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Case 20 - Retropharyngeal Space Collections

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Let's finish our discussion of retropharyngeal collections

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with this classic article written by one of my

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colleagues at Johns Hopkins, Jenny Hong.

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And the article was published in 2011 before she

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came to Hopkins, she was actually at Duke,

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and this is entitled Multiplanar CT and MRI of

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Collections in the Retropharyngeal space: Is it an abscess?

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And she refers to this four step procedure to determine

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whether or not you're dealing with an abscess, a lymph node,

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or just retropharyngeal edema. And she says,

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look at the distribution of the fluid,

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look at the configuration, whether it has mass effect,

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look at whether or not it has a thick enhancing wall,

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and look at ancillary findings.

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So retropharyngeal, by enlarged,

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doesn't have that much in the way of mass effect.

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It kind of fills the retropharyngeal

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space from side to side and

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does not show contrast enhancement, and

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may be secondary to adjacent infections.

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Contrast that with Suppurative

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Retropharyngeal lymph node,

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which you heard me use the term necrotizing lymphadenitis,

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is another term here. It's usually unilateral,

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doesn't cross the midline and more rounded,

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it may have an enhancing wall and look like an abscess

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but it's really just the wall of the lymph node.

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And usually, it's a secondary reactive

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lymph node to adjacent pharyngitis.

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The final entity is the retropharyngeal abscess.

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Remember, this is one that crosses the midline,

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goes from side to side.

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If it's unilateral,

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probably a lymph node. If it's going into the midline or

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crossing from side to side, more likely to be an abscess,

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has mass effect, has an enhancing wall, and again,

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may have the same thing,

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a tonsillitis or a pharyngitis as

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the initial ideology of that.

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What Jenny did not refer to in this article is a phlegmon.

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And that's sort of this transition

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zone between retropharyngeal edema

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and abscess. The phlegmon will have mass effect.

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It will expand the retropharyngeal space.

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It does look like a localized collection,

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and yet it does not have a peripheral enhancing wall, and

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it does not have such well-defined borders

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as you would see with a retropharyngeal abscess.

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The final thing I want to mention about the retropharyngeal

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space, is this concept of the danger space.

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So the danger space is a reflection of the fascia

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that also encloses the retropharyngeal space.

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And the difference being that the retropharyngeal space,

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as you see depicted in this diagram,

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extends to the T3, T4 level, down here.

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Whereas, the danger space is the space that's in purplish,

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dark purple, that actually expands and can extend to the

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inferiormost portion of the thoracic cavity,

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and even down to the diaphragm in its location.

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So these are reflections of, in general,

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what we call the Alar fascia, that separates and distinguish

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retropharyngeal space versus danger space.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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