Presentation
Represented with neck pain. Not responding to analgesia. No history of trauma or heavy lifting. Midline tenderness.
Patient Data
Reversal of normal cervical lordosis. Increased width of prevertebral tissues at the upper cervical spine. Well corticated bony fragment below the anterior arch of C1 is presumably degenerative.
Prevertebral fluid density extends from C1 to C3/4 with associated lymph node enlargement. This raises the possibility of retropharyngeal abscess/cellulitis given the lack of a history of trauma. Some calcification is seen anteriorly at the C1/2 level.
Large retropharyngeal/prevertebral abnormality extending from base of skull to the level of hypopharnx and demonstrates increased T2 signal and almost uniform contrast enhancement with areas of possible linear liquefaction/abscess formation.
As the alar fascia is not identifiable, it is unclear whether this abnormality is centered within the retropharyngeal space or danger space.
Conclusion:
Large retropharyngeal/prevertebral cellulitis/evolving abscess.
Case Discussion
This case demonstrates the need to keep a careful eye on prevertebral tissues on plain film and also the difficulty in determining which space the infection lies in.
An important differential is calcific tendinitis of the longus colli muscles, however, the presence of extensive enhancement and lymph node enlargement should dissuade you from raising this as a possibility even in the presence of calcification at C1/2 level.