Differentiation of retropharyngeal calcific tendinitis and retropharyngeal abscess: a case series and review of the literature

Abstract

Introduction: Retropharyngeal calcific tendinitis (RCT) is a self-limiting aseptic inflammation of the tendon of the longus colli muscle, which can be clinically and radiologically misdiagnosed as abscess formation. This is a particular challenge for ENT specialists. However, articles about RCT are highly underrepresented in ENT journals and existing articles in ENT journals almost exclusively report overtreatment.

Methods: This study presents five patients, in which the diagnosis of RCT was delayed and of which one patient underwent incision and draining of a suspected retropharyngeal abscess under general anesthesia. In addition, the literature on the reported cases of RCT, between 1990 and 2020 was reviewed. For each case, epidemiological characteristics, complaints on presentation, symptoms, imaging and laboratory finding and treatment were summarized and compared to our own findings.

Results: In all the five patients, the correct diagnosis was delayed. One patient underwent incision and draining of a suspected RA under general anesthesia. All patients received antibiotic treatment. The literature review revealed a total of 116 reported cases of RCT. A total of 99 CT scans and 72 MRI showed soft tissue swelling in 89.6% and calcifications in 91.4% of the cases, 6.9% received invasive treatment.

Conclusion: This article emphasizes the importance of knowledge about RCT and its management to avoid invasive and potentially harmful treatment. The focus in establishing the correct diagnosis of RCT is the identification and correct interpretation of clinical symptoms together with the specific radiological findings.

Keywords: Neck; Neck stiffness; Pain; Prevertebral tendinitis.

Fig. 1

MRI and CT of a 56-year-old male patient with acute neck pain and impairment of neck movement (Patient 1). a Sagittal T2-weigthed image demonstrating prevertebral calcification at the level of C1/C2 (upper white arrowhead) with adjacent long sectional edematous prevertebral infiltration from C2–C5 (lower white arrowhead). Due to the diagnosis of a RA on the initial MRI, which was performed on an outpatient basis, he received intravenous antibiotic and analgetic therapy (Table 1). b Sagittal reconstruction of a CT scan in bone window setting demonstrating coarse prevertebral calcification at the level C1/C2 (white arrowhead). This follow-up CT was performed one day after treatment initiation. After the initiation of antibiotic and analgetic treatment, symptoms resolved within one week

Fig. 2

MRI of a 55-year-old male patient presenting with a 2-week history of pain when moving his neck with acute limitation of neck mobility (Patient 2). Upon clinical examination including transnasal fiberoptic endoscopy of the pharynx and larynx, no visible swelling was noted. a Sagittal T2-weighted MR image with fat saturation of the cervical spine showing extensive prevertebral edema at the level of C1–C6 (white arrowhead) and discrete joint effusion of the atlanto-axial joint leading to the diagnosis of RA/septic arthritis. Subsequently, the patient underwent a transcervical exploration of the retropharyngeal space. However, intraoperatively, no abscess formation was found. Six hours after surgery, the patient suffered from a postoperative bleeding from the surgical field that made the revision surgery necessary. As a complication, the patient suffered from a postoperative hypoglossal nerve paresis. b Sagittal T2-weightend MR image with fat saturation 5 days postoperatively showing increased effusion with postoperative edema (white arrowhead). At this time, neck pain had decreased under antibiotic and analgetic treatment. c Sagittal T2-weightend MR image with fat saturation 6 weeks postoperatively showing complete resolution of MRI findings

Fig. 3

Short-term remission of MRI findings in a 55-year-old female patient (Patient 3) initially presenting at another hospital with fever and tachycardia, who was treated with oral antibiotics. During the course of treatment, she developed progressive odynophagia. On clinical presentation at our institution, symptoms had already decreased. a Sagittal T1-weighted image with fat saturation after contrast agent administration of the initial MRI performed on the day of admission with large edema in the retropharyngeal space at level C1–C5/6 (white arrowheads). RCT was diagnosed and a conservative treatment was initiated. b Sagittal T1-weighted follow-up MRI with fat saturation 8 days after initiation of the treatment showing decreased inflammatory infiltrations (white arrowheads). By that time, the patient was asymptomatic