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Clinical Problem Solving
May 2014

Spinal Lesions and Retropharyngeal Fluid in an Immunocompetent Patient

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Tulane University, New Orleans, Louisiana

Copyright 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Otolaryngol Head Neck Surg. 2014;140(5):473-474. doi:10.1001/jamaoto.2014.195

A man in his 30s presented to the emergency department with a 5-day history of minor neck swelling and a sore throat. The patient denied severe pain and dysphagia but mentioned neck tightness when turning his head. He also denied recent illnesses, fevers, chills, night sweats, contact with sick individuals, or recent trauma to the head or neck. His medical and surgical history was noncontributory. The patient had recently immigrated from Mexico and frequently visited immediate family there. The physical examination showed an afebrile, nontoxic-appearing man with stable vital signs and a muffled voice. He had no stridor and was able to tolerate his oral secretions. His neck was mildly full but not painful to palpation. His tonsils were grade 1+ in size, and the uvula was not deviated. Findings from pulmonary, cardiac, musculoskeletal, and skin examinations were benign. Results from flexible laryngoscopy showed submucosal edema of the lateral pharyngeal walls, posterior displacement of the epiglottis and patency of the endolarynx. Laboratory testing demonstrated a white blood cell count of 8700/μL (8.7 × 109/L) and a negative result for a rapid human immunodeficiency virus test. His chest radiograph did not demonstrate any abnormality, but contrast-enhanced axial, sagittal, and coronal computed tomographic (CT) images (Figure, A-C) showed a large retropharyngeal abscess with definite prevertebral and epidural space involvement. The abscess appeared to arise from the cervical spine, where osteolytic lesions could be seen at multiple vertebral levels. Near-complete vertebral collapse of C5 was present with a resulting kyphotic deformity. Sagittal T2-weighted magnetic resonance imaging (MRI) of the neck best demonstrated the prevertebral and epidural components of the abscess (Figure, D). A purified protein derivative (PPD) skin test was placed at time of admission.