WhiteCoat

What’s the Diagnosis #2

A 27 year old patient has had a sore throat for the past 10 days. He received antibiotics from his primary care physician without a lot of improvement. He comes in on a Saturday because he is out of antibiotics and wants a refill.
He doesn’t appear uncomfortable. He doesn’t have any problems swallowing. No fever. He does have pain on the left side of his neck along a swollen lymph node. It hurts for him to turn his head to the left. On exam, his throat is red, but there is no pus and his airway is patent. There are several swollen and tender lymph nodes in the neck. He complains of pain turning his head to the left side. He doesn’t have any signs of meningitis. Nothing else seems abnormal on his physical exam.

Think about what your differential diagnosis would be and what you’d do to work the patient up … if anything.

Now look at the x-ray below. What is the calcified foreign body in the front of his neck? Are there any other abnormalities? What other test(s) would you do and who would you call?

Scroll down for answers and other pictures.

xray-lateral

The calcified foreign body in the front of the neck is actually the hyoid bone. Coroners look to see whether this bone is intact during autopsy since a broken hyoid bone suggests that strangling took place.

The neck x-ray shows prevertebral soft tissue swelling. Remember 7 mm at C2 and 22mm at C7. Got the diagnosis now?

Answer is retropharyngeal abscess. More about the diagnosis here and here.

CT scans of the neck below.

retropharyngeal-abscess-ct-1

retropharyngeal-abscess-ct-2

16 Responses to “What’s the Diagnosis #2”

  1. rlbates says:

    Very nice case presentation!

  2. Christine says:

    Very cool. How often do you see cases like this?

    • WhiteCoat says:

      Somewhat more common in young children because there are lymph glands in this area. By late childhood and into adulthood, the lymph glands atrophy, so retropharyngeal abscesses in adults are much less common.

  3. toni says:

    Nice catch.

  4. Nice case…nice images too!

  5. ee says:

    Very cool!

  6. What prompted you to go in that direction? It was scary to read because if I had been on ABT, had no fever and still had a sore throat with some pain when turning head, I probably would have thought just suck it up and take some ES tylenol. Pretty amazing story…

    • WhiteCoat says:

      One of the things I remembered from medical school was the saying that “bad things don’t get better.” Doesn’t always apply, but that, plus the patient’s apparent stoicism are what made me order the x-ray.

  7. ERP says:

    The key is if he has severe pain with turning the neck – that is in my opionion the symptom that makes me suspect these things.

    • WhiteCoat says:

      I initially thought it was a spasm or pain in the sternocleidomastoid muscle – the muscle was quite tender when I palpated it. The big swollen tender glands made me think more of an infectious cause.

  8. Nurse K says:

    My 9-year-old looked at the xray and said that his wisdom teeth had been removed.

    • WhiteCoat says:

      Smart kid.
      I’m honored to know that my blog has appeal to the future doctors of America.

      • Nurse K says:

        Hey, smart people can become nurses too ;-)

        I didn’t even know that my son knew what wisdom teeth were or where they should be located. He creeps me out sometimes.

  9. MBJ says:

    I have over the years seen two patients requiring intubation for airway obstruction related to dental abscesses.

  10. paul says:

    what space is that abscess in? parapharyngeal?

  11. hooman(medical student) says:

    I have two questione.is it a typical case?I think one of the common symptoms of this patient is odinophagia,but in this case we dont see it.
    what is your opinione about examinatione the hypopharynx whit meirror in the first step before using x.ray?

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