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Infectious arteritis of the internal carotid artery complicating retropharyngeal abscess
G Model
ARTICLE IN PRESS
ANORL-476; No. of Pages 3
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Case report
Infectious arteritis of the internal carotid artery complicating retropharyngeal abscess Q. Lisan ∗ , H. Tran , B. Verillaud , P. Herman Service d’otorhinolaryngologie et chirurgie cervicofaciale, hôpital Lariboisière, AP–HP, université Paris 7 Denis-Diderot, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
a r t i c l e
i n f o
Keywords: Retropharyngeal abscess Infectious arteritis Internal carotid artery Endovascular embolization
a b s t r a c t Introduction: Retropharyngeal abscess is a well-known entity in children, but can also occur in adults. The two main vascular complications are vascular compression and pseudoaneurysm, while infectious arteritis of the internal carotid artery is exceptional. Case report: The authors describe a case of a retropharyngeal abscess in an adult woman complicated by infectious arteritis of the internal carotid artery. This rare complication was treated by endovascular occlusion of the internal carotid artery and incision and drainage of the abscess in combination with antibiotic and anticoagulant therapy. The patient did not present any neurological sequelae and follow-up MRI did not reveal any signs of vascular or neurological complications. Discussion: This case highlights the importance of thorough examination of imaging performed in the context of deep neck space abscess to detect signs of vascular involvement. Treatment must be aggressive in view of the life-threatening risk of arterial rupture or septic embolism. This is the first reported case of infectious arteritis involving the internal carotid artery complicating retropharyngeal abscess. © 2015 Elsevier Masson SAS. All rights reserved.
1. Introduction Retropharyngeal abscess is a well-known entity in children. Although rare, this disease can also occur in adults and can be responsible for serious complications. We report a case of infectious arteritis of the internal carotid artery (ICA) complicating retropharyngeal abscess in an adult. This is the first reported case in the international literature. In the light of this case and a review of the relevant literature, we discuss the management of this exceptional complication. 2. Case report A 20-year-old woman with no notable history presented with odynophagia, initially treated by antibiotics (amoxicillin 1 g t.i.d.) and non-steroidal anti-inflammatory drugs. Forty-eight hours later, following the onset of fever and trismus, the patient attended the emergency department. Physical examination revealed swelling of the posterior pharyngeal wall suggestive of retropharyngeal abscess. Laboratory tests showed a leukocyte count of 16 × 109 /L and C-reactive protein of 552 mg/L. Contrast-enhanced CT scan
∗ Corresponding author. E-mail address: quentin [email protected] (Q. Lisan).
performed to determine the site and extent of infection, revealed a retropharyngeal low-density image lateralised to the left measuring 15 × 19 × 38 mm, and a stenotic appearance of the left ICA (Fig. 1). MR angiography was then performed, revealing features of arteritis of the left ICA with gadolinium enhancement of the arterial wall, responsible for 50% stenosis of its prepetrosal segment (Fig. 2). After discussion with the vascular neurology and interventional neuroradiology teams, it was decided to perform embolization of the left ICA due to the high risk of carotid artery rupture and septic embolism. Arteriography initially confirmed the carotid artery stenosis. After an occlusion test, the intrapetrosal and post-bulbar segment of the left ICA was embolized and intraoral incision and drainage of the abscess was performed at the same time. Antibiotic therapy was instituted with ceftriaxone (1 g once daily) and metronidazole (500 mg t.i.d.), which was subsequently completed by ofloxacin (200 mg b.i.d.) due to the presence of gram-positive cocci on bacteriological examination. Follow-up MRI 10 days later did not reveal any neurological or vascular complications related to internal carotid artery occlusion and no signs of recurrence of the abscess. Clinically, the patient was afebrile with no neurological signs and resolution of the laboratory signs of inflammation. Follow-up MRI at 1 month showed no signs of revascularization of the ICA, no intracranial complications and a normal appearance of the retropharyngeal space.
http://dx.doi.org/10.1016/j.anorl.2015.08.039 1879-7296/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Lisan Q, et al. Infectious arteritis of the internal carotid artery complicating retropharyngeal abscess. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.08.039
G Model ANORL-476; No. of Pages 3
ARTICLE IN PRESS Q. Lisan et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
2
Fig. 1. Contrast-enhanced CT scan of the neck: stenosis of the left internal carotid artery (white arrow).
Fig. 2. MRI, gadolinium-enhanced T1 FAT SAT sequence, axial section: low-intensity collection with peripheral enhancement in contact with the left internal carotid artery, which has a stenotic appearance. Regular thickening and contrast enhancement of the artery wall corresponding to infectious arteritis (white arrow), features which are not observed in the case of simple extrinsic compression or pseudoaneurysm.
ically, the retropharyngeal space is situated posterior to the pharynx, extending from the skull base to the superior mediastinum. This space is limited anteriorly by the buccopharyngeal fascia, posteriorly by the prevertebral fascia and laterally by the carotid space. These anatomical relations account for the potentially serious complications of retropharyngeal abscess, such as involvement of the jugular veins and carotid arteries or spread of infection resulting in deep neck space infection and/or mediastinitis [1–3]. As vascular complications of retropharyngeal infection are rare, the diagnosis may be missed by an inexperienced surgeon. This article describes a rare complication, as this is the first case to be reported in the international literature. The two main complications involving the ICA reported in the literature are extrinsic carotid artery stenosis due to compression by the abscess and pseudoaneurysm. According to Hudgins, carotid artery compression by retropharyngeal abscess is a very common and frequently asymptomatic phenomenon in paediatric populations [4]. Symptoms suggestive of a vascular complication are external bleeding, cranial nerve palsy, Horner syndrome or a pulsatile mass in the neck [2,3,5]. Optimal imaging consists of contrast-enhanced CT of the neck, including the superior mediastinum [1]. CT reveals a low-density image with peripheral enhancement confirming the abscess. A poorly visualized ICA in contact with a retropharyngeal abscess must alert the surgeon to the potential risk of arterial involvement. Extrinsic compression causes lateral and/or posterior displacement of the ICA. Intense and homogeneous contrast enhancement of a mass in contact with the ICA should raise the suspicion of pseudoaneurysm [6]. MR angiography, although not always readily available in the emergency setting, can visualize the arterial lesion [3,7]. Imaging examinations also allow assessment of the circle of Willis before performing embolization or surgical ligation [3]. The treatment of retropharyngeal abscess is based on intravenous antibiotic therapy and surgical drainage, often performed transorally or sometimes via a neck incision [8,9]. Incision-drainage is not performed systematically in this difficult site, especially because of the vascular risk [7]. The treatment of vascular complications constitutes the most critical aspect of this disease. In the case of extrinsic compression by the abscess, treatment is based on antibiotics, surgical drainage, when it can be performed, and anticoagulation [4,7]. In the case of pseudoaneurysm, several authors recommend arterial occlusion, ideally endovascular [3,5] or by surgical ligation [9]. Surgical drainage is not always possible for a small abscess in contact with the ICA or a pseudoaneurysm, in which case medical treatment and surveillance can be instituted [7]. Absence of the classical radiological signs of vascular complications described above and the presence of an abscess immediately in contact with the ICA suggested a diagnosis of infectious arteritis. This diagnosis was adopted due to its severity, although it cannot be definitively confirmed in the absence of histological evidence. By extrapolation with published cases of vascular rupture or septic emboli complicating infectious aortitis [10], we considered that our patient presented a similar risk. Embolization of the ICA was designed to prevent these serious life-threatening and/or functional risks. If the clamping test had induced neurological signs, we would have initiated medical treatment with daily radiological surveillance. CT signs of deterioration of carotid artery stenosis or carotid artery rupture would then have constituted an indication for ICA occlusion.
4. Conclusion 3. Discussion Deep neck space abscesses can occur in several anatomical zones: peritonsillar, parapharyngeal and retropharyngeal. Anatom-
Although rare in adults, retropharyngeal abscess is associated with a risk of serious, possibly life-threatening, complications. This article reports the first case of infectious arteritis of the internal
Please cite this article in press as: Lisan Q, et al. Infectious arteritis of the internal carotid artery complicating retropharyngeal abscess. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.08.039
G Model ANORL-476; No. of Pages 3
ARTICLE IN PRESS Q. Lisan et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
carotid artery, which was treated by ICA occlusion and drainage of the abscess. This case illustrates the importance of thorough examination of imaging examinations, particularly looking for vascular involvement. We believe that this exceptional complication should be treated aggressively, ideally by endovascular occlusion or surgical ligation.
[3]
[4]
[5]
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Maroldi R, Farina D, Ravanelli M, Lombardi D, Nicolai P. Emergency imaging assessment of deep neck space infections. Semin Ultrasound CT MR 2012;33:432–42. [2] Fernández CA, Tagarro S, Lozano-Arnilla CG, Preciado J, Lacosta JL. Internal carotid pseudoaneurysm within a parapharyngeal infection: an
[6]
[7] [8] [9]
[10]
3
infrequent complication of difficult diagnosis. Otolaryngol Head Neck Surg 2005;132:671–3. Ide C, Bodart E, Remacle M, De Coene B, Nisolle JF, Trigaux JP. An early MR observation of carotid involvement by retropharyngeal abscess. Am J Neuroradiol 1998;19:499–501. Hudgins P, Dorey JH, Jacobs IN. Internal carotid artery narrowing in children with retropharyngeal lymphadenitis and abscess. Am J Neuroradiol 1998;19:1841–3. Beningfield A, Nehus E, Chen AY, Yellin S. Pseudoaneurysm of the internal carotid artery after retropharyngeal abscess. Otolaryngol Head Neck Surg 2006;134:338–9. Krysl J, Noël de Tilly L, Armstrong D. Pseudoaneurysm of the internal carotid artery: complication of deep neck space infection. Am J Neuroradiol 1993;14:696–8. Elliott M, Yong S, Beckenham T. Carotid artery occlusion in association with a retropharyngeal abscess. Int J Pediatr Otorhinolaryngol 2006;70:359–63. Goldenberg D, Golz A, Joachims HZ. Retropharyngeal abscess: a clinical review. J Laryngol Otol 1997;111:546–50. Daya H, Lo S, Papsin BC, Zachariasova A, et al. Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int J Pediatr Otorhinolaryngol 2005;69:81–6. Stephens CT, Pounds LL, Killewich LA. Rupture of a non aneurysmal aorta secondary to Staphylococcus aortitis. Angiology 2006;57:506–12.
Please cite this article in press as: Lisan Q, et al. Infectious arteritis of the internal carotid artery complicating retropharyngeal abscess. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.08.039
ARTICLE IN PRESS
ANORL-476; No. of Pages 3
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Case report
Infectious arteritis of the internal carotid artery complicating retropharyngeal abscess Q. Lisan ∗ , H. Tran , B. Verillaud , P. Herman Service d’otorhinolaryngologie et chirurgie cervicofaciale, hôpital Lariboisière, AP–HP, université Paris 7 Denis-Diderot, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
a r t i c l e
i n f o
Keywords: Retropharyngeal abscess Infectious arteritis Internal carotid artery Endovascular embolization
a b s t r a c t Introduction: Retropharyngeal abscess is a well-known entity in children, but can also occur in adults. The two main vascular complications are vascular compression and pseudoaneurysm, while infectious arteritis of the internal carotid artery is exceptional. Case report: The authors describe a case of a retropharyngeal abscess in an adult woman complicated by infectious arteritis of the internal carotid artery. This rare complication was treated by endovascular occlusion of the internal carotid artery and incision and drainage of the abscess in combination with antibiotic and anticoagulant therapy. The patient did not present any neurological sequelae and follow-up MRI did not reveal any signs of vascular or neurological complications. Discussion: This case highlights the importance of thorough examination of imaging performed in the context of deep neck space abscess to detect signs of vascular involvement. Treatment must be aggressive in view of the life-threatening risk of arterial rupture or septic embolism. This is the first reported case of infectious arteritis involving the internal carotid artery complicating retropharyngeal abscess. © 2015 Elsevier Masson SAS. All rights reserved.
1. Introduction Retropharyngeal abscess is a well-known entity in children. Although rare, this disease can also occur in adults and can be responsible for serious complications. We report a case of infectious arteritis of the internal carotid artery (ICA) complicating retropharyngeal abscess in an adult. This is the first reported case in the international literature. In the light of this case and a review of the relevant literature, we discuss the management of this exceptional complication. 2. Case report A 20-year-old woman with no notable history presented with odynophagia, initially treated by antibiotics (amoxicillin 1 g t.i.d.) and non-steroidal anti-inflammatory drugs. Forty-eight hours later, following the onset of fever and trismus, the patient attended the emergency department. Physical examination revealed swelling of the posterior pharyngeal wall suggestive of retropharyngeal abscess. Laboratory tests showed a leukocyte count of 16 × 109 /L and C-reactive protein of 552 mg/L. Contrast-enhanced CT scan
∗ Corresponding author. E-mail address: quentin [email protected] (Q. Lisan).
performed to determine the site and extent of infection, revealed a retropharyngeal low-density image lateralised to the left measuring 15 × 19 × 38 mm, and a stenotic appearance of the left ICA (Fig. 1). MR angiography was then performed, revealing features of arteritis of the left ICA with gadolinium enhancement of the arterial wall, responsible for 50% stenosis of its prepetrosal segment (Fig. 2). After discussion with the vascular neurology and interventional neuroradiology teams, it was decided to perform embolization of the left ICA due to the high risk of carotid artery rupture and septic embolism. Arteriography initially confirmed the carotid artery stenosis. After an occlusion test, the intrapetrosal and post-bulbar segment of the left ICA was embolized and intraoral incision and drainage of the abscess was performed at the same time. Antibiotic therapy was instituted with ceftriaxone (1 g once daily) and metronidazole (500 mg t.i.d.), which was subsequently completed by ofloxacin (200 mg b.i.d.) due to the presence of gram-positive cocci on bacteriological examination. Follow-up MRI 10 days later did not reveal any neurological or vascular complications related to internal carotid artery occlusion and no signs of recurrence of the abscess. Clinically, the patient was afebrile with no neurological signs and resolution of the laboratory signs of inflammation. Follow-up MRI at 1 month showed no signs of revascularization of the ICA, no intracranial complications and a normal appearance of the retropharyngeal space.
http://dx.doi.org/10.1016/j.anorl.2015.08.039 1879-7296/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Lisan Q, et al. Infectious arteritis of the internal carotid artery complicating retropharyngeal abscess. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.08.039
G Model ANORL-476; No. of Pages 3
ARTICLE IN PRESS Q. Lisan et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
2
Fig. 1. Contrast-enhanced CT scan of the neck: stenosis of the left internal carotid artery (white arrow).
Fig. 2. MRI, gadolinium-enhanced T1 FAT SAT sequence, axial section: low-intensity collection with peripheral enhancement in contact with the left internal carotid artery, which has a stenotic appearance. Regular thickening and contrast enhancement of the artery wall corresponding to infectious arteritis (white arrow), features which are not observed in the case of simple extrinsic compression or pseudoaneurysm.
ically, the retropharyngeal space is situated posterior to the pharynx, extending from the skull base to the superior mediastinum. This space is limited anteriorly by the buccopharyngeal fascia, posteriorly by the prevertebral fascia and laterally by the carotid space. These anatomical relations account for the potentially serious complications of retropharyngeal abscess, such as involvement of the jugular veins and carotid arteries or spread of infection resulting in deep neck space infection and/or mediastinitis [1–3]. As vascular complications of retropharyngeal infection are rare, the diagnosis may be missed by an inexperienced surgeon. This article describes a rare complication, as this is the first case to be reported in the international literature. The two main complications involving the ICA reported in the literature are extrinsic carotid artery stenosis due to compression by the abscess and pseudoaneurysm. According to Hudgins, carotid artery compression by retropharyngeal abscess is a very common and frequently asymptomatic phenomenon in paediatric populations [4]. Symptoms suggestive of a vascular complication are external bleeding, cranial nerve palsy, Horner syndrome or a pulsatile mass in the neck [2,3,5]. Optimal imaging consists of contrast-enhanced CT of the neck, including the superior mediastinum [1]. CT reveals a low-density image with peripheral enhancement confirming the abscess. A poorly visualized ICA in contact with a retropharyngeal abscess must alert the surgeon to the potential risk of arterial involvement. Extrinsic compression causes lateral and/or posterior displacement of the ICA. Intense and homogeneous contrast enhancement of a mass in contact with the ICA should raise the suspicion of pseudoaneurysm [6]. MR angiography, although not always readily available in the emergency setting, can visualize the arterial lesion [3,7]. Imaging examinations also allow assessment of the circle of Willis before performing embolization or surgical ligation [3]. The treatment of retropharyngeal abscess is based on intravenous antibiotic therapy and surgical drainage, often performed transorally or sometimes via a neck incision [8,9]. Incision-drainage is not performed systematically in this difficult site, especially because of the vascular risk [7]. The treatment of vascular complications constitutes the most critical aspect of this disease. In the case of extrinsic compression by the abscess, treatment is based on antibiotics, surgical drainage, when it can be performed, and anticoagulation [4,7]. In the case of pseudoaneurysm, several authors recommend arterial occlusion, ideally endovascular [3,5] or by surgical ligation [9]. Surgical drainage is not always possible for a small abscess in contact with the ICA or a pseudoaneurysm, in which case medical treatment and surveillance can be instituted [7]. Absence of the classical radiological signs of vascular complications described above and the presence of an abscess immediately in contact with the ICA suggested a diagnosis of infectious arteritis. This diagnosis was adopted due to its severity, although it cannot be definitively confirmed in the absence of histological evidence. By extrapolation with published cases of vascular rupture or septic emboli complicating infectious aortitis [10], we considered that our patient presented a similar risk. Embolization of the ICA was designed to prevent these serious life-threatening and/or functional risks. If the clamping test had induced neurological signs, we would have initiated medical treatment with daily radiological surveillance. CT signs of deterioration of carotid artery stenosis or carotid artery rupture would then have constituted an indication for ICA occlusion.
4. Conclusion 3. Discussion Deep neck space abscesses can occur in several anatomical zones: peritonsillar, parapharyngeal and retropharyngeal. Anatom-
Although rare in adults, retropharyngeal abscess is associated with a risk of serious, possibly life-threatening, complications. This article reports the first case of infectious arteritis of the internal
Please cite this article in press as: Lisan Q, et al. Infectious arteritis of the internal carotid artery complicating retropharyngeal abscess. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.08.039
G Model ANORL-476; No. of Pages 3
ARTICLE IN PRESS Q. Lisan et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
carotid artery, which was treated by ICA occlusion and drainage of the abscess. This case illustrates the importance of thorough examination of imaging examinations, particularly looking for vascular involvement. We believe that this exceptional complication should be treated aggressively, ideally by endovascular occlusion or surgical ligation.
[3]
[4]
[5]
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Maroldi R, Farina D, Ravanelli M, Lombardi D, Nicolai P. Emergency imaging assessment of deep neck space infections. Semin Ultrasound CT MR 2012;33:432–42. [2] Fernández CA, Tagarro S, Lozano-Arnilla CG, Preciado J, Lacosta JL. Internal carotid pseudoaneurysm within a parapharyngeal infection: an
[6]
[7] [8] [9]
[10]
3
infrequent complication of difficult diagnosis. Otolaryngol Head Neck Surg 2005;132:671–3. Ide C, Bodart E, Remacle M, De Coene B, Nisolle JF, Trigaux JP. An early MR observation of carotid involvement by retropharyngeal abscess. Am J Neuroradiol 1998;19:499–501. Hudgins P, Dorey JH, Jacobs IN. Internal carotid artery narrowing in children with retropharyngeal lymphadenitis and abscess. Am J Neuroradiol 1998;19:1841–3. Beningfield A, Nehus E, Chen AY, Yellin S. Pseudoaneurysm of the internal carotid artery after retropharyngeal abscess. Otolaryngol Head Neck Surg 2006;134:338–9. Krysl J, Noël de Tilly L, Armstrong D. Pseudoaneurysm of the internal carotid artery: complication of deep neck space infection. Am J Neuroradiol 1993;14:696–8. Elliott M, Yong S, Beckenham T. Carotid artery occlusion in association with a retropharyngeal abscess. Int J Pediatr Otorhinolaryngol 2006;70:359–63. Goldenberg D, Golz A, Joachims HZ. Retropharyngeal abscess: a clinical review. J Laryngol Otol 1997;111:546–50. Daya H, Lo S, Papsin BC, Zachariasova A, et al. Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int J Pediatr Otorhinolaryngol 2005;69:81–6. Stephens CT, Pounds LL, Killewich LA. Rupture of a non aneurysmal aorta secondary to Staphylococcus aortitis. Angiology 2006;57:506–12.
Please cite this article in press as: Lisan Q, et al. Infectious arteritis of the internal carotid artery complicating retropharyngeal abscess. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.08.039