Featured Article: A Pain in the Neck--Nontraumatic Causes of Neck Pain
Direct visualization via flexible oral or nasolaryngoscopy is the diagnostic gold standard but may be deferred in a stable patient. When absolutely indicated, it must be performed with caution, ideally by an anesthesiologist/otolaryngologist in a controlled setting, lest it precipitate further obstruction. Through the use of fiber optics, the need for emergent intubation can be more directly assessed and, if necessary, performed by “tube-over-scope” technique. In the ED, standby equipment for intubation and cricothyrotomy/needle cricothyrotomy should be immediately available and ready in the event of rapid deterioration, at the same time as intravenous (IV) infusion of third-generation cephalosporin or ampicillin/sulbactam, and methicillin-resistant Staphylococcus aureus (MRSA) coverage. Though the rationale for empirical use of antibiotics is evident, the role of corticosteroids and of nebulized racemic epinephrine is controversial.
Death, airway obstruction, epiglottic abscess, necrotizing epiglottitis, and secondary infections (eg, pneumonia, cervical adenitis, septic arthritis, meningitis) are the potential complications that make this source of neck pain one not to be missed. If epiglottitis is suspected, the patient must be admitted to an intensive care setting.
Retropharyngeal Abscess
The retropharyngeal space, immediately behind the posterior pharynx and esophagus, extends from the base of the skull to the mediastinum. It lies anterior to the deep cervical fascia and is bound laterally by the carotid sheaths.30 Because it is fused down the midline, abscesses in this area tend to be unilateral. The space cannot be directly assessed by physical examination, and infections in this area are rare. Timely diagnosis demands consideration of retropharyngeal abscess in patients presenting with fever, neck stiffness, and sore throat. The potential for serious morbidity and mortality is related to the host of vital structures immediately adjacent to the retropharyngeal space. Complications include mediastinitis, carotid artery erosion, jugular vein thrombosis, pericarditis, epidural abscess, sepsis, and airway compromise.
Most cases are typically observed in children younger than age 6 years. In this pediatric population, the retropharyngeal space has two parallel chains of lymph nodes draining the nose, sinuses, and pharynx; retropharyngeal abscesses usually occur as a suppurative extension from infections of these upper airway structures structures. Penetrating trauma, eg, from objects held in the mouth, is another possible cause. These nodes atrophy around 6 years of age; thereafter, the main cause of retropharyngeal abscess is purulent extension of an adjacent (frequently odontogenic) infection or posterior pharyngeal trauma (eg, from a fish bone or instrumentation).31 As befits its origin with oral flora, cultures are almost always polymicrobial (eg, Streptococci viridans and pyogenes, Staphylococcus, H influenza, Klebsiella, anaerobes).
Although retropharyngeal abscess is considered a disease of childhood, like epiglottitis, its incidence in adults is increasing. 32 Presenting symptoms are signs of respiratory distress, such as wheezing, stridor, and drooling with impending airway obstruction from the expanding posterior pharyngeal mass. Late signs of the illness are respiratory failure due to airway obstruction and septic shock, but an astute clinician should recognize the entity long before these symptoms present. Early symptoms include fever, sore throat, odynophagia, and neck pain and stiffness (typically manifesting as a reluctance to turn the neck).33 Patients may also complain of feeling a lump in the throat or pain in the posterior neck or shoulder with swallowing.34 Ninety-seven percent of pediatric patients present with neck pain,32 which could manifest dramatically as torticollis. Most likely, a child will have a subtle reluctance to move his or her neck during the course of the physical examination. In addition, there may be posterior pharyngeal edema and/or a visible unilateral posterior pharyngeal bulge, cervical adenopathy, and a “croupy” cry or cough resembling a duck’s quack—the “cri du canard.”35 Definitive diagnosis is made using X-ray and/or CT. A lateral soft-tissue neck X-ray will demonstrate widening of the prevertebral soft tissues. CT with contrast provides a more definitive diagnosis, and is also useful to differentiate abscess (ie, a hypodense lesion with ring enhancement) from cellulitis.
Regarding treatment, empiric IV antibiotics must be started immediately and may alone prevent progression if the diagnosis is made before cellulitis has progressed to abscess. Intravenous clindamycin is a reasonable first-line antibiotic; other suggested drugs include a penicillin/ beta lactamase inhibitor, penicillin G plus metronidazole, and cefoxitin.36 Airway protection is mandatory, and an otolaryngologist should be consulted early. Because of the potential for sudden airway deterioration, the emergency physician must be prepared to establish a surgical airway.
Ludwig’s Angina
Ludwig’s angina derives its name from the German physician Wilhelm Friedrich von Ludwig, who first described this deadly, rapidly progressive, fascial space/ connective tissue gangrenous cellulitis of the floor of the mouth and adjoining neck in 1836. In a curious twist of fate, it is believed that Dr Ludwig died from this very disease that bears his name.37
