Presentation
5 days sore throat, and worsening swelling of neck. O/E: septic, tense + tender red hot swelling midline neck + left side, difficult to feel for isolated collection, FNE: moderate erythema + edema epiglottis/pyriform fossa, aryepiglottis. CT neck for ?collection ?necrotizing fasciitis
Patient Data
Collection in left level IV of the neck, distorting and displacing the left lobe of thyroid and the supraglottic airway. This collection measures approximately 8 x 4 cm. Foci of gas are noted within this collection.
No definite airway mass or edema, but the left pyriform fossa is effaced.
Sclerosis of the left clavicular head.
The collection was aspirated by ENT with negative microbiology results, however a Staphylococcus aureus bacteremia was confirmed on peripheral blood cultures.
A follow up MRI post-aspiration and six weeks antibiotic course was performed. The neck continued to be swollen and painful with a static, elevated CRP.
There are changes of a florid left sternoclavicular joint septic arthritis, and in retrospect this was probably the source of infection, although less evident on the previous CT.
The joint space is widened, currently 13 mm diameter, reflecting instability, and there is high signal pus within the joint space. This infections tracts laterally, along the posterior aspect
of the medial two thirds of the left clavicle, with a small retroclavicular abscess cavity measuring 20 x 7 x 8 mm. Of note, this abscess directly abuts the left subclavian
vein, which is currently patent.
Bone marrow edema extending into the left side of the sternum, and there is localized periarticular soft tissue edema, but no direct involvement of the thyroid gland or
larynx, and no significant retrosternal extension.
The rest of the imaged brain, skull base, orbits, facial sinuses, nasal passages and suprahyoid and infrahyoid soft tissues are normal. No significant lymph node enlargement on either side of the neck at any level. The imaged lung apices are normal.
Case Discussion
What was initially considered a more typical airway / soft tissue infection in the left base of neck was later confirmed to be a large abscess from a septic sternoclavicular joint with associated osteomyelitis.
On review of the initial CT, there was sclerosis of the left clavicle head and asymmetric widening of the sternoclavicular joint.