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A 36-year-old woman comes to the emergency department with worsening fever and sore
throat. Four days ago, the patient accidently swallowed a fish bone that scratched her
throat and caused some discomfort. She felt better after some time and did not seek
medical attention, but for the past 2 days she has had severe sore throat and difficulty
swallowing. The patient also reports neck pain and stiffness. Her temperature is 39 C
(1 02.2 F), blood pressure is 126/80 mm Hg, and pulse is 106/min. Examination shows
pooling of saliva in the hypopharynx. The posterior pharyngeal wall is red and bulging.
The neck is stiff with reduced passive range of motion. Lung auscultation is normal.
Lateral radiographs of the neck reveal increased thickness of the prevertebral soft
tissues with an air-fluid level. Due to potential contiguous spread of the disease process,
this patient is at greatest risk of developing which of the following?

o A. Acute necrotizing mediastinitis

o B. Cranial subdural empyema
o C. Ludwig angina
o D. Septic cavernous sinus thrombosis
o E. Spinal epidural abscess

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A 36-year-old woman comes to the emergency department with worsening fever and sore
throat. Four days ago, the patient accidently swallowed a fish bone that scratched her
throat and caused some discomfort. She felt better after some time and did not seek
medical attention, but for the past 2 days she has had severe sore throat and difficulty
swallowing. The patient also r.eports neck pain and stiffness. Her temperature is 39 C
(1 02.2 F), blood pressure is 126/80 mm Hg, and pulse is 106/min. Examination shows
pooling of saliva in the hypopharynx. The posterior pharyngeal wall is red and bulging.
The neck is stiff with reduced passive range of motion. Lung auscultation is normal.
Lateral radiographs of the neck reveal increased thickness of the prevertebral soft
tissues with an air-fluid level. Due to potential contiguous spread of the disease process,
this patient is at greatest risk of developing which of the following?

A Acute necrotizing mediastinitis [53%)

B. Cranial subdural empyema [3%)
C. Ludwig angina [1 3%)
D. Septic cavernous sinus thrombosis [7%)
-· E. Spinal epidural abscess [24%)

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Explanation : User

Deep neck space anatomy

+t-.- -----o;...:....__ _ _ _ _ Pretracheal

fascia
H+- ...,.,.........,..,c:-:----- Ret ropharyngeal
space
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Explanation: User ld

Deep neck space anatomy

·- ...
•

+t-r- - + - - - - - - - Pretracheal
fascia
H+--r--:.,..,.,....- - - Retropharyngeal
space

H+:::-=- + - --:-7- - Alar fascia

\-\.h.--'---1-~=:-:L---- "Danger" space

\ti::;::--t-~::::::=---- Prevertebra I
Pharynx fascia

Mediastinum ---:..._

@USMLEWorld, LLC

The retropharyngeal space is a deep compartment of the neck defined anteriorly by

the buccopharyngeal fascia and constrictor muscles of the pharynx and posteriorly by the
alar fascia. It communicates laterally with the parapharyngeal space. This patient has a
retropharyngeal abscess with neck pain, odynophagia, and fever following penetrating
trauma to the posterior pharynx. Examination findings can include nuchal rigidity and
bulging of the pharyngeal wall. Although deep space infections of the neck have become
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@USMLEWorld, LLC

The retropharyngeal space is a deep compartment of the neck defined anteriorly by

the buccopharyngeal fascia and constrictor muscles of the pharynx and posteriorly by the
alar fascia. It communicates laterally with the parapharyngeal space. This patient has a
retropharyngeal abscess with neck pain, odynophagia, and fever following penetrating
trauma to the posterior pharynx. Examination findings can include nuchal rigidity and
bulging of the pharyngeal wall. Although deep space infections of the neck have become
less common since the advent of widespread antibiotic use, they can progress rapidly
with potentially fatal complications.
Infection within the retropharyngeal space drains inferiorly to the superior
mediastinum. Spread to the carotid sheath can cause thrombosis of the internal
jugular vein and deficits in cranial nerves IX, X, XI, and XII. Extension through the alar
fascia into the "danger space" (between the alar and prevertebral fasciae) can rapidly
transmit infection into the posterior mediastinum to the level of the diaphragm. Acute
necrotizing mediastinitis is a life-threatening complication characterized by fever, chest
pain, dyspnea, and odynophagia, and requires urgent surgical intervention.

(Choice S) Extension of infection from the paranasal sinuses through the underlying
bone can lead to subdural empyema. Clinical findings include fever, headache, and
mass effect signs (eg, altered mental status).

(Choice C) Ludwig angina is a rapidly progressive bilateral cellulitis of the

submandibular and sublingual spaces, most often arising from an infected mandibular
molar. Clinical findings include fever, dysphagia, odynophagia, and drooling.

(Choice 0) Cavernous sinus thrombosis is most often due to contiguous spread of

infection from the medial third of the face, sinuses, or teeth via the valveless facial
venous system. Clinical findings include headache, fever, cranial nerve deficits (eg,
diplopia), and proptosis.
(Choice E) Spinal epidural abscess can be caused by hematogenous dissemination (eg,
intravenous drug abuse), contiguous spread from vertebral osteomyelitis, or direct
inoculation (eg, epidural anesthesia). Symptoms include fever, focal back pain, and
neurologic deficits.
Educational objective:
Retropharyngeal abscess presents with neck pain, odynophagia, and fever following
penetrating trauma to the posterior pharynx. Infection within the retropharyngeal space
can drain into the superior mediastinum. Extension through the alar fascia into the.
"danger space" can transmit infection into the posterior mediastinum and result in acute
necrotizing mediastinitis.

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The retropharyngeal space is a deep compartment of the neck defined anteriorly by

the buccopharyngeal fascia and constrictor muscles of the pharynx and posteriorly by the
alar fascia. It communicates laterally with the parapharyngeal space. This patient has a
retropharyngeal abscess with neck pain, odynophagia, and fever following penetrating
trauma to the posterior pharynx. Examination findings can include nuchal rigidity and
bulging of the pharyngeal wall. Although deep space infections of the neck have become
less common since the advent of widespread antibiotic use, they can progress rapidly
with potentially fatal complications.
Infection within the retropharyngeal space drains inferiorly to the superior
mediastinum. Spread to the carotid sheath can cause thrombosis of the internal
jugular vein and deficits in cranial nerves IX, X, XI, and XII. Extension through the alar
fascia into the "danger space" (between the alar and prevertebral fasciae) can rapidly
transmit infection into the posterio.r mediastinum to the level of the diaphragm. Acute
necrotizing mediastiniti!! is a life-threatening complication characterized by fever, chest
pain, dyspnea, and odynophagia, and requires urgent surgical intervention.
(Choice B) Extension of infection from the paranasal sinuses through the underlying
bone can lead to subdural empyema. Clinical findings include fever, headache, and
mass effect signs (eg, altered mental status).
(Choice C) Ludwig angina is a rapidly progressive bilateral cellulitis of the
submandibular and sublingual spaces, most often arising from an infected mandibular
molar. Clinical findings include fever, dysphagia, odynophagia, and drooling.

(Choice 0) Cavernous sinus thrombosis is most often due to contiguous spread of

infection from the medial third of the face, sinuses, or teeth via the valveless facial
venous system. Clinical findings include headache, fever, cranial nerve deficits (eg,
diplopia), and proptosis.
(Choice E) Spinal epidural abscess can be caused by hematogenous dissemination (eg,
intravenous drug abuse), contiguous spread from vertebral osteomyelitis, or direct
inoculation (eg, epidural anesthesia). Symptoms include fever, focal back pain, and
neurologic deficits.
Educational objective:
Retropharyngeal abscess presents with neck pain, odynophagia, and fever following
penetrating trauma to the posterior pharynx. Infection within the retropharyngeal space
can drain into the superior mediastinum. Extension through the alar fascia into the
"danger space" can transmit infection into the posterior mediastinum and result in acute
necrotizing mediastinitis.

Time Spent: 3 seconds Copyright © UWorld Last updated: [08/08/2016)

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Media Exhibit

veless ophthalmic venous system

The valveless ophthalmic venous system

Lacrimal vein

Superior ophthalmic vein

Cavernous sinus

Inferior Posterior Anterior Nasofrontal

ophthalmic ethmoidal ethmoidal vein
vein vein vein
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Q
ll
~tropharyngeal abscess -- •
Ear, Nose & Throat (ENT) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Fe_e_d_b_a_ck_ _ End Block
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