Diagnosis and Management of Retropharyngeal Abscess Caused by Cervical Potts Disease

Abstract
Introduction: Retropharyngeal abscess due to cervical Pott's is rare case. Retropharyngeal abscess
caused by cervical Pott's should be suspected if there is any cervical vertebra destruction as well as
the presence of symptoms and signs of retropharyngeal abscess. Retropharyngeal abscess due to
Pott's cervical disease treated by intraoral incision and explorations of retropharyngeal abscess.
While the Pott's cervical disease can be treated with debridement and reconstruction of the
vertebrae along with the treatment for tuberculosis. Case report: Reported a case of
retropharyngeal abscess due to Pott's cervical disease and treated with an anterior cervical
discectom fusion, also incision and exploration of the retropharyngeal abscess intraorally.
Conclusion: Diagnosis of retropharyngeal abscess due to cervical Pott's disease established based
on anamnesis, physical examination,blood workups and imaging. The management of this disease
are both pharmacologically and surgery
Keywords: Retropharyngeal abscess, Pott's cervical, incision and exploration abscess, anterior
cervical dissectomy fusion

Introduction

Retropharyng abscess is an abscces formed between pharynx posterior wall and pre
vertebrae fascia. Spinal Potts or spondylitis tuberculosis (TB) is vertebrae tuberculosis that can
cause osteomyelitis in vertebrae 1. In Spinal Potts, the most common affected area is lower thoracic
vertebrae, lumbar, and cervical 2-4. Involvement of cervical vertebrae in Spinal Potts is about 2-
3%. Involvement cervical vertebrae (C) 2-7 is 3-5% and atlantoaxial articulation is less than 1%
among all spinal Potts case 6. Spinal Potts affects two or more adjacent corpus vertebraes 1,7.
Spinal Potts is mostly originated from lungs or abdomen 6.

Retropharyngeal asbces caused by Potts cervical is not a common finding 8-10.

Retropharyngeal abces caused by cervical Potts is suspected if vertebrae destruction is present and
followed by symptoms of retopharyngeal abscess 8.

Retropharyngeal abscess from cervical Potts is treated with incision and intraoral
exploration 1, 2, 10, 11. Meanwhile for cervical Potts, debridement, vertebrae reconstruction, anti TB
drugs can be done as treatment. If cervical Potts is diagnosed early, this disease can be treated
conservatively using anti TB drugs 1

Etiology
Acute retropharyngeal abscess among children is originated from infection of
retropharyngeal gland 1. Meanwhile among adults, acute retropharyngeal abscess is caused by local
trauma, foreign body, or tooth infection 12. Chronic retropharyngeal abscess could be originated
from cervical Potts and it affects all ages 1.

Anatomy of deep neck fascia

Neck fascia is categorized into superficial neck fascia and deep neck fascia. Deep neck
fascia is divided into three layers of component such as superficial layer, media, and deep layer
(Figure 1). Superficial neck fascia is located underneath head skin and neck, extends from tip of the
head to shoulders, armpit, and deltopectorial 13, 14. This layer consists of fat tissue, sensory nerve,
superficial capillary such as posterior jugular vein (v) and external jugular vein, platisma muscle
(m) and expression muscle 14.

Figure 1. Sagittal view of neck showing deep neck space

Cervical fascia is connective tissue 13. Cervical fascia inside superficial layer is called
investing layer. On the posterior side, this fascia adheres to superior nuchal line, neck vertebrae
nuchal ligament, and mastoid processes. This fascia splits and then cover sternocleidomastoid
muscle and trapezius muscle, elongated to anterior. Fascia then elongated to anterosuperior and
adheres to inferior zigomaticum arch. Fascia then elongated to inferior and cover superficial parotid
glands, submandibular glands and mastication muscle 14. Expansion to inferior involve hyoid bone,
acromion, clavicle, and scapula 13, 14. Medial cervical fascia is divided into muscle and visceral.
Muscle goes around strep muscle (sternohyoid muscle, sternothyroid muscle, thyrohyoid muscle,
and omohyoid muscle). Visceral has two side, pretracheal fascia and buccopharyngeal fascia.
Pretracheal fascia will cover trachea and buccopharyngeal located on posterior side of esophagus
separates esophagus and cervical fascia inside deep layer and form anterior wall of retropharyngeal
space 13, 14. Buccopharyngeal space will form raphe in posterior midline, adheres to alar of cervical
fascia in deep layer 14. Cervical fascia inside deep layer which covers trachea and esophagus fuses
with pericardium connective tissue on superior mediastinum 13.

Cervical fascia in deep layer also called prevertebrae fascia, consists of prevertebrae and alar
13, 14
. Prevertebrae has cervical vertebrae, phrenic nerve (n) and paraspinosus muscle 13. This fascia
extends from base of cranium to coccyx, forms anterior wall of prevertebrae space. Lateral and
posterior of vertebrae adhere to transversal spinosus process. Alar is located between prevertebrae
in posterior and buccopharyngeal fascia from visceral in anterior middle part of deep fascia and
separate danger space with retropharyngeal space. This layer extends from cranial base to second
thoracic vertebrae 13, 14.

Retropharyngeal space, danger space, and prevertebrae space.

Retropharyngeal space extends from cranial base to tracheal bifurcation in anterior

mediastinum. This space is located medial of carotid sheath, anterior of danger space and located
posterior of buccopharyngeal fascia. In this space, Rouviere lymph nodes is found 13, 14.

Danger space is located between prevertebrae space with retropharyngeal space, extends
from cranial base to diaphragm. Lateral of this space is traverses vertebrae process. This space often
get infection from retropharyngeal space, parapharyngeal, and prevertebrae 13, 14.

Prevertebrae space extends from the base of cranial to coccyx, with vertebrae corpus as
posterior margin, danger space on anterior, and transverses pocess on lateral. Neuromuscular
component in this space includes vertebrae capillary, phrenic nerve, and brachial plexus. Infection
in this space is originated from vertebrae (Spinal Potts) or penetrating injury 13, 14.

Diagnosis of retropharyngeal abscess

Retropharyngeal abcess can be made with anamnesis, physical examination, and imaging.
1. Anamnesis
Retropharyngeal abscess symptoms such as difficulty and pain during swallowing, accumulation of
saliva in the mouth, humming sound, and pain in the neck 2, 12.
2. Physical exam
Accentuation is found along pharyngeal posterior wall 10. Cervical adenopathy, high temperature,
and neck stiffness are present 13.
3. Radiology
Lateral neck x-ray can help in diagnosing retropharyngeal abscess if these findings present:
prevetebrae tissue thickening, air fluid level in soft tissue, and loss or decrease of cervical vertebrae
arch 15. Computed tomography of the neck is sensitive in diagnosing retropharyngeal involvement if
central hypodense imaging surrounded by thickening circumference area is visible 1.
4. Aspiration
Aspiration with spinal needle number 18 will strengthen the diagnosis 4, 13. Aspiration specimen can
be cultured to identify the bacteria 13.

Treatment
Airway control before drainage can be done with endotracheal intubation if there's no
complication. Tracheostomy is suggested in big abscess because the risk of rupture and abscess
aspiration 13, 14.

In the case with abscess above hyoid bone and easy to be seen, this abscess can be evacuated
intraoral 12. This procedure is done with Rose position. In a patient with multiple involvement of
deep neck fascia, or with difficulty in visualizing the abscess, abscess drainage can be done
externally 13, 14. In some cases, to perform an adequate drainage in recurrent abscess, combination of
intra oral incision and cervical can be done 16.
Spondylitis TB (Spinal Potts)
Spinal Potts is 50% of all TB extrapulmonal. Lower thoracic and thoracolumbar area is the
most common infected location, followed by lumbar and cervical area 17.

Diagnosis
Spinal Potts is hard to diagnose. Diagnose is established through anamnesis, physical exam,
lab findings and imaging 4, 7
1 Anamnesis and physical exam
Early symptoms of Spinal Potts is not specific. The most common symptom is back pain 7, 17, 18.
Presence of torticalist can help in diagnosing involvement of cervical vertebrae 7.

Neurological symptoms in Spinal Potts is about 23-76% 17. Neurological deficit occurs
because abscess mechanical pressure in spinal chord, granulated tissue, necrotic debris, and
sometimes spinal artery thrombosis 5, 17. Deformity and neurological deficit is complication of
spinal Potts and intervention is needed 17.

Anterior spinal column is often involved in Spinal Potts. Discus destruction or adjacent
vertebrae corpus causes kyphosis and leads to knuckle deformity if one vertebrae is collapse,
gibbous deformity (if 2 or 3 vertebraes are collapse), or global kyphosis (if multiple adjacent
vertebraes are collapse) 6, 17

2. Imaging
Anteroposterior and lateral spinal imaging can be use in early evaluation of Spinal Potts.
On early stages of Spinal Potts, Rontgen often shows normal findings, and as time goes by
vertebrae discus involvement and depletion of vertebrae end plate become visible 6, 17. On the late
stage, progressive destruction causes vertebrae to collapse and kyphosis is visible. X-ray can show
soft tissue with abscess. Calcification in abscess is a diagnostic value in Spinal Potts 17.

CT scan can be used to evaluate bone destruction area and to differentiate spinal problem
caused by inflammation, abscess, and bone material or discus 17. Calcification in abscess is
diagnostic point in Spinal Potts 6.

Magnetic Resonance Imaging (MRI) has important role in diagnosing Spinal Potts with
sensitivity and specificity up to 96% and 94% 7. MRI shows adjacent corpus destruction,
intervertebrae discus destruction, vertebrae corpus edema, and prevertebrae, paravertebrae, or
abscess. MRI has high accuracy in differentiating granulation tissue and abscess 6.

3. Lab finding
ESR and C-reactive protein (CRP) are sensitive inflammation marker to monitor response of
treatment 7, 17.

4. Biopsy
Biopsy is gold standard in diagnosing Spinal Potts. Sample can be obtained with CT or C-
arm in Spinal Potts without complication and can be obtained during surgery 17, 19. Classic
histological finding in Spinal Potts such as caseous necrotic, granuloma epitheloid cell and
Langerhan cell 17.

Treatment
Spinal Potts is treated with conservative and surgical method . Conservative treatment is
indicated if neurological deficit, spine instability, sever pain, or high risk patients for surgical are
absent 7.

Other treatment is surgery. Main purpose of surgery is to decompress spinal canal and
stabilize vertebrae in patient with neurological deficit, tissue debridement including paravertebrae
abscess drainage, sampling for microbiology, and histology investigation 7.

1 Abscess drainage
Recently, isolated abscess drainage rarely become indication of surgery since pharmacological
therapy can eliminate abscess. If difficulty of swallowing is present, abscess drainage is indicated 17.
2. Debridement
Debridement is not the most preferred procedure because it doesn't prevent deformity and stabilize
vertebrae 17, 19. Beside, debridement doesn't help healing process 17.
3. Anterior debridement, decompression, and fusion
TB damages intervertebrae corpus and discus, anterior approach will allow direct access to
pathological tissue and ideal for debridement and defect reconstruction. In lower cervical Potts and
cervicothoracal Spinal Potts, anterior debridement and fusion are gold standard. 17

Cervical Potts Retropharyngeal Abcess Pathogenesis

Spread of infection from cervical into retropharyngeal space can occur through anterior
longitudinal ligament 15. Also, spread of infection can occur through retropharyngeal lymph node 5,
10
.

In Cervical Potts, debris forms liquid accumulation called cold abscess. Exudate in cold
abscess consists of leucocyte, caseous, bone fragments, and bacilli tubercle. In the course of illness,
one or more vertebrae corpus can be destructed and collapse 20. This condition will lift up anterior
longitudinal ligament 21. Then this debris will be pushed out and spread into retropharyngeal
space.22

Treatment of Cervical Potts Retropharyngeal Abscess

Retropharyngeal abscess treatment caused by Cervical Potts is treated with anti TB drugs
and abscess drainage. Drainage can be performed with intraoral approach, external, and
combination 4.

CASE REPORT
A 59 years old came to Emergency Department (ED) RSUP DR M DJAMIL Padang on
April 17, 2016 with chief complaint of swallowing difficulties that getting worse in 1 week before.
Patient was consulted from Internal Medicine Department with diagnose of disseminated TB,
suspected pulmonary TB, lymphadenitis TB, laryngitis TB, suspected spondylitis TB and
malnutrition. The complaint has been occured since 1 month before, but patient was still able to eat
soluble foods. There were stiffness and pain in neck movement that continuously happened 5
months before. There was nocturnal sweating, and weight loss more than 5 kg in 3 months.
Coughing more tham 2 weeks without sphlegm. There was no difficulty in opening the mouth nor
shortness of breathing. There was a history of lump on the right neck and has been operated on
Agustus 2015, with the results of specific chronic inflammation. Patient has been treated with TB
drugs since1 week ago from a specialist of Internal Medicine. No history of bone malformation or
history of surgery around throat area. There was no family history of TB.
On general examination, general condition were weak, vital signs within normal range. On
the physical examination of the neck, there were no stridor found, and no retraction found on thorax
examination. On ENT examination ear and nose within normal range. On oral examination there
were no trismus found. On throat examination; symmetical pharyngeal arcus, uvula on the middle,
T1-T1 tonsil, posterior pharyngeal wall was implanted and not hyperemic (Fig 2). On
submandinular examination, the mandibular angle was palpable. On right side neck examination,
level III lymphadenopathy was obtained, no tenderness nor pus out from the fistula. There was a
gibbus in the cervical vertebrae
The lateral cervical x-ray examination showed soft tissue thickening on the retropharyngeal
and retrotracheal area, the curvature of cervical vertebrae appeared to be straight, narrowing of
intervertebral disc space on C5-6 Vertebrae, destruction was seen on C5-5 vertebrae, and
calcification of nuchal ligament was also seen. Conclusion was suggestive of retropharyngeal
abcess and spondylosis with calcification of nuchal ligament (Fig. 3)
The blood test results were hemoglobin 10,2 g%, leukocytes 9000 / mm3, platelets
299.000 / mm3, 32% hematocrite, erythroscyte sedimentation rate (ESR) 39 mm / hr, PT 12.3
seconds, APTT 48.7 seconds. Ureum 12 mg / dl, creatinine 0.4 mg / dl. Blood glucose 94 mg / dl.
Total protein 5.7 g / dl, Albumin 2.4 g / dl, globulin 3.3 g / dl. Sodium 132 mmol / L, potassium 3
mmol / L, chloride 107 mmol / L. Impression was mild anemia, increased ESR, decreased total
protein, decreased albumin and increased globulin. The patient then performed aspiration and
obtained 10 cc of pus.

The patient were diagnosed with retropharyngeal abcess, lymphadenitis TB, vertebaral
TB, and suspected pulmonary TB. The patient was then undergo aspiration and obtained 30 cc of
pus. Patient were consulted to the Orthopaedic Department, treated together with ENT department,
antibiotics and analgesic were given in accordance with orthopaedic department, and positioned in
Tredelenberg position.

Consultation result from Orthopaedic Department:

On cervical examination, gibbus (+) was found, no tenderness and pain. Cervical
movement was limited due to the pain. On extremity examination there were decreased muscle
strength in upper and lower extrimities and hipoesthesia as high as C5 below. On cervical
examination, there were an impression of C5-6 destruction and abcess (Fig. 4). Patient was
diagnosed with tetraparese et causa suspected spondylitis TB C5-6 with differential diagnosis of
SOL spinal cord. Patient was treated with the usage of rigid neck collar and was given RL
intravenously 28drops/min, cephalazim injection 2x1 gr intravenously (IV), paracetamole 3x500 mg
orally, Fixed Dose Combiantion (FDC) of anti-TB drugs (INH 1x400 mg, Etambutol 1x500 mg,
Rifampicin 1x450 mg, Pyrazinamide 1x500mg) continuously, and elective debreidement was
planned.
 From Internal Medicine Department, patient was treated with postero-anterior (PA)
thoracal x-ray examination and was treated together with Pulmonolgy subdepartment. PA thoracal
examination showed tracheal was located in the middle, no heart enlargement, both hillus were
thickening or dilated, there was a thickening on right suprahiler, bronchovesicular pattern was
within normal range, both diaphargms was smooth, both costophrenicus sinus were taper, the bones
were intact, and no destrcution and concluded with suspected lymphadenopathy (Fig. 4)

On April 18, 2016, patient complained of swallowing difficultiens and stiffness was
reduced, no shortness of breath and chest pain. On throat examination was obtained symmetrical
pharyngeal arch, uvula located in the middle, T1-T1 tonsil, a protrusion and hyperemic on posterior
pharyngeal wall. The previous treatment were continued and added dexamethasone injection 3x5
mg (IV) and ranitidine injectiom 2x50 mg (IV). Join operation was planned with Orthopaedic
Department for incision and exploration of retropharyngeal abcess and anterior cerviacl dissectomy
fusion.

On April 19, 2016, join operation of anterior cervical dissectomy fusion was done by
orthopaedic department while abcess incision and exploration was done by ENT department, with
the procedures as followed, patient lied in supine position on operating table under anesthesia.
Aseptic and antisepctic was done on operation field. Cervical level was identified using C-arm,
Smith Robinson approach was done from the left side, identification of carotid shearh, identification
of C5, C5 corpectomy, and graft was taken from left illiac. Mesh cage and graft was placed from
left illiac. Plate no. 46.5 was placed followed by stabilization test. Hemorragic was treated.
Operation was closed layer by layer and drain left. NGT was placed. Operation was followed by
Davis gag placement. Prolaps posterior wall was seen and aspiration was done with abocath no. 18,
and pus was obtained. Incision was done using sickle knife on the most prominent area, the wound
then dilated using clam, about 50 cc pus was out, Davis gag was removed. Operation was done.

Post-operative treatment was as previous and added with 100 mg tramadol on 500 cc drip,
post-operative onstruction were to observe vital, bleeding, and aspiration signs, patient was
positioned on Tredelenberg position, diet MC via NGT. Pus was administered to
microbiology laboratory and the rest of cervical bone was administered to PA laboratory

On April 20, 2016 (day one after operation).

The complaints were swallowing difficulties, no saliva mixed with blood, chest pain and
shortness of breath. On general condition, vital signs within normal range. Throat
examination showed symmetrical pharyngeal arch, uvula was located in the middle, T1-T1
tonsils, insicion wound was found on posterior wall of pharynx, blood flow and blood clot
Patient was diagnosed with post incision and exploration of retropharyngeal abcess + post
decompression and stabilization et causa spondylitis TB C5-6, Lymphadenitis TB and
suspected pulmonary TB. Previous treatment was continued. From internal medicine, patient
was suggested to to check BTA sputum. But the sputum couldn.t be obtained since the
patient had no phlegm cough complaint. On April 22, 2016, qualitative CRP examination
was done and the result was positive.

On April 25, 2016, microbiology laboratory examination found no bacteries growth. From
PA laboratory examination obtained microscopic view of connective tissue contained solid
lymphocytes, plasma cell, histiocytes, epithelioid cells, datya cell with horshoe-liked
 nucleus (resembled Langan cell), and a group of foamy marcopha. On the other part, there
was a PMN leucocytebetween necrotic mass, hyperemic capillers and bone sequester.
Patient was diagnosed with acute exacerbation of chronic granulomatous inflammation
might be due to specific process that hadnt been removed yet.

On April 29, 2016 (day 10 post operation), pain and swallowing difficulties was reduced, no
neck stiffness, shortness of breath, chest pain, and fever. On general condition, vital signs
was within normal range. Throat examination showed symmetrical pharyngeal arch, uvula
was located in the middle, T1-T1 tonsil. incision wound on posterior wall of pharynx, no pus
and blood discharge (Fig. 5). Patient was discharged. NGT was removed and given OAT
FDC first category and paracetamol 3x500mg orally.

DISCUSSION

Reported a case, a 59 years old woman was diagnosed with retropharyngeal abcess caused
by cervical Potts, disseminated TB, lymphadenitis TB, vertebral TB, and suspected pulmonary TB.
Patient was diagnosed based on anamnesis, physical examination, and imaging and laboratory
examination

Abscess retropharyngeal due to cervical Potts was diagnosed based on anamnesis,

physical examination, radiology examnitaion and aspiration. In this patients, there were clinical
manifestations, physical examination, radiology examination and aspiration that supported the
diagnosis.

In this case there were pain and swallowing difficulties. This is in accordance with classic
symptoms of retropharyngeal besides shortness of breathing. Stiffness and pain in neck movement
were the most common symptoms found in cervical Potts. As the abcess grows, it can cause the
prolaps of posterior wall of pharynx, which was found in this patient.

There was a decreased in muscle strength of upper and lower extrimities. Garg stated that
neurology deficit might happen if there is an involvement of thoracal and cervical vertebrae. If this
condition is not treated immediately, neurology involvement may be developed into paraplegi or
tetraplegia.

Aspiration was done in this patient to confirm retropharyngeal abnormalities. Ekka stated
that retropharyngeal pus aspiration may confirm the diagnosis of retropharyngeal abcess.

Rontgen of lateral neck showed the thickening of posterior wall of pharynx where C2
vertebra was 35 cm and C6 vertebra was 25 cm. Retropharyngeal abcess was suspected if on the
measurement of retrpharyngeal space of C2 vertebra level is more than 7 mm and C6 vertebra is
more than 22 mm on adults. Retropharyngeal abcess may also diagnosed if the thickening is more
than 2/3 of corpus vertebrae. Lateral neck rontgen also showed the narrowing of C5-6invertebra
vertebrae disc spoace and destruction on C5-6 vertebra. This findings is relevant to spondylitis TB
which found erosion and destruction of vertebra, osteolytic lesion, and compression fracture. CT
scan showed C5-6 destruction and abcess on retropharyngeal. Anshari reported cervical Potts
characteristic was the destruction of two adjacent corpus vertebrae and abcess in prevertebrae,
paravertebrae, or epidural.
 ESR rate was 39/hour, leucocyte 9.000/mm3, and CRP (+). CRP (+) is found in non-acute
infection Spinal Potts. ESR more than 20 mm/hour was found in 60-83% of Spinal Potts patient.
Garg reported that Spinal Potts was characterized by increased ESR and normal leucocyte count,
while in pyogenic infection, there would be increased ESR and leucocytosis,

On microbiology examination, the results found no bacterial growth. According to Marc,

culture was not the gold standard due to the difficulties in detecting Mycobacterium tuberculosa in
extrapulmonal TB. Anatomy Pathology examination showed acute exacerbation of granulomatous
chronic inflammation that might be due to specific process that hadnt been removed yet. Garg
stated that bipsy might show a false negative results, therefore, extrapulmonal TB was diagnosed
based on clinical and radiology examination if the bacteriology examination show negative results.

This patient was given pharmacological treatment and surgical intervention.

Retropharyngeal abcess drainage due to cervical Potts might be done intraorally, extraorally, or
both. Intraoral abcess drainage is done with aspiration approach under local anesthesia or incision.
Intraoral abcess drainage is a standard procedure in this case. Patient was aspirated in ED.
According to Sigh, aspiration may be repeated if needed and done under local anethesia. This
patient undergo intraoral incision during joim operation. According to Echevarria, intraoral incision
in accordance with cold absess of TB. Retropharyngeal abcess due to TB need to be treated with TB
drugs and surgical approach to prevent further complications

Potts cervical of this patient was treated with surgical intervention. Ansari said that
combination of pharmacological and surgical approach might give a satisfying results.

TB drugs were given to this patient. This is in relevant with Duerte, pharmaological
treatment were given as long as 10-24 months to achieve an adequate healing and prevent the
recurrency.

Surgical intervention was done by anterior approach. Varatharajah said that in patient with
wide abcess, anterior approach was the recommended standard. This approach allowed direct
debridement of prevertebra and intraspinal infected lesion. In addition, during the same prosedure,
anterior graft can be done to fill the lytic defect and strenghten anterior coloumn. On anterior
approach, abcess drainage, corpectomy, bone graft fusion and internal fixation can be done
simultaneously.

Bone graft was taken from illiac bone of this patient. This is in accordance with Duerte,
where illiac graft gave a consistent and satisfying results.

After the surgery, collar neck was applied to this patient. This is in accordance with Duerte
that Collar neck was the way to immobilize cervical spine and reduced long duration of resting

CONCLUSION

Retropharyngeal abcess due to Potts cervical is rarely occur. Therefore, high suspicious
(anamnesis, physical examination, imaging, and laboratory examintaion) is needed to diagnose this
disease immediately. The treatment of this disease is combination of pharmacological and surgical
intervention.