RETROPHARYNGEAL ABSCESS WITH MEDIASTINITIS REQUIRING VIDEO-ASSISTED THORACOSCOPIC SURGERY

Abstract

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Retropharyngeal abscesses are rare in adults. We present a case of anterior and posterior mediastinitis and empyema secondary to retropharyngeal abscess requiring video-assisted thoracoscopic surgery (VATS) and median sternotomy. CASE PRESENTATION: A 58-year-old male with chronic obstructive pulmonary disease presented to the ED with 2 days of right sided pleuritic chest pain with associated worsening dyspnea on exertion, odynophagia/dysphagia, hoarseness, and night sweats over the past two weeks. He had two prior ED visits with milder symptoms where he was cleared by ENT and sent home with oral corticosteroids. No history of immunosuppression, recent drug use, or odontogenic procedures. He was afebrile, tachycardic, and saturating 95% on 2 L nasal cannula. Exam was significant for neck swelling with tenderness of the submandibular region and right chest wall along with expiratory coarse prolonged wheezes. Labs were notable for leukocytosis with neutrophilia and bandemia. He was started on corticosteroids and broad spectrum antibiotics. Computed tomography (CT) of the neck showed a rim enhancing hypodensity around the post cricoid region of the hypopharynx with extension into the anterior mediastinum (Figure 1). He had emergent incision & drainage by ENT and thoracic surgery where a Jackson-Pratt drain was placed. Repeat imaging revealed progression with a loculated empyema and mediastinal tracking which required VATS with right pleural decortication (Figure 2 & 3). Two days later, the patient's clinical status did not improve despite broad spectrum antibiotics and drainage and he required a median sternotomy with washout of the anterior/posterior mediastinal fluid collections and three chest tubes. Abscess cultures were positive for Streptococcus parasanguinis, Rothia mucilaginosa, and Candida glabrata. All drains were removed after minimal drainage. On discharge, he was requiring oxygen with exertion and went to a long term acute care hospital to continue broad spectrum antibiotics. DISCUSSION: Retropharyngeal abscess can be associated with high mortality and morbidity (1). It may be secondary to accidental penetrating trauma, iatrogenic, or spread of oropharyngeal infection (2). This case is unique in that there was no clear etiology for the retropharyngeal abscess. Deep neck infections tend to follow the path of least resistance of the well-defined cervical fascial planes and can lead to pericardial and pleural effusions. High index of suspicion should be entertained for patients presenting with fevers, sore throat, and dysphagia. Contrast enhanced CT imaging is utilized to characterize the extent of the abscess. Management typically requires surgical intervention and intravenous antibiotics. CONCLUSIONS: Descending mediastinitis can be life-threatening if not diagnosed promptly. Early intervention with surgical management and antibiotics is vital to improved outcome. Reference #1: Jain H, Knorr TL, Sinha V. Retropharyngeal Abscess. In: StatPearls. StatPearls Publishing; 2020. Accessed May 30, 2020. http://www.ncbi.nlm.nih.gov/books/NBK441873/ Reference #2: Mark R, Song S, Mark P. Taking heed of the ‘danger space’: acute descending necrotising mediastinitis secondary to primary odontogenic infection. Case Rep. 2018;2018:bcr-2018-225019. doi:10.1136/bcr-2018-225019 DISCLOSURES: no disclosure on file for Frank Ajatta; No relevant relationships by Venkata Bandi, source=Web Response No relevant relationships by Lorraine Cornwell, source=Web Response No relevant relationships by Kalpalatha Guntupalli, source=Web Response My spouse/partner as a Consultant relationship with Abbvie Please note: $1-$1000 Added 05/27/2020 by Ebtesam Islam, source=Web Response, value=Consulting fee No relevant relationships by Sarah Jaroudi, source=Web Response