Retropharyngeal space infection as a complication of endotracheal intubation is rarely reported in the current literature. The few case reports that have been published are usually related to emergency intubation and are rarely associated with mediastinitis. We report a case of a seemingly routine endotracheal intubation, which resulted in retropharyngeal abscess, mediastinitis, and empyema.
Case Report
A 36-year-old female was transferred to the Department of Otolaryngology at The Toronto Hospital 4 days after laparoscopic surgery for ovarian cysts with increasing pharyngeal pain, dysphagia, and neck edema. The patient had undergone routine laparoscopic surgery with one attempt and a second successful oral endotracheal intubation. The following day, the patient returned to the hospital emergency department complaining of a sore throat and was prescribed a beta-lactam antibiotic with beta-lactamase inhibitor (clavulin). The patient returned to the emergency department 3 days later complaining of persistent pain, dysphagia, and fever. She was found to have air in her retropharyngeal space on a lateral neck radiograph. The patient was subsequently transferred to The Toronto Hospital where a contrast-enhanced computed-tomographic (CECT) examination revealed a massive amount of air in the retropharyngeal space (Fig. 1), descending mediastinitis (Fig. 2), and a right empyema (Fig. 3). Interestingly, a flexible laryngoscopy, done prior to CECT, revealed little more than mild pharyngeal edema. The patient was taken to the operating room where an awake fibre-optic intubation was completed followed by exploration and incision and drainage of the neck and mediastinoscopy. A drain was inserted into the mediastinum via a supraclavicular approach and a chest tube was placed, along with Penrose drains, into the retropharyngeal space. During the exploration, a perforation was found in the retropharyngeal wall. Microbiology revealed penicillin- and erythromycin-resistant Staphylococcus aureus, with light growth of Streptococcus anginosus and alpha-hemolytic streptococcus. Antimicrobial therapy was originally started with broad-spectrum coverage and later restricted based on the culture and sensitivity results. Eleven days after the incision and drainage, the patient was extubated and shortly thereafter transferred out of the intensive care unit. Due to persistent drainage and difficulty swallowing, the patient made a slow but gradual recovery. Thirty-eight days after her incision and drainage, the patient was discharged from hospital. She has now been followed for 14 months and has made a complete recovery with resolution of dysphagia.
Discussion
Retropharyngeal space abscesses are an uncommon complication of endotracheal intubation. Those cases that have been reported usually occurred after emergent intubations.1-7 In this case, the perforation in the posterior pharyngeal wall and massive amount of air in the retropharynx suggest that this space was not only intubated but also ventilated. The retropharyngeal space extends from the base of the skull to the superior mediastinum. Posterior to this space is the danger space 4, which extends into the inferior mediastinum.8 The retropharyngeal space transmits about 71% of all cases of nontraumatic deep-neck infections that result in mediastinitis.9
Estera et al.10 reported on 51 cases of mediastinitis of which 5 were the result of endotracheal intubation. Two other reports11,12 of mediastinitis secondary to retropharyngeal intubation have been published since that time. Mediastinitis was originally reported to have a mortality rate of greater than 50%13 in 1938, which remained virtually unchanged when another report in 1983(10) estimated the mortality at 42%. A recent review of the world literature estimates the current mortality at 25%.14 This dramatic decrease in mortality over the past 15 years has been attributed to early detection of deep-neck infection with CECT examination.
This case was also complicated by a right-sided empyema. This is rarely associated with mediastinitis15-18 and carries with it a much greater mortality, although specific figures are difficult to estimate due to the rarity of the disease. The case presented in this report shows a particularly aggressive infection that resulted in mediastinitis and empyema. It may be speculated that this was due to a difference in microbiology (staphylococcal versus normal oral flora) or wide dissection of the fascial planes by ventilating the tissues. One can only speculate if the retropharynx was truly ventilated; however, it would explain the wide spread of disease. Earlier detection of the infection may have been more likely if a CT scan had been obtained at first presentation. This may also have prevented the infection from progressing to an empyema.
Conclusion
Retropharyngeal space infection with mediastinitis and empyema is a potentially life-threatening disease with mortality between 25% and 42%. Careful management of the airway and early evaluation with CECT should be completed immediately. Debridement of necrotic tissue and drainage of pus in both the neck and mediastinum is key to optimizing patient outcome.
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Ian Furst, DDS, David Ellis, MD, FR CSC, and Timothy Winton, MD, FR CSC
Received 1/6/99. Received revised 21/9/99. Accepted for publication 21/9/99.
Ian Furst: Division of Oral & Maxillofacial Surgery, The University of Toronto, David Ellis: Department of Otolaryngology and Timothy Winton: Division of Surgery, Department of Thoracic Surgery, The Toronto Hospital, Toronto, Ontario.
Address reprint requests to: Dr. David Ellis, Department of Otolaryngology, University Health Network, The Toronto Hospital, Toronto, ON MSG 2C4.
Copyright Decker Periodicals, Inc. Oct 2000