal abscess develops secondary to cervical Pott's disease, it may compress the spinal cord and cause significant neurological deficits, as in our case.
Early diagnosis and management of TBRPA and cervical Pott's disease are vital to prevent life-threatening complications such as airway obstruction, damage to the carotid sheath, septic shock, tracheobronchial aspiration of contents of abscess following spontaneous or traumatic rupture, or spread of pus into the mediastinum through the “danger” space that lies behind anatomic retropharyngeal area. In the presence of these complications, the mortality rate may rise to 40%–50%. The diagnosis of TBRPA can be challenging at times due to the absence of specific symptoms. It requires careful history taking, clinical examination, and a high index of suspicion. Imaging helps in assessing the extent of the disease and possible damage caused by it. Laboratory investigations such as complete blood cell, ESR, and CRP further provide supporting evidence of the ongoing disease process.
TBRPA is usually treated with antituberculous polychemotherapy. Extensive pus collection requires drainage either through intraoral approach or external cervical approach. Cervical Pott's disease is traditionally treated with antituberculous polychemotherapy and conservative neck stabilization. Surgical intervention is needed in case of significant neurologic deficit, deformity of the spine with instability and pain, or large epidural/paraspinal abscess. The surgical procedure includes exploration, drainage of epidural pus collection, corpectomy, internal fixation, and stabilization of the cervical spine.
| Conclusion|| |
Giant TBRPA is a relatively rare entity in the pediatric age group. Prompt diagnosis of an abscess, surgical drainage of pus, and antituberculous medication can prevent fatal complications with good clinical outcomes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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