Anesthetic management of tuberculous retropharyngeal abscess in adult.

Sir,

Airway management in retropharyngeal abscess is an anesthetic challenge due to distortion of airway anatomy and the possibility of spontaneous rupture of abscess leading to aspiration or stridor due to laryngeal edema.[1] We report the management of an adult with tuberculous retropharyngeal abscess.

A 38-year-old man with retropharyngeal abscess was posted for emergency drainage of abscess. He had a history of pain in the throat, difficulty in swallowing, and change in voice since 1 month. On clinical examination, there was a diffuse swelling below the chin, tenderness on the nape, and on the either side of the neck. Neck movements were limited. Mouth opening was restricted to one finger breadth. Erythrocyte sedimentation rate was 65mm/1st h, while other investigations were normal. Plain lateral X-ray of neck revealed a prevertebral soft tissue shadow [Figure 1]. Endoscopy showed unusual bulge in the throat [Figure 2]. Magnetic resonance imaging (MRI) of the neck showed a reduction in C3-C4 intervertebral disc height with abnormal anterior epidural soft tissue at C2-C5 compressing and displacing larynx and trachea anteriorly [Figure 3].

Figure 1

Plain lateral X-ray of neck showing increased prevertebral soft-tissue shadow

Figure 2

Endoscopy showing unusual bulge in the throat

Figure 3

MRI of the neck showing C3-C4 intervertebral disc is reduced in height and appears hyper intense and abnormal anterior epidural soft tissue at C2-C5 compressing and displacing larynx and trachea anteriorly

General anesthesia was planned after elective tracheostomy. Oxygen was supplemented with nasal catheter. Glycopyrrolate 0.2 mg was given intravenously. Keeping ready an emergency tracheostomy set, we decided to do needle aspiration under oral topical anesthesia to reduce the tense abscess. Patient was asked to gargle 15 ml of viscous lignocaine 2% 15 min before the surgery. The patient was made to lie down in Trendlenberg position and needle aspiration of the abscess done. Aspirated fluid was like pus of cold abscess and therapeutic needle drainage of the abscess was planned. Tracheostomy was not needed as the patient was comfortable after aspiration. Patient was put on antitubercular therapy.

Tuberculosis of the cervical spine is unusual and can present as retropharyngeal abscess and/or neurological complications. The method to secure the airway, in such a case, depends on the site and size of the collection of abscess. The described methods are tracheostomy or fiberoptic intubation performed under local anesthesia. Tracheostomy is the safest way to secure the airway.[3] The choice between tracheostomy and fiberoptic intubation can sometimes be made by reference to computerized tomography or MRI scan, to demonstrate the position of the abscess and preparation for an emergency tracheostomy must be made.[2] However, performing tracheostomy is difficult due to distortion of the airway anatomy.[1] Recent reports have shown that needle aspiration of tuberculous retropharyngeal abscess and antitubercular therapy is a useful alternative approach.[4] A clinician with less expertise in airway management can avoid an airway mishap by simple needle aspiration.