5: Sore Throat

Sore Throat and Stiff Neck

A young woman in her 20’s presents to the ED for 9 days of sore throat followed by neck stiffness. On exam the oropharynx appears normal. She has a stiff neck. What does this x-ray show? What is the differential diagnosis of meningismus?

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ANSWER:
Meningeal signs can be caused by a variety of conditions other than meningitis. Chronic conditions include degenerative arthritis, ankylosing spondylitis and muscle contractions in bedridden patients. Infectious causes include spinal epidural abscess, retropharyngeal abscess and tetanus. Muscular conditions that may cause a stiff neck include torticollis, dystonic reactions and muscle spasm following injury.

This patients’ x-ray demonstrates widening of the prevertebral soft tissues consistent with a retropharyngeal abscess which was demonstrated on CT scan. Normally these soft tissues should measure less than 6mm at C2 and less than 22mm at C6. There is normally a step-off around C4 which is not noted in this film. Retropharyngeal abscess is classically thought to be a disease of childhood, but has been increasing recognized in adults as well. The clinical presentation usually starts with fever and sore throat which may progress to trouble swallowing, dehydration, and neck stiffness. Stridor, drooling and sepsis signify severe disease. The disease may stem from local infection that then drains to the retropharyngeal nodes and becomes suppurative however risk factors include trauma such as a recent foreign body or medical procedure.

A lateral neck x-ray is 85-90% sensitive for retropharyngeal abscess. CT scanning is more sensitive, especially in children and can help the determine if surgery is necessary and if so by what approach. This patients CT is shown below.  Note the dark fluid collection anterior to the vertebral body (Ignore the arrow).

Management includes airway stabilization when necessary followed by IV fluids and antibiotics to cover gram positive, gram negative and anaerobic organisms. Formal drainage in the OR may be required and an Ear, Nose and Throat specialist should be consulted early on. Drainage in the ED may increase the risk for aspiration and should not be attempted. Complications of retropharyngeal abscess carry a high mortality and include airway obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, and erosion into the carotid artery

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RetroPharyngeal Abscess from “Quick Essentials“

Causes:    Endoscopy, foreign body, primary infection
Sx:           Sore throat, pain, fever, enlarged lymph nodes, meningismus.
Tests:       Lateral neck XR, CT with contrast
Rx:           Airway management if needed, Zosyn or Clindamycin, Consult ENT for surgery