Abstract
Purpose
A retropharyngeal abscess (RPA) is an extremely rare entity in adults that has a tendency to spread vertically and cause a mediastinal abscess. Traditionally, immediate aggressive drainage is recommended via a transcervical or transthoracic approach for the treatment of a retropharyngeal abscess with mediastinal extension. Here, we present a case of a retropharyngeal and mediastinal abscess using a transoral negative-pressure catheter drainage approach.
Patients and methods
A 24-year-old woman was admitted with a 4-day history of severe sore throat and painful swallowing. Computed tomography identified a retropharyngeal abscess extending to the upper posterior mediastinum. We performed transoral negative-pressure catheter drainage.
Results
The postoperative course was uneventful. The patient reported a rapid improvement in symptoms and had a good tolerance of the catheters in the nasal cavity. At 2 years postoperatively, physical examinations revealed no recurrence or surgical complications.
Conclusions
Transoral negative-pressure catheter drainage is a minimally invasive operation for the treatment of RPA in adults with or without a mediastinal abscess. This method could be recommended as an alternative approach in such cases.
1
Introduction
A retropharyngeal abscess (RPA) is an infection deep within the neck. This uncommon clinical entity occurs more frequently in children and is usually described as a pediatric disease . Only 51 RPA cases in adults were described in the literature between 1970 and 1995 . Medical therapy for RPA in children and adults, without surgical drainage, has been supported by several reports . However, surgical intervention can be reserved for patients whose clinical conditions do not improve with medical therapy alone. The majority of these RPA cases can be managed transorally. In adults, the literature has suggested that a much more aggressive transcervical surgical approach is likely necessary . In recent years, Ultrasound and CT scanning-guided drainage have been proposed as alternatives to open surgical incisions for the placement of needles or indwelling catheters into these abscesses .
Anatomically, the retropharyngeal space extends from the base of the skull into the mediastinum, up to the T2 thoracic vertebral level. The RPA has a tendency to develop mediastinal abscesses, an affliction with high mortality rates . Surgical managements vary in mediastinal abscesses, but they can include transcervical approaches, median sternotomy, and video-assisted or mediastinoscopically assisted drainage . Although conventional invasive procedures have been recommended by many investigators, such approaches may lead to unexpected results, such as massive tissue injury, osteomyelitis, dehiscence of the sternum, and other complications. Percutaneous drainage has been reported as an alternative, minimally invasive operation with excellent results .
In cases of retropharyngeal abscess with posterior upper mediastinal extension, some authors have advocated a cervicotomy and transcervical mediastinal or video-assisted thoracic surgery (VATS) drainage . Although less traumatic than traditional mediastinal drainage, a cervicotomy is still a high-risk approach because of the complicated anatomy of the neck.
Negative-pressure drainage has been used in head and neck surgeries for several years to remove body fluids, thereby preventing the accumulation of serous fluid and improving wound healing . There have been few reports in the literature of the application of this technique to deep neck infections. We present a case of a retropharyngeal and mediastinal abscess caused by neck trauma to a healthy, young patient who had a successful outcome with the transoral approach and continuous negative-pressure catheter drainage. We discuss this minimally invasive surgical technique in the context of therapies for retropharyngeal and mediastinal abscesses.
2
Case report
A 24-year-old woman was admitted with the clinical diagnosis of a retropharyngeal and mediastinal abscess. Her history revealed that, 10 days prior to her admission, she had been wounded on the right side of her neck by a knife. Surgical debridement and sutures were performed in another hospital. She received a 2-day intravenous therapy (cefazolin sodium) to prevent infections. No detailed information was available about the condition of the trauma. According to her, the sore throat started 4 days before admission with a temperature of 38.7 ºC and rapidly worsened. Despite her prescription of intravenous cefazolin sodium and successfully controlling her temperature to the normal level, her symptoms of sore throat dysphagia were not improved. She was referred to our hospital. Upon examination, her neck movements were markedly restricted by pain. The oral examination showed a marked edema in the posterior pharyngeal wall mucosa. The bilateral tonsils appeared normal. Her blood tests on admission revealed leukocytosis of 12.23 × 10 9 cells/L, but there were no systemic toxic signs. An urgent CT scan of the neck and chest demonstrated a large, hypodense lesion extending from the base of the skull into the upper posterior mediastinum, with the greatest transverse diameter of 6.4 cm ( Figs. 1 and 2 ). Gas formation was also revealed in the center of the hypodense area. A transoral needle aspiration examination in the posterior pharyngeal wall demonstrated yellowy, purulent material, and the pus sample was sent for microbiology. She was given a diagnosis of retropharyngeal and mediastinal abscess.
The patient was taken to the operating room, where she underwent transoral drainage of the abscess under orotracheal intubation general anesthesia. A horizontal incision, 1.5 cm in length, was made in the posterior pharyngeal wall. A substantial amount of purulent liquid overflowed from the incision. Two catheters were carefully advanced into the abscess cavity, over 12 cm in depth. Saline was pumped in through one catheter while fluid was sucked out from the other until the liquid appeared clear. The distal ends of the two catheters were driven from the posterior naris to the external naris and were fixed to the paranasal skin with a retention device ( Fig. 3 ). The patient was admitted to the intensive care unit, where she received appropriate supportive and antibiotic therapies (ampicillin/sulbactam).
Postoperatively, the patients underwent additional irrigation with 10 ml of 0.9% normal saline solution twice daily, which is the same technique used in surgical operations to maintain catheter patency. For the remaining time, one catheter was closed, and the other was connected to a low-pressure continuous vacuum pump, which employed a negative pressure of approximately 8–10 mmHg. The postoperative course was uneventful. The patient reported a rapid improvement in her symptoms and had a good tolerance to the catheters in her nasal cavity. Cultures of the pus did not reveal any organisms. The catheters were gradually withdrawn on postoperative day 5 when the daily output decreased to less than 5 ml, and they were subsequently removed on day 8. The patient was discharged on the tenth postoperative day and maintained on intravenous antibiotic treatment until day 14. A follow-up examination 2 weeks later exhibited a healing incision and no edema in the posterior pharyngeal wall. Unfortunately, the patient refused a CT examination. At 2 years postoperatively, physical examinations revealed no recurrence or surgical complications.
2
Case report
A 24-year-old woman was admitted with the clinical diagnosis of a retropharyngeal and mediastinal abscess. Her history revealed that, 10 days prior to her admission, she had been wounded on the right side of her neck by a knife. Surgical debridement and sutures were performed in another hospital. She received a 2-day intravenous therapy (cefazolin sodium) to prevent infections. No detailed information was available about the condition of the trauma. According to her, the sore throat started 4 days before admission with a temperature of 38.7 ºC and rapidly worsened. Despite her prescription of intravenous cefazolin sodium and successfully controlling her temperature to the normal level, her symptoms of sore throat dysphagia were not improved. She was referred to our hospital. Upon examination, her neck movements were markedly restricted by pain. The oral examination showed a marked edema in the posterior pharyngeal wall mucosa. The bilateral tonsils appeared normal. Her blood tests on admission revealed leukocytosis of 12.23 × 10 9 cells/L, but there were no systemic toxic signs. An urgent CT scan of the neck and chest demonstrated a large, hypodense lesion extending from the base of the skull into the upper posterior mediastinum, with the greatest transverse diameter of 6.4 cm ( Figs. 1 and 2 ). Gas formation was also revealed in the center of the hypodense area. A transoral needle aspiration examination in the posterior pharyngeal wall demonstrated yellowy, purulent material, and the pus sample was sent for microbiology. She was given a diagnosis of retropharyngeal and mediastinal abscess.
