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Age: 8 months

Sex: Female

Indication: Fever, drooling

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Case #19


Findings

  • Marked thickening of the retropharyngeal soft tissues measuring up to 2 cm in thickness at the level of C2


Diagnosis

  • Retropharyngeal abscess

Sample Report

Marked thickening of the retropharyngeal soft tissues measuring up to 2 cm in thickness at the level of C2, concerning for retropharyngeal edema and/or abscess. Consider contrast-enhanced neck CT for further evaluation.

Normal appearance of the epiglottis.

No ballooning of the hypopharynx.


Discussion

  • Retropharyngeal abscesses most commonly occur in children below the age of 4
  • Evaluation of the retropharyngeal soft tissues on lateral neck radiographs is unfortunately very prone to false positives as suboptimal patient positioning will often produce artificial retropharyngeal thickening
  • The study should be performed with neck extension to lower the false positive rate
  • However, if there is high clinical concern for retropharyngeal abscess, the first imaging study should be a contrast-enhanced neck CT. Make sure that CT imaging includes the superior mediastinum given the propensity for retropharyngeal space infections to descend into the mediastinum
  • A rough (but easy to remember) rule-of-thumb for retropharyngeal soft tissues is that they should be no greater than 7 mm in thickness at C2 and no greater than 2 cm in thickness at C7 (7 at 2 and 2 at 7)


Images

Comparison normal on the left and patient with retropharyngeal abscess on the right. Note the marked retropharyngeal soft tissue thickening in the patient on the right indicated by the red line.

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