International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 271-275
Published Online November 2013 (http://www.scirp.org/journal/ijohns)
http://dx.doi.org/10.4236/ijohns.2013.26056
Open Access IJOHNS
Giant R etropha ryngeal Abscess in a Nigerian Adult
Following Fish Bone Throat Injury
Stanley B. Amutta1*, Daniel Aliyu1, Mohammed Abdullahi1, Mohammed Danfulani2,
Yunusa A. Mufutau3
1ENT Department, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2Radiology Department, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
3Psychiatry Department, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
Received August 26, 2013; revised September 25, 2013; accepted October 6, 2013
Copyright © 2013 Stanley B. Amutta et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Retropharyngeal abscess (RPA) is an uncommon disease entity that typically occurs in children under 5 years of age,
which has the potential to cause upper airway obstruction. Upper respiratory tract infection is the most common predis-
posing factor to RPA in children while cervical spine tuberculosis and trauma are the major aetiological factors in the
adult. We report a case of a 21-year-old Nigerian farmer with giant retropharyngeal abscess following fish bone throat
injury causing life-threatening upper airway obstruction. The patient responded well to emergency tracheostomy, intra-
oral surgical drainage and empirical antibiotic therapy. We highlight the diagnostic and therapeutic challenges of man-
aging such a patient.
Keywords: Giant Retropharyngeal Abscess; Fish Bone; Tracheostomy; Antibiotic; Intra-Oral Drainage
1. Introduction
Retropharyngeal abscess (RPA) though an uncommon
disease entity occurs usually in children under the age of
5 years [1-3]. However, recent findings indicate that
adults could also be involved [4,5]. The involvement of
the airway results in upper airway obstruction which
could lead to life threatening condition thus, it is a surgi-
cal emergency. The pathological basis for the higher
prevalence in children is due to the loose aggregate of
lymph nodes in the prevertebral space which may be-
come infected with resultant suppuration. These lymph
nodes are not usually present in adults because they at-
rophy while the child grows; hence retropharyngeal ab-
scess is not a common disorder among adults. Upper
respiratory tract infection is the most common predis-
posing factor to RPA in children [3-6] while cervical
spine tuberculosis and trauma are the major aetiological
factors in adults [3-5,7]. Other factors reported among
adults include diabetes mellitus [4] and human immuno-
deficiency virus (HIV) infection [7,8].
In a retrospective study in Ibadan, Nigeria [9], thirty
cases of retropharyngeal abscess were reported compris-
ing of 25 children and 5 adults. In that study, adult pa-
tients presented early while the children presented late. A
recent study from north central Nigeria reported RPA
due to fish bone but in a child [5]. We report a case of
giant retropharyngeal abscess in a 21-year-old subsis-
tence adult Nigerian farmer following fish bone throat
injury while highlighting the diagnostic and therapeutic
challenges of managing this type of patient.
2. Case Report
A 21-year-old subsistence farmer, presented at the Emer-
gency department of our hospital with 10-day history of
progressive sore throat, persistent low grade fever, neck
pain, dyspnoea, odynophagia and voice changes. There
was an antecedent history of fish bone impaction in the
throat two weeks prior to the onset of symptoms however;
the patient did not seek medical intervention. He was
unable to take both fluid and solid diet at presentation.
There was associated hoarseness and inability to sit or
stand without support. There was no history suggestive
of recurrent tonsillitis, dental infection, chronic cough,
night sweats or contact with a patient with pulmonary
tuberculosis and was not a known diabetic.
*Corresponding author.

S. B. AMUTTA ET AL. 272
Examination revealed an acutely ill-looking young
man in painful and respiratory distress, was dehydrated,
in stridor, with inaudible hoarse voice, limitation of neck
movement and also had trismus. He was not pale and
there was no significant peripheral lymphadenopathy.
There was no impairment in the mental state. Vital signs
were blood pressure of 90/60 mmHg, pulse rate of 96/
minute, respiratory rate of 30/minute and temperature
was 37.4˚C.
Ear and nasal examinations were essentially normal.
There was moderate trismus and poor oral hygiene, but
there was no evidence of dental infection. Examination
of the posterior pharyngeal wall was difficult due to
trismus and neck pain. There was remarkable decreased
air entry in both lung fields with wide spread transmitted
sounds. Heart sounds were I and II were essentially nor-
mal. Abdominal and central nervous system examina-
tions were normal and there was no cervical spine ten-
derness or gibbous deformity.
A provisional diagnosis of upper airway obstruction
secondary to deep neck space infection possibly secon-
dary to retropharyngeal abscess was made to rule out
peritonsillar and parapharyngeal abscesses. The patient
had X-ray of the neck with a conventional X-ray machine
Silhouette VR GE 2007 using automatic processor,
Colenta 2007 model 2226680/MS18s serial number
48202HL6, with inherent filtration of 0.6 mmAL and
additional filtration of 1.0 mmAL. The X-ray soft tissue
neck lateral view showed the reversal of the normal cer-
vical curvature with a huge soft tissue mass in the retro-
trachael space displacing the trachea anteriorly with sig-
nificant associated luminal narrowing. This soft tissue
mass measured about 65 mm at its widest point at the
level of 4th cervical vertebra (C4). The anteroposterior
view also showed huge soft tissue mass around its mid
portion. No areas of calcifications or lucencies were
demonstrated within the soft tissue mass. Overall, fea-
tures of the X-ray of the neck were those of a huge
retropharyngeal mass lesion, presumably retropharyngeal
abscess. These radiological features further supported the
provisional diagnosis of RPA (Figure 1). The soft tissue,
bony framework of the chest, lung fields and heart ap-
peared normal on Chest X-ray. Patient could not do
computerized tomography (CT) scanning due to financial
constraints.
Other laboratory studies showed packed cell volume of
40%, random blood sugar 6.4 mmol/L, serum electro-
lytes, urea and creatinine were within normal limits.
Screening for HIV I and II using ELISA (enzyme linked
immunoabsorbent assay) was non-reactive. White blood
cell count was elevated and demonstrated neutrophilia
while the erythrocyte sedimentation rate (ESR) was 15
mm/hr Westergreen.
Patient was rehydrated and intravenous cefuroxime 1
Figure 1. Lateral view, soft tissue X-ray of the neck showing
grossly increased prevertebral soft tissue shadow delineated
by white arrows.
gram 12-hourly, metronidazole 500 mg 8-hourly; para-
cetamol 300 mg 8-hourly and diclofenac sodium 50 mg
8-hourly were administered. Emergency tracheostomy
was done under local anaesthesia infiltration with 2%
xylocaine 1:200,000 adrenaline to relieve the life threat-
ening upper airway obstruction and the procedure con-
tinued with administration of general anaesthesia via the
tracheostomy tube. He was then placed in Rose position
and the oropharynx was exposed with Davis-Boyle gag
frame.
Operative findings were grossly enlarged posterior
pharyngeal wall which was tense and fluctuant and 500
mls of thick pus under tension was drained via a vertical
incision. The abscess cavity was irrigated with warm
normal saline and a feeding nasogastric tube (NGT) was
passed. The specimen from the abscess cavity was sent
for microscopy, culture and sensitivity and Ziehl-Neelsen
(ZN) staining for acid-fast bacilli (AFB). The specimen
yielded florid pus cells, but no bacterial growth and the
ZN stain was negative for AFB.
Post operatively the patient had intravenous cefu-
roxime, metronidazole, paracetamol and diclofenac so-
dium for 72 hours, and this was changed to oral cefu-
roxime and metronidazole which were administered via
the NGT for further 7-days. He had NGT feeding for the
first five days post operative period, started feeding
around the NGT from the 6th day after the surgical
drainage, and the NGT was finally removed on the 16th
day after surgery as oral feeding was adequately restored.
He was decanulated on the 8th post operative day when
post operative lateral radiograph of the neck showed only
straightening of the cervical spine with significant reduc-
tion of the retrotrachael space, and reversal of the nar-
rowed airways in comparison with the previous examina-
tion (Figures 1 and 2). The retrotrachael space at the
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S. B. AMUTTA ET AL. 273
Figure 2. Lateral view, post operative soft tissue X-ray of
the neck with nasogastric tube in situ and resolution of the
increased prevertebral soft tissue shadow.
level of C4 was reduced to about 20 mm (Figure 2) and
no recurrence on follow-up visit.
3. Discussion
The retropharyngeal space is one of the deep neck spaces
with the skull base as the superior border, the inferior and
the posterior limits are the superior mediastinum and the
prevertebral fascia respectively while the posterior bor-
der of the pretrachael fascia forms the anterior border.
Laterally, it is bounded by the carotid sheath and it con-
tains lymph nodes [10]. RPA may present with life
threatening upper airway obstruction, as it was in our
index patient [1-5,9]. Delay in the diagnosis of RPA is
often associated with other serious morbidities such as
aspiration pneumonia, sepsis, mediastinitis, empyema
and erosion of carotid artery [4,6,11]. The diagnosis is
usually made based on clinical symptoms, signs as well
as radiological features. However, these symptoms and
signs are non-specific to retropharyngeal abscess [6]. In
adults RPA may present with fever, sore throat, odyno-
phagia, dysphagia, drooling, and dyspnoea and muffled
voice. Signs of the disease include limitation of neck
movement, torticolis, cervical tenderness, bulging poste-
rior oropharyngeal wall, increased prevertebral soft tissue
shadow on plain lateral neck X-ray and contrast en-
hanced CT scanning may demonstrate the extent of the
abscess [1,2]. Our patient presented with most of these
clinical and plain X-ray features of RPA. The grossly
increased prevertebral soft tissue shadow was the indica-
tor for the provisional diagnosis of RPA in this index
case. The use of X-ray for this purpose is limited and
controversial because of its inability to differentiate in-
flammatory oedema from abscess.
It was not possible to delineate the extent of the ab-
scess or involvement of other deep neck spaces before
the surgical drainage. Contrast enhanced CT scanning
would have made this possible, [1-4,6] but it was not
done to avoid further delay of the worsening severe up-
per airway obstruction and besides, the patient could not
afford to pay for the CT scan at presentation which costs
₦20000.00 (about $130.00) as he was not covered by any
health insurance because he was not in federal civil ser-
vice as this is the main agent providing health insurance
cover for Nigerians. Furthermore, in a resource limited
society with prevalent poverty, clinical history, physical
examinations and X-ray findings still form the basis for
the diagnosis of RPA [5] as in this case report.
It is important to consider the differential diagnosis in
a patient with suspected RPA before initiating any treat-
ment options. Congenital cystic lesions like infected
branchial cleft cyst, thyroglossal duct cyst and cervical
thymic cyst may mimic or be the source of a deep neck
abscess [12]. Incision and drainage make definitive exci-
sion of these cysts cumbersome. Additionally, malignant
head and neck cancers, and lymphoma may metastasize
to cervical lymph node and present with deep neck space
infection or abscess [12]. Therefore, high index of suspi-
cion is suggested for prompt diagnosis. Epiglottitis, sia-
loadenitis and infected laryngocele have been implicated
in the development of deep neck abscesses [13]. Calcific
retropharyngeal tendinitis and RPA [14] have similar
clinical features. Contrast enhanced CT scan features of
calcific retropharyngeal tendinitis includes increased
prevertebral soft tissue mass with calcification and it
does not require surgical drainage as it responds very
well to non-steroidal anti-inflammatory drugs and steroid
[14].
Treatment of RPA includes rehydration, intravenous
antibiotic and surgical drainage under general anaesthe-
sia administered by an experienced anaesthetist [1,2,12,
15,16]. Provision of adequate airway is a priority in a
patient with RPA and life threatening upper airway ob-
struction; hence, the patient in this report had emergency
tracheostomy under local anaesthesia before the surgical
drainage of the abscess. This is in agreement with other
reports [3,15]. In addition, tracheostomy may be used in
the absence of upper airway obstruction to prevent acci-
dental rupture of the abscess during intubation by an in-
experienced anaesthetist [3] and in addition, compro-
mised airways resulting from post operative oedema is
another indication for routine tracheostomy in these pa-
tients.
The surgical approaches for drainage of RPA are tran-
soral, transcervical, transnasal endoscopic or combined
approach [15]. The transoral approach is usually recom-
mended for acute RPA and those located medially [15].
This approach yields good result and avoids a neck inci-
sion and the subsequent scar [15] however it requires
administration of general anaesthesia.
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S. B. AMUTTA ET AL. 274
Trans-nasal endoscopic guided needle aspiration is
suitable for very small and unilocular abscesses [15-17].
It has the advantage of avoiding general anaesthesia and
probable injury to local structures such as blood vessels
and nerves [17], although repeated aspirations may be
required to achieve complete resolution. Additionally, it
is not appropriate for large abscesses with potential for
airways obstruction [17]. Cold RPA from tuberculosis is
drained by external transcervical approach to prevent
dissemination of the infection into the gastrointestinal
tract. Besides, large or recurrent acute RPA that extend
behind carotid artery can be safely approach by the trans-
cervical route [17] to limit bleeding. Disadvantages are
neck scar and injury to surrounding structures.
The main aetiological factors of RPA in adult are
trauma induced by foreign bodies, iatrogenic, orodental
infection and tuberculosis [3,4,6-8]. Fish bone injury was
the responsible agent in our index patient. It is important
to note that the patient did not seek medical help until
complications set in thus compelling him to come to the
hospital. Ignorance coupled with poverty and poor access
to specialist otolaryngologic service was some of the
reasons that hindered the patient from seeking medical
care early. In contrast to this, adults with RPA in another
report from Western Nigeria presented early [9]. The
high level of awareness, better economic environment
and exposure to western education in western region of
Nigeria may be the explanation for this difference.
Clinical conditions associated with impaired immunity
such as tuberculosis, diabetes mellitus and infection with
HIV which are relatively common in developing coun-
tries are sometimes associated with RPA [18-21]. The
patient in this report did not have destructive lesion of
the cervical vertebra and Ziehl-Neelsen staining of the
specimen smear for acid-fast bacilli was negative while
random blood sugar value was within normal range and
he was non-reactive to HIV I and II viruses.
The organisms frequently encountered in RPA are po-
lymicrobial including aerobes (group A β-haemolytic
streptococcus, staphylococcus aureus and haemophilus
influenza), anaerobes (gram negative cocci and bacter-
oides) [11,22]. The specimen from our patient yielded no
bacterial growth. This could be due to prior antibiotic
therapy from rural patent medicine shops which is a
common practice by our patients though inappropriate
culture technique and media for the isolation of anaer-
obes could be responsible.
The retropharyngeal abscess was described as giant
because it measured 65 mm in diameter and this so far
the biggest reported from our sub-region. However, we
could not verify if larger size has been reported else-
where. In an earlier report Ozbek et al., [3] reported a
giant RPA which was 61 mm in transverse diameter but
this is smaller than that reported in the present case.
The prognosis for patients with RPA is very good es-
pecially with early diagnosis and appropriate intervention.
However, with late presentation, delayed diagnosis and
in the presence of significant co-morbidities such as im-
munosuppression, HIV, tuberculosis, diabetes mellitus,
head and neck malignancies the prognosis may be poor.
Ridder et al. [12] reported 6 (2.6%) mortality among 234
cases over an 8-year period and the deaths were due to
sepsis and multiple organ failure. Overall, the patient in
this report responded very well to the tracheostomy, in-
tra-oral drainage and the broad spectrum antibiotics. He
was decanulated on the 8th day post surgical drainage and
was discharged home after achieving full recovery and
no recurrence on follow-up visit.
4. Conclusion
The prognosis of giant retropharyngeal abscess is good
with tracheostomy, surgical drainage and medical inter-
vention as seen in this case report.
REFERENCES
[1] B. Hartley, “Cervicofacial Infection in Children,” In: G.
Michael, Ed., Scott’s Browns Otorhinolaryngology, Head
and Neck Surgery, 7th Edition, Hodder Arnold, London,
2008, pp. 1213-1214.
http://dx.doi.org/10.1201/b15118-107
[2] L. W. Tom and I. N. Jacobs, “Diseases of the Oral Cavity,
Oropharynx, and Nasopharynx,” In: B. James, Ed.,
Ballenger’s Otorhinolaryngology, Head and Neck Sur-
gery, 16th Edition, BC Decker Inc., Hamilton, 2003, pp.
1039-1040.
[3] C. Ozbek, S. Dagli, E. E. U. Tuna, O. Ciffci and C. Oz-
dem, “Giant Retropharyngeal Abscess in an Adult as a
Complication of Acute Tonsillitis: Case Report,” Ear
Nose Throat Journal, Vol. 88, No. 11, 2009, p. E20.
[4] S. B. Sharma and P. Hong, “Ingestion and Pharyngeal
Trauma Causing Secondary Retropharyngeal Abscess in
Five Adult Patients,” Case Report in Emergency Medi-
cine, Vol. 2012, 2012, Article ID: 943090.
[5] O. A. Afolabi, J. O. Fadare, E. O. Oyewole and S. A.
Ogah, “Fish Bone Foreign Body Presenting with an Acute
Fulminating Retropharyngeal Abscess in a Resource-
Challenge Centre: A Case Report,” Journal of Medical
Case Reports, Vol. 5, 2011, p. 165.
http://dx.doi.org/10.1186/1752-1947-5-165
[6] A. Harkani, R. Hassani, T. Ziad, L. Aderdour, H. Nouri,
Y. Rochdi and A. Raji, “Retropharyngeal Abscess in
Adults: Five Case Reports And Review of the Literature,”
The Scientific World Journal, Vol. 11, 2011, pp. 1623-
1629. http://dx.doi.org/10.1100/2011/915163
[7] E. Mevio, P. Calabro, F. De Paoli, A. Maccabruni and G.
Michelone, “Unusual Extracranial Complications of Otitis
Media in a Young HIV Patient: Retropharyngeal and
Mouret’s Abscess,” Revue de Laryngologie-Otologie-
Rhinologie, Vol. 119, No. 3, 1998, pp. 199-201.
[8] R. Meyer, S. Argarwal and I. Singh, “Tuberculous Retro-
Open Access IJOHNS

S. B. AMUTTA ET AL.
Open Access IJOHNS
275
pharyngeal Abscess in an HIV Patient,” Hong Kong Medi-
cal Journal, Vol. 12, No.6, 2006, pp. 483-485.
[9] O. G. Nwaorgu, P. A. Onakoya, J. A. Fasunla and T. S.
Ibekwe, “Retropharyngeal Abscess: A Clinical Experi-
ence at the University College Hospital Ibadan,” Nigeria
Journal of Medicine, Vol. 14, No. 4, 2005, pp. 415-418.
[10] C. R. Jennings, “Surgical Anatomy of the Neck,” In: G.
Michael, Ed., Scott’s Browns Otorhinolaryngology, Head
and Neck Surgery, 7th Edition, Vol. II, Hodder Arnold,
London, 2008, pp. 1744-1745.
http://dx.doi.org/10.1201/b15118-153
[11] I. Brook, “Microbiology and Management of Peritonsillar,
Retropharyngeal Abscess and Pharyngeal Abscesses,”
Journal of Oral & Maxillofacial Surgery, Vol. 62, No. 12,
2004, pp. 1545-1550.
http://dx.doi.org/10.1016/j.joms.2003.12.043
[12] G. J. Ridder, K. Technau-Ihling, A. Sander and C. C.
Boedeker, “Spectrum and Management of Deep Neck
Space Infections: An 8-Year Experience of 234 Cases,”
Otolaryngology—Head and Neck Surgery, Vol. 133, No.
5, 2005, pp. 709-714.
http://dx.doi.org/10.1016/j.otohns.2005.07.001
[13] J. Stalfors, A. Adielsson, A. Ebenfelt, G. Nethander and T.
Westin, “Deep Neck Space Infections Remain a Surgical
Challenge. A Study of 72 Patients,” Acta Otolaryngology,
Vol. 124, No. 10, 2004, pp. 119-1196.
http://dx.doi.org/10.1080/00016480410017864
[14] K. Terao, T. Kusunoki, K. Mori. K. Murata and K. Doi,
“A Case of Calcific Retropharyngeal Tendinitis: The Sig-
nificance of Early Diagnosis,” Ear, Nose and Throat
Journal, Vol. 92, No. 2, 2013, pp. 74-83.
[15] P. J. Schuller, M. Cohen, J. Greve, C. Plettenberg, J.
Chereath, M. Wagemann, et al., “Surgical Management
of Retropharyngeal Abscess,” Acta Oto-Laryngologica,
Vol. 129, No. 11, 2009, pp. 1274-1279.
http://dx.doi.org/10.3109/00016480802642088
[16] D. K. C. Wong, C. Brown, N. Mills, P. Spielmann and M.
Neeff, “To Drain or Not to Drain-Management of Pediat-
ric Deep Neck Abscesses: A Case Conrol Study,” Inter-
national Journal Pediatric Otorhinolaryngology, Vol. 76,
No. 12, 2012, pp. 1810-1813.
http://dx.doi.org/10.1016/j.ijporl.2012.09.006
[17] K. Chang, Y. Chen, S. Hao and S. Chen, “Ultrasound-
Guided Closed Drainage for Abscesses of the Head and
Neck,” Otolaryngology—Head and Neck Surgery, Vol.
132, No. 1, 2004, pp. 119-124.
http://dx.doi.org/10.1016/j.otohns.2004.08.004
[18] M. P. Kamath, K. M. Bhojwani, S. U. Kamath, C. Maha-
bala and S. Argawal, “Tuberculous Retropharyngeal Ab-
scess,” Ear Nose Throat Journal, Vol. 86, No. 4, 2007, pp.
236-237.
[19] H. A. Soub, “Retropharyngeal Abscess Associated with
Tuberculosis of Cervical Spine,” Tubercle and Lung Dis-
ease, Vol. 77, No. 6, 1996, pp. 563-565.
http://dx.doi.org/10.1016/S0962-8479(96)90057-X
[20] A. Christoforidou, S. Metallidis, P. Kollaras, A. Agathange-
lidis, P. Nikolaidia, V. Vital and K. Markou, “Tubercu-
lous Retropharyngeal Abscess as a Cause of Oropharyn-
geal Dysphagia,” American Journal of Otolaryngology-
Head and Neck Medicine and Surgery, Vol. 33, No. 2,
2012, pp. 272-274.
[21] C. Patil, R. Kharat, P. Deshmukh, S. Singhal and B.
D’Souza, “Tuberculous Retropharyngeal Abscess without
Cervical Spine TB,” Asian Pacific Journal of Tropical
Medicine, Vol. 4, No. 3, 2011, pp. 251-252.
http://dx.doi.org/10.1016/S1995-7645(11)60080-1
[22] H. S. Sharma, D. S. Kurl and M. Hamza, “Retropharyn-
geal Abscess: Recent Trend,” Auris Nasus Larynx, Vol.
25, No. 4, 1998, pp. 403-406.
http://dx.doi.org/10.1016/S0385-8146(98)00007-8