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Pain in the neck
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  1. Zaid Makzal1,
  2. Alison Evans2,
  3. Kavitha Masilamani3
  1. 1Department of Paediatrics, University Hospital of Wales, Cardiff, UK
  2. 2Department of Paediatric Radiology, University Hospital of Wales, Cardiff, UK
  3. 3Department of General Paediatrics, University Hospital of Wales, Cardiff, UK
  1. Correspondence to Dr Zaid Makzal, makzal{at}hotmail.com

https://doi.org/10.1136/bcr-2016-217479

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    Description

    A girl aged 4 years presented with a 1-month history of headache, malaise and episodes of unsteady gait. She appeared well with normal observations. She had limited neck extension and lateral rotation with normal neurological examination. A CT head showed no space-occupying lesion and the patient was discharged.

    She re-presented a week later with neck pain, stiffness and intermittent fever. There were no signs of upper airway obstruction and she continued to eat as normal. Repeat CT of the neck and MRI revealed significant thickening of the retropharyngeal soft tissue with collection in keeping with a retropharyngeal abscess causing significant narrowing of the pharynx along with osteomyelitis of the clivus (see figure 1).

    Figure 1
    Figure 1

    CT neck with contrast showing retropharyngeal abscess and osteomyelitis of the clivus.

    She was started on broad-spectrum intravenous antibiotics and surgical drainage was attempted but no pus was aspirated. Histology revealed reactive adenoid tissue with no evidence of malignancy.

    Follow-up imaging after 8 weeks showed resolution of the collection but persistent bony changes, which resolved completely by 5-month follow-up. No further investigations were necessary once resolution was confirmed.1 The patient was seen in clinic and remained well.

    Retropharyngeal abscess can present insidiously with non-specific symptoms such as general malaise. However, neck pain and fever appear to be the most common symptoms.2

    Surgical intervention is not always indicated,3 and there is not always a strong correlation between CT and intraoperative findings.4

    Learning points

    • It is important to remember that seemingly well children may be hiding a life-threatening pathology.

    • Abnormal posture in children is a significant finding that needs a low threshold for further investigation.

    • CT neck with contrast is first-line investigation if a retropharyngeal abscess is suspected

    References

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      . Retropharyngeal abscess. BMJ Best Practice Jun 2016. http://bestpractice.bmj.com/best-practice/monograph/599/follow-up/recommendations.html (accessed 22 Dec 2016).
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      1. Craig FW,
      2. Schunk JE
      . Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics 2003;111(Pt 1):1394–8.
    3. ↵
      1. Lander L,
      2. Lu S,
      3. Shah RK
      . Pediatric retropharyngeal abscesses: a national perspective. Int J Pediatr Otorhinolaryngol 2008;72:1837–43. doi:10.1016/j.ijporl.2008.09.001
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      1. Grisaru-Soen G,
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      3. Aizenstein O, et al
      . Retropharyngeal and parapharyngeal abscess in children—epidemiology, clinical features and treatment. Int J Pediatr Otorhinolaryngol 2010;74:1016–20. doi:10.1016/j.ijporl.2010.05.030
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    View Abstract

    Footnotes

    • Contributors All authors, ZM, AE and KM, contributed to the conception and design, including reviewing the patient notes, investigations and images for the preparation of the case report. The article was drafted by ZM and revised by AE and KM. The final approval of the submitted version for publication was approved by ZM, AE and KM. All three authors agree to be accountable for the article.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.