Retropharyngeal abscess and necrotizing fasciitis in neck complicated by descending mediastinitis

Case contributed by Maria Grazia Papi
Diagnosis certain


Acute patient presenting with fever, dysphagia, neck swelling and pain

Patient Data

Age: 65 years
Gender: Female

It was possible to acquire only a limited T1C + sequence for the clinical instability of the patient.

The typical presentation of retropharyngeal abscess: fills RPS part to part, oval/rounded shape, moderate to severe mass effect, thick enhancing wall. From the suprahyoid neck to the upper mediastinum, some abscess collections involving multiple neck spaces, following DCF layers distribution are detectable.

There are fluid collections surrounded by a thick enhancing wall within submandibular space, visceral mucosal space, para-pharyngeal space, anterior cervical space, retropharyngeal space and danger space. Inferiorly within the upper mediastinum and left supraclavicular fossa some fluid collection associated with soft tissue enhancement as well visible.

 Axial T1 C+ MRI at the level of the suprahyoid neck:

Septic fluid collection within the neck spaces delimited by fascial layers of DCF (deep cervical fascia): fluid collections within retropharyngeal space, within submandibular spaces bilaterally detectable. There is thick contrast enhancement of pharyngeal mucosal space and of parapharyngeal space.

Axial T1 C+ MRI at the level of the thyroid gland:

Septic fluid collection within the neck spaces delimited by fascial layers of DCF: collection filling retropharyngeal space from side-to-side showing an oblong shape, is visible; there is only mild mass effect, but thick wall enhancement is present.

Further collections are visible within the pharyngeal visceral space and within anterior cervical space bilaterally. Extensive contrast enhancement of deep and superficial fat spaces as well noted.

Axial enhanced CT imaging of neck shows multiple collections filling the parapharyngeal space, submandibular space, pharyngeal mucosal space, anterior cervical space and retropharyngeal space from side-to-side.

Axial enhanced CT images of upper thorax show fluid collection within posterior mediastinum tracking into the right middle mediastinum. 

The patient did not improve with IV antibiotics and required surgical drainage

Ancillary findings of likely primary infection: there is extensive sino-nasal inflammatory change with bone interruption of the base of the right maxillary sinus.

Authors who contributed to this case: Dr M.G. Papi, Dr S.P. Pirillo.

Case Discussion

Fascial layers of the deep cervical fascia (DCF) delineate neck spaces that communicate with each other.

In this case, fluid collections originating from a primary infective source and then involving multiple neck spaces are detectable; the way of infection spreading followed DCF layers distribution: there is anterior spread from the submandibular space to the anterior cervical space and to the supraclavicular fossa. There is posterior spread from the retropharyngeal space to the danger space and to the upper mediastinum.

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