OTORHINOLARNGOLOGY

SPECIALTY (MED 4058)

CASE WRITE UP

RETROPHARYNGEAL ABSCESS

NAME: AMIR ARIF B ROSLAN

MATRIC NO: MBBS 1709-8225

YEAR/GROUP: 4/4B1

SUPERVISOR: AP. DR. SATHAPPAN SUBRAMANIAM

Name: Hasbullah B Samad

Age: 52 years old

Gender: Male

Race: Malay

Address: Putrajaya

Date of Admission: 14th December 2020

Chief Complaint

Mr Hasbullah, a 52 years old Malay gentleman presented to the emergency department with neck

pain in the last 3 days with progressive swelling in the left side of the neck

History of Presenting Illness

1 week prior to admission, patient reported symptoms of sore throat that has been slightly

improved after 2 days of self-prescribed penicillin but however, symptoms got worse on the 5th

day. At the emergency department, he was found to have pain over a swelling on the right side of

the neck. He mentioned that his wife first noticed the swelling. It has been gradually increasing

in size since day 5 along with pain that is dull-aching in nature but it doesn’t radiate to any other

side of the body.

He also complained of sore throat and pain while swallowing. He found it hard to ingest both

solid and liquid hence the poor oral intake associated with fever of 38°C. The patient reported a

recent development of trismus and muffled “hot potato” voice.

Otherwise, he denied ingesting any foreign body, no recent dental check-up, no trauma to

the oral cavity, no loss of weight and loss of appetite and systemic examination shows no

abnormalities.
Past Medical and Surgical History

Patient has no known medical illness upon admission.

Drug History

Patient was taking self-prescribed penicillin to relieve his sore throat prior to admission. He does

not report taking any supplements. No known drug allergy.

Family History

Patient’s father was diagnosed with heart disease and his mother was diagnosed with diabetes

mellitus. Patient is the second from four siblings. No blood disorders and history of malignancy

in the family.

Social History

Patient lives in Putrajaya with his spouse and their 3 years old child. He’s a lawyer at his firm

and the wife works as a fashion designer both working in Kuala Lumpur. He’s a smoker for 24

years smoking 1 pack of cigarettes per day. He denied and alcohol assumption and illicit drugs

use.
PHYSICAL EXAMINATION

Patient was sitting on the bed comfortably. He was alert and well oriented time, place and

person. He was not in respiratory distress and was pink. There was a blue branula attached at the

right dorsum of the patient’s hand. However, there was no drip attached to the branula. There

was also dressing on his right neck as patient mentioned he went to undergo incision and

drainage of abscess.

Vital signs:

Temperature: 36.9 degrees Celsius

Pulse: 75 beats per minute

Blood pressure: 130/74 mmHg

Respiratory rate: 16 breaths per minute

sPO2: 99% under room temperature

Pain score: 2/10

Peripheries are pink and warm. Capillary refill time is less than 2 seconds. No sign of

clubbing, splinter haemorrhage, leukonychia, koilonychia, palmar erythema or dupuytren’s

contracture. No sign of tremors. No sign of eczema at ante cubital area. Patient had no

conjunctival pallor or scleral jaundice. Oral hygiene and hydration status are good. No sign of

central cyanosis.
SPECIAL EXAMINATION

Examination of oral cavity

Inspection

Lips and buccal mucosa are moist. The gums and teeth are healthy and there were no

lesions on the gums or gum bleeding and no presence of dental carries. The hard palate was

normal and not inflamed. There is no glossitis or ulcers on the anterior 2/3rd of the tongue.

The tongue was normal with no tongue coating or inflamed tongue. The floor of mouth is

clear.

Examination of oropharynx

Inspection

The right tonsil was erythematic and swollen with the presence of exudate, however,

the left tonsil was normal. Anterior and posterior pillars of the right side are normal. The

uvula is centrally located and no abnormality detected.

Examination of nose

Inspection

Outer nose – No deviation of nasal septum. No lesion, abscess or scar.

Inner nose – Both nostrils are equal in size. No nasal discharge. No mass or lesion.

Palpation
 No tenderness over paranasal sinuses.

Examination of ear

Inspection

The ear pinna and the skin are normal, with normal meatus of the ear. On otoscopy,

tympanic membranes were pearly white in colour, external ear canal was clear.

Examinations of neck

Inspection

No mass or skin lesion. No skin changes, venous dilatation or visible pulsation.

Palpation

Trachea is centrally located. No palpable lymph nodes.

PATIENT’S SUMMARY

Mr Hasbullah, a 52 years old man from Putrajaya admitted to the ENT ward with

complaint of pain over swelling associated with pain at the maxillary area, mild fever, sore

throat, odynophagia, trismus and muffled voice.

Upon physical examination, right tonsil was erythematic and swollen with the presence

of exudate.
INVESTIGATION

Full blood count

COMPONENT RESULTS NORMAL INTERPRETA

RANGE TION
Hb (g/dL) 14 12.0-16.0 Normal
Hematocrit (%) 44 36-46 Normal
MCV (fL) 89 80-100 Normal
MCH (pg) 30 25.4-34.6 Normal
MCH 33.4 31-36 Normal

concentration %

Hb/cell
RDW 5.1 3.5-5.5 Normal

(millions/mm^3)
Platelets 380 150-400 Normal

(x10^9/L)
Total WBC 13.4 4.5-11.0 Abnormal

(x10^9/L)
C-reactive 49.6 < 1.0 Abnormal

protein (mg/L)

Leucocytosis was detected together with elevation of C-reactive protein. This indicates

active inflammation. Total white cell differentials may help with determining the origin of the

infection, bacterial or viral in origin.

RESULTS (mmol/L) NORMAL RANGE INTERPRETATION

12.5 < 5.6 Abnormal

Patient was diagnosed recently with diabetes mellitus.

Renal profile

COMPONENT RESULTS NORMAL INTERPRETA

RANGE TION
Blood Urea 6.8 1.8-8.3 Normal

Nitrogen

(mmol/L)
Sodium 139 135-152 Normal

(mmol/L)
Potassium 3.9 3.5-5.4 Normal

(mmol/L)
Creatinine 92 62-115 Normal

(umol/L)
Chloride 100 98-106 Normal

(mmol/L)
BUN/Creatinine 61 48-80 Normal

ratio
Normal value for every parameter. Good hydration status and kidney function.

Microbiology

Pus culture was taken from the drainage identifying the organism as Staphylococcus

aureus.

DIFFERENTIAL DIAGNOSIS

Differential Diagnosis Differentiating signs/symptoms

Acute epiglotttitis • Difficult to distinguish from RPA

but generally has a more acute

onset

• History of difficulty in breathing

medialised uvula

• Normal appearance of the posterior

pharyngeal wall
PROVISIONAL DIAGNOSIS

Retropharyngeal abscess.

MANAGEMENT

Retropharyngeal abscess
Prehospital care

 Supplemental oxygen and attention to upper airway patency are the essential components

of prehospital care in patients with suspected retropharyngeal abscess

 Endotracheal intubation or cricothyrotomy may be required if the patient exhibits signs of

upper airway obstruction.

Emergency Department Care

ED management of retropharyngeal abscess includes attention to the airway, fluid resuscitation if

necessary, antibiotic treatment and preparation for an emergency operation. Frequent vital sign

checks and continuous oxygen saturation monitoring are essential.

 Airway management

1. Apply supplemental oxygen.

2. Endotracheal intubation is required if patient has signs of upper airway obstruction.

3. Cricothyrotomy may be required in patient with upper airway obstruction who cannot

be intubated. Tracheostomy may be required for definitive airway management.

 Intravenous fluids are required if patient is dehydrated because of fever and difficulty

swallowing.

Antibiotics

Empirical antibiotic therapy

 Ampicillin/sulbactam, 1-2g intravenously every 6-8 hours, maximum 12 g/day

 Ceftriaxone, 1-2g intravenously every 12-24 hours

and

 Clindamycin, 1.2 to 2.7 g/day intravenously given in divided doses every 6-12 hours

Surgery

 Incision and drainage

Supportive care + Analgesics

 Paracetamol, 500-1000mg orally every 4-6 hours when required, maximum 4000 mg/day

Diabetes Mellitus

 Start initial treatment on diabetes mellitus and refer patient to medical department for

follow up

DISCUSSIONS

DEFINITION

Retropharyngeal abscess (RPA) is a neck infection involving abscess formation in the

space between the pre-vertebral fascia and the constrictor muscles. The condition occurs most

frequently in children but its incidence is increasing in adults

know diabetic patient also develops hyperglycaemia which became an ideal culture medium for

bacterial infection and growth.

ETIOLOGY

45% of RPAs are the sequalae of an upper respiratory tract infection (e.g., pharyngitis,

tonsillitis, sinusitis, dental infections). The most common microorganisms implicated are

Streptococcus viridans, Staphylococcus aureus, Streptococcus epidermidis and beta-haemolytic

streptococci. Less common causes include Veillonella species, Bacteroides melaninogenicus,

haemophilus parainfluenzae, and Klebsiella pneumoniae. Infections with both methicillin-

resistant Staphylococcus aureus and Mycobacterium tuberculosis have also been reported.

Normal commensals of the upper respiratory tract can become pathologically offending

organisms in an RPA. 27% of RPAs are associated with accidental trauma to the retropharyngeal

area from, for example, foreign body ingestion, a child running along with a lollipop in their

mouth and falling or swallowing sharp objects such as chicken bones. The remaining 28% are

idiopathic.

PATHOPHYSIOLOGY

The retropharyngeal space is immediately anterior to the prevertebral fascia that

continues inferiorly from the skull base for the length of the pharynx. It is in continuity with the

parapharyngeal space and the infratemporal fossa. The retro- and parapharyngeal spaces are

separated by the alar fascia, which seems to be an ineffectual barrier to the spread of infection.
As the retropharyngeal space is in continuity with the superior and posterior mediastinum, it is a

potential pathway for spread of infection into the chest.

The retropharyngeal space contains loose areolar tissue and lymphatic chains, the former

allowing movement of the pharynx and oesophagus on swallowing. The lymph flowing through

the space originates from tissues in the nose, paranasal sinuses, eustachian tubes and adjacent

pharyngeal tissues. Pus formation in the retropharyngeal nodes is often well contained and

therefore vertical spread of infection can occur late in the progression of the condition although

this rarely occurs in practice.

Most of the symptoms and signs of RPA relate to the increasing obstruction of the upper

aerodigestive tract and irritation of local muscle groups (e.g., sternomastoid pterygoids).
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