Abstract
Tuberculosis is known to affect almost every organ in the body, but its manifestations in the head and neck region are quite rare. A tuberculous retropharyngeal abscess is a very rare condition and can be the cause of oropharyngeal dysphagia. It is usually secondary to tuberculosis of the spine and has the potential of significant morbidity and mortality if not treated appropriately. We present a case of a 74-year-old man with a retropharyngeal abscess with no evidence of spinal tuberculosis.
1
Introduction
Retropharyngeal abscess primarily occurs in children, but it can also be seen in adults, although it is quite rare. It is usually associated with direct extension from adjacent structures, penetrating trauma, granulomatous disease, and cervical spine spondylodiscitis . On the other hand, in recent years, we have witnessed an increasing incidence of extrapulmonary tuberculosis in developed countries that has been attributed to immigration from endemic areas and the rising number of immunocompromised individuals. Although described, a tuberculous retropharyngeal abscess without evidence of cervical osteomyelitis is an uncommon condition .
2
Case report
A 74-year-old man, nonsmoker, with no significant medical history, was admitted to our hospital with a 2-month history of progressive oropharyngeal dysphagia. The patient described that a solid food bolus could not be propelled successfully within 1 second after swallowing, whereas liquid swallowing sometimes caused coughing. The initial diagnosis by his general practitioner was reflux disease. His symptoms did not improve after the administration of proton pump inhibitors, so he consulted a gastroenterologist in our hospital. The patient underwent an upper gastrointestinal endoscopy that revealed nothing but a bulging mass originating from the retropharyngeal wall. Subsequently, he was referred to the Ear Nose and Throat (ENT) department.
The patient did not mention any other symptoms. Physical examination performed in the ENT department otherwise showed nothing remarkable. The patient was apyrexial and did not mention any night sweating. Flexible endoscopy of the vocal cords, auscultation of the lungs, and neurologic examination were also normal.
Laboratory investigations revealed white blood cell, 7 K/ μ L (Neutrophils, 63.9%; Lymphocytes, 28.6%); Hemoglobulin, 13.2 g/dL; Hematocrit, 39.5; primed lymphocyte typing, 215 K/ μ L; and erythrocyte sedimentation rate, 42 mm/h. C-reactive protein was 3 mg/dL (<1 mg/dL). Hepatitis B surfice antigen and antibodies for HIV and hepatitis C virus were negative. The rest of the laboratory examinations were unremarkable. The lung x-ray was normal. Tuberculin (Mantoux) test was negative.
A magnetic resonance imaging of the neck was performed, which revealed the presence of a mass in the retropharyngeal wall, infiltrating the anterior surface of the C1 to C2 vertebrae ( Fig. 1 ). A biopsy of the mass performed under general anesthesia revealed that the mass consisted of a purulent collection limited in 1 side of the pharynx. Drainage of the abscess was performed through an intraoral vertical incision in the posterior pharyngeal wall. Specimens were taken to perform Ziel Nielsen staining, Gram staining, cytologic examination, cultures, polymerase chain reaction for Mycobacterium tuberculosis , and histologic examination of the tissue obtained. The cytologic examination showed absence of neoplasmatic cells and presence of 70% lymphocytes. Ziel Nielsen staining and Gram staining were negative. Cultures were negative for common bacteria. Histology showed no evidence of malignancy. Polymerase chain reaction for Mycobacterium tuberculosis was positive. The culture of the pus revealed acid-fast bacteria after 4 weeks of inoculation. The patient received isoniazid (300 mg), rifampicin (600 mg), pyrazinamide (1500 mg), and ethambutol (1200 mg) for 2 months, followed by isoniazid (300 mg) and rifampicin (600 mg) for 4 months. The patient made an uneventful postoperative recovery with complete remission of the lesion.
2
Case report
A 74-year-old man, nonsmoker, with no significant medical history, was admitted to our hospital with a 2-month history of progressive oropharyngeal dysphagia. The patient described that a solid food bolus could not be propelled successfully within 1 second after swallowing, whereas liquid swallowing sometimes caused coughing. The initial diagnosis by his general practitioner was reflux disease. His symptoms did not improve after the administration of proton pump inhibitors, so he consulted a gastroenterologist in our hospital. The patient underwent an upper gastrointestinal endoscopy that revealed nothing but a bulging mass originating from the retropharyngeal wall. Subsequently, he was referred to the Ear Nose and Throat (ENT) department.
The patient did not mention any other symptoms. Physical examination performed in the ENT department otherwise showed nothing remarkable. The patient was apyrexial and did not mention any night sweating. Flexible endoscopy of the vocal cords, auscultation of the lungs, and neurologic examination were also normal.
Laboratory investigations revealed white blood cell, 7 K/ μ L (Neutrophils, 63.9%; Lymphocytes, 28.6%); Hemoglobulin, 13.2 g/dL; Hematocrit, 39.5; primed lymphocyte typing, 215 K/ μ L; and erythrocyte sedimentation rate, 42 mm/h. C-reactive protein was 3 mg/dL (<1 mg/dL). Hepatitis B surfice antigen and antibodies for HIV and hepatitis C virus were negative. The rest of the laboratory examinations were unremarkable. The lung x-ray was normal. Tuberculin (Mantoux) test was negative.
A magnetic resonance imaging of the neck was performed, which revealed the presence of a mass in the retropharyngeal wall, infiltrating the anterior surface of the C1 to C2 vertebrae ( Fig. 1 ). A biopsy of the mass performed under general anesthesia revealed that the mass consisted of a purulent collection limited in 1 side of the pharynx. Drainage of the abscess was performed through an intraoral vertical incision in the posterior pharyngeal wall. Specimens were taken to perform Ziel Nielsen staining, Gram staining, cytologic examination, cultures, polymerase chain reaction for Mycobacterium tuberculosis , and histologic examination of the tissue obtained. The cytologic examination showed absence of neoplasmatic cells and presence of 70% lymphocytes. Ziel Nielsen staining and Gram staining were negative. Cultures were negative for common bacteria. Histology showed no evidence of malignancy. Polymerase chain reaction for Mycobacterium tuberculosis was positive. The culture of the pus revealed acid-fast bacteria after 4 weeks of inoculation. The patient received isoniazid (300 mg), rifampicin (600 mg), pyrazinamide (1500 mg), and ethambutol (1200 mg) for 2 months, followed by isoniazid (300 mg) and rifampicin (600 mg) for 4 months. The patient made an uneventful postoperative recovery with complete remission of the lesion.
