Presentation
Unwell for 5 days with escalating throat, jaw, neck and ear pain on the right. Decreasing oral intake secondary to pain. Hoarse voice. Nil trismus/stridor/shortness of breath. Observations within normal limits.
Patient Data
Rim enhancing fluid collection of some 28 x 46 x 46 mm within the right parapharyngeal space with associated fat stranding. The collection is producing a mass effect with medial displacement and narrowing of the adjacent nasopharynx. There is also posterolateral displacement of the external carotid artery and effacement of the jugular vein in supine posture.
In comparison to the prior CT, the previous right parapharyngeal abscess has expanded to 50 x 40 x 43 mm (28 x 46 x 46 mm previously). The leftward deviation of the nasopharynx is redemonstrated and now extends caudally into to the oropharynx. Inferior to the primary collection, in the space between the facial and lingual branches of the external carotid artery, lie new loculations . There are new collections in the right retroparotid space adjacent to the anterior border of sternocleidomastoideus that extend proximally into the neck and measure up to 8 x 20 x 44mm.
Case Discussion
After the first imaging, the patient underwent needle aspiration in the ED, which failed due to the thickness of the fluid. He then went to theater for trans-oral I+D with IV antibiotics and was discharged into the community. Fluid M/C/S grew only normal commensal flora.
Two weeks later he represented and exhibited the second set of imaging findings. The re-accumulation and expansion of this purulent focus necessitated a transcervical surgical debridement with extensive washout and placement of a Yates drain. Fluid M/C/S in this instance demonstrated resistant S.aureus.
The patient was reviewed in a pediatric/radiology MDT meeting and it was thought the recrudescence of disease may be secondary to a cystic remnant of a branchial cleft.
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