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Torticollis with tonsillitis. Is imaging necessary?

Nikila Pandya, R Jayalakshmi, Eleni Daykin, George Worley

Department of Paediatrics, Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 0EZ, UK

Correspondence to:
Nikila Pandya, nikilapandya{at}nhs.net

Tonsillitis can be complicated by a retropharyngeal abscess. It causes cervical pain, torticollis, swelling, inability to extend the neck and stridor. Throat examination is often difficult in severe trismus. In patients with tonsillitis complicated with torticollis, early imaging is important in ruling out retropharyngeal collections.

A 6-year-old boy presented with a sore throat, trismus, left-sided neck swelling and pain. He was febrile, drooling and had a left torticollis. Investigations revealed white cell count (WCC) 16x10⁶/l and C-reactive protein (CRP) 119 mg/dl. Throat examination was not possible due to pain. An ultrasound scan was unremarkable. He was treated with intravenous antibiotics for 4 days and oral antibiotics for presumed tonsillitis, with good recovery.

He was readmitted 2 weeks later with odynophagia, noisy stertorous breathing and inability to extend his neck. Throat examination revealed a large protuberant swelling on the left side of his pharynx (fig 1).

View this figure (92K): in this window | in a new window | PowerPoint for Teaching   Figure 1 Intraoperative photograph showing left posterior pharyngeal swelling.

 

CT scan of the neck and chest revealed a left retropharyngeal abscess over the left tonsil measuring 4.8x3.8x2 cm (fig 2).

View this figure (105K): in this window | in a new window | PowerPoint for Teaching   Figure 2 CT scan. A left retropharyngeal abscess centred on the left tonsil with involvement of the left prevertebral muscles and deviation of the airway.

 

A total of 20 ml of pus was drained under general anaesthetic (fig 3), with good recovery. The cultures were negative.

View this figure (107K): in this window | in a new window | PowerPoint for Teaching   Figure 3 Transoral drainage of the retropharyngeal abscess.

 

Retropharyngeal abscess is a rare but serious complication of tonsillitis. Torticollis, odynophagia, drooling and inability to extend the neck in a child with tonsillitis are characteristic features.^1,2 Severe complications such as mediastinitis and epidural abscess can occur if untreated.² CT scan with contrast is the recommended radiological investigation when there is high clinical suspicion.³

Competing interests: none.

Patient consent: Patient/guardian consent was obtained for publication.

1. Majumdar, S, Bateman, NJ, & Bull, PD. Paediatric stridor. Arch Dis Child ED Pract 2006; 91: ep101–5.
2. Craig, FW, & Schunk, J. Retropharyngeal abscess in childhood: clinical presentation,utility of imaging and current management. Pediatrics 2003; 111: 1394–8.[Abstract/Free Full Text]
3. Nagy, M, & Backstrom, J. Comparison of sensitivities of lateral neck radiographs and computerised scanning of deep pediatric neck infections. Laryngoscope 1999; 109: 775–9.[CrossRef][Medline]

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