A case of mediastinitis secondary to retropharyngeal abscess.

A 50 year old male patient who consumed chicken bone soup, 4 days back, presented with dysphagia, high grade fever with chills, shortness of breath and swelling in face, neck and upper chest. Patient was toxic and in respiratory distress with room air oxygen saturation of 83%, which increased to 92% with 6 lit of oxygen through simple face mask. Indirect laryngoscopy revealed a retro pharyngeal abscess and CT chest revealed Sub-cutaneous and mediastinal emphysema. The abscess was immediately drained and followed with parenteral anti-microbials and high flow oxygen theapy. Patient improved and was discharged after 12 days. This case was reported as, foreign body causing Retro-pharyngeal abscess is a very rare entity in this anti-biotic era especially leading to a very rare complication of mediastinitis and Pneumomediastinum is unusual.

Retropharyngeal abscesses are rare in adults. They occur mostly in immunocompromised patients or as a complication of foreign body impaction. In adults, retropharyngeal abscesses can occur as a result of local trauma, such as foreign body ingestion (fishbone), or instrumental procedures (laryngoscopy, endotracheal intubation, feeding tube placement, etc.), or in the particular context of an associated disease.[12] Here, we present a case of mediastinitis after rupture of retropharyngeal abscess, which occurred after chicken bone injury.

Case Report

A 50-year-old male patient presented with a history of consuming chicken bone soup, 4 days back. Since then, he had difficulty and pain during swallowing. 2 days later he developed high grade fever with chills, shortness of breath and swelling in face, neck and upper chest.

He had no chronic medical or surgical comorbid illnesses.

Clinical examination revealed subcutaneous emphysema in face, neck and upper chest and severe stridor. Patient was febrile, toxic and in respiratory distress with room air oxygen saturation of 83%, which increased to 92% with 6 l of oxygen through simple face mask.

Indirect laryngoscopy revealed a retro pharyngeal abscess [Figure 1].

Figure 1

Computed tomography chest-mediastinal emphysema

Treatment

Hypotension was managed with fluid resuscitation, vasopressors.

Due to impending airway compromise and respiratory arrest, abscess was drained immediately and the patient was put on antimicrobials. A post drainage computed tomography neck and chest revealed a subcutaneous emphysema and mediastinal emphysema. Patient was put on continuous high flow oxygen and supportive care was given.

Outcome and Follow-up

Patient steadily improved and was discharged after 12 days.

Discussion

Mediastinitis secondary to spread of infection from elsewhere has become rare in the antibiotic era.[3] The usual route of spread of oropharyngeal infections is via retropharyngeal space to mediastinum.[456] The mainstay of treatment for mediastinitis is open drainage via a cervical or thoracic approach.[34] In this particular case, the patient improved with retropharyngeal abscess drainage and antimicrobials and supportive care.