Clinical Review

Featured Article: A Pain in the Neck--Nontraumatic Causes of Neck Pain

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Diagnosis of cervical epidural hematoma is complicated by the rarity of the event and the lack of specific symptoms. When trauma is involved, cervical disc or nerve root injury is a more likely cause of sudden onset of neck pain, with rapid development of a radicular component. However, when symptoms occur following minor exertion (eg, sneezing, coitus, coughing) and in the presence of risk factors such as hematologic disorders, pregnancy, rheumatologic disorders, or liver dysfunction, epidural hematoma must be considered.16 Emergent magnetic resonance imaging (MRI) is the modality of choice for detecting this condition (Figure 2).

Figure 2. Sagittal T2-weighted magnetic resonance image of the cervical spine reveals a T2 bright epidural collection (white arrows). Note that this fluid collection is anterior to the dura (red arrow).

Coronary Ischemia Angina pectoris secondary to coronary ischemia is described as retrosternal “heaviness” or pressure, which may spread to either or both arms, the neck, or jaw. Pathology originating in the neck can be experienced as chest pain and may confound the diagnosis. Because cervical nerve roots C4-C8 contribute to the innervation of the anterior chest wall, irritation of any one of these nerves secondary to neck pathology can mimic true angina.17,18 Conversely, the likelihood that the only pain caused by coronary ischemia might be felt in the neck is low, but possible— especially in women.19,20 Coronary ischemia should be considered in patients with cardiac risk factors but no other obvious etiology for neck pain.21

Secondary Infection
Since emergency physicians are accustomed to dealing with infection, it is hard to imagine that we could fail to recognize infection as the etiology in a patient with a chief complaint of neck pain. Diagnosis in such cases is complicated by the anatomical location of deep neck-space infections, which limits the usefulness of standard physical examination. These sites are difficult to palpate and often impossible to visualize because they are covered with noninfected tissue. Unless specifically considered in the differential, more obscure causes of neck pain associated with infection may be missed, including retropharyngeal abscess, epiglottitis, Ludwig’s angina, vertebral osteomyelitis and discitis, cervical epidural abscess, and Lemierre’s syndrome.

Epiglottitis
Epiglottitis is inflammation of the epiglottis and adjacent supraglottic structures including the pharynx, uvula, and base of the tongue. The first recorded case is thought to have been that of George Washington, who is believed to have died from this disease.22 The high mortality rate (7% to 20% in the adult population) is a direct result of airway obstruction from inflammatory edema of the epiglottis and adjacent tissues.

Epiglottitis was originally considered a childhood disease; however, the widespread use of Haemophilus influenza vaccination has resulted in a decline in pediatric incidence. Most cases are now seen in adults (mean age of 46 years).23,24

Bacterial infection, especially from the genera Hemophilus, Streptococcus, Staphylococcus, and Klebsiella, is by far the most frequent cause of acute epiglottitis; viral and fungal-associated infections are rare. Thermal injury from swallowing hot foods or liquids, and even from inhaling crack cocaine,25 also has been implicated.

Figure 3. Lateral radiograph of the neck demonstrates a thickened and enlarged epiglottis (white arrow). Referred to as the thumbprint sign, the “second” epiglottis creates a “thumbprint” on the anterior margin of the trachea, the classic sign of epiglottitis.

Clinical presentations of epiglottitis differ between children and adults. While children are typically dyspneic, drooling, stridorous and febrile, adults tend to present with a milder form of the disease and have painful swallowing, sore throat, and a muffled voice. In both children and adults, the larynx and upper trachea are tender to light palpation at the anterior neck.26 Although sore throat and odynophagia are more often symptoms of pharyngitis, suspicion should be aroused when pain is severe and/or there is dyspnea, severe pain with an unremarkable oropharynx examination, or anterior neck tenderness. When present, muffled voice and stridor indicate greater potential for airway compromise.27 In cases of significant airway obstruction, patients may assume the “tripod position,” leaning forward with neck extended and mouth open—panting. Since soft-tissue lateral neck radiographs are about 90% sensitive and specific for epiglottitis, a normalappearing film cannot reliably exclude the diagnosis.28 Evaluation for the classic “thumb sign” of epiglottic swelling27 (Figure 3) should be combined with the newly described “vallecula sign” for greatest accuracy.29 The vallecula sign is described as the partial or complete obliteration of a well-defined linear air pocket between the base of the tongue and the epiglottis seen on a closed mouth lateral neck X-ray.

Although CT is a useful modality for detecting epiglottic, peritonsillar, or deep neck space abscess, there are risks to patients with airway compromise; moreover, placing patients in a supine position for the study increases the likelihood of respiratory distress. Despite these risks, when indicated, CT is useful in differentiating these abscesses from similarly presenting entities such as lingual tonsillitis and upper airway foreign body.

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