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Retropharyngeal abscess secondary to penetrating foreign bodies
Journal of Cranio-Maxillofacial Surgery (2000) 28, 243–246 # 2000 European Association for Cranio-Maxillofacial Surgery doi:10.1054/jcms.2000.0151, available online at http://www.idealibrary.com on
Retropharyngeal abscess secondary to penetrating foreign bodies Ashok Poluri, Bhuvanesh Singh, Neil Sperling, Gady Har-El, Frank E. Lucente Department of Otolaryngology, State University of New York, Health Science Center at Brooklyn, Brooklyn, New York, USA SUMMARY. A retrospective study was conducted on patients with upper aerodigestive tract foreign bodies requiring operative intervention over a 12-year period to aid in the recognition and management of foreign body associated complications. Oesophagoscopies were performed for the removal of foreign bodies in 37 patients, age one to 82 years with a male to female ratio of 1.2 : 1. Retropharyngeal abscesses accounted for eight of 11 foreign body-associated complications. Fish bones were the cause in six cases, chicken bone and a pen refill in one case each. An abscess was already present at the time of initial procedure in six cases and developed in two cases after successful removal of the foreign body. A high level of suspicion for a retropharyngeal abscess should be maintained in cases with perforation, and in patients with immunodeficiency. # 2000 European Association for CranioMaxillofacial Surgery
the duration and types of symptoms, diagnostic work-up, treatment required, and outcome. Radiographic examinations, when available, were reviewed as well.
INTRODUCTION Most foreign bodies pass through the alimentary tract spontaneously. However, large or sharp ones may become lodged in the aerodigestive tract causing trauma and leading to severe complications. Death may ensue if prompt intervention is not provided. Early detection and removal of the foreign body is mandatory. Rarely, foreign bodies perforate the digestive tract to cause complications involving surrounding structures. In the review of 2902 cases, Jackson and Jackson (1936) identified only 31 cases and Remsen et al. (1983) found a total of 321 penetrating foreign bodies in his review, the majority of which occurred in children. The formation of an abscess as a complication of perforating foreign body is especially rare. Remsen et al. identified only 10 of these in the medical literature. We found 33 additional cases reported in the literature since then (Bizakis et al., 1993; Barratt et al., 1984; Sethi and Chew, 1991). We have had experience with eight cases of retropharyngeal abscesses as the consequence of a perforating foreign body. Our approach to diagnosis and management of this condition is presented.
RESULTS During the study period, 37 esophagoscopies were performed for the removal of foreign bodies from the upper aerodigestive tract. These patients ranged in age from one to 82 years, with a male to female ratio of 1.2 : 1. Animal bones were present in 24 cases (fish=21; chicken=2; ox tail=1), lodged meat, a partial denture, and a pen refill in one case each. Coins were recovered in the remaining 10 cases. Complications associated with perforations were seen in 11 cases, all of which were infectious in nature. Out of the 11 cases, eight were retropharyngeal abscesses, with fish bones being the cause in six cases, and chicken bones and a pen refill in one case each. The abscesses were present in six cases at the time of initial procedure for foreign body removal, and developed after the successful removal in two cases. Four of the six patients presenting already with a retropharyngeal abscess had sought medical treatment for the presence of a foreign body within one week prior to presentation. Radiographic and fiberoptic examination performed at the initial presentation in four and three cases respectively had not shown evidence of the presence of foreign body at that time.
MATERIAL AND METHODS A retrospective review of all patients presenting with upper aerodigestive tract foreign bodies requiring operative treatment over a 12-year period was performed. It covered all such patients of our institution from January 1983 to June 1995. The records were reviewed to identify the demographic information, symptoms at presentation, diagnostic evaluation, and type of foreign body and associated complications. The medical records of patients with retropharyngeal abscesses as a consequence of foreign body were further reviewed to identify
CASE REPORTS Case 1 A 41-year old black male presented to our service five days after initial presentation to his primary 243
244 Journal of Cranio-Maxillofacial Surgery
physician with a sensation of a foreign body in his throat after a fishmeal. At the time of presentation, a thorough physical and radiologic examination of his primary physician failed to reveal the presence of a foreign body or upper aerodigestive tract injury. The patient was sent home on oral antibiotics with instructions to return if symptoms persisted or worsened. At the time of presentation to our service, the patient was in obvious distress. He was complaining of fever, chills, and progressive dysphagia for both solids and liquids in addition to drooling. Fibreoptic laryngoscopy revealed a bulging posterior pharyngeal wall with a small laceration in the lateral aspect. Radiographic examination (Fig. 1) revealed the presence of a retropharyngeal abscess. Computerized tomography confirmed the presence of pus collection. The patient underwent tracheotomy under local anaesthesia, with external drainage of the abscess. A necrotic area on the posterior pharyngeal wall was noted corresponding to the area of perforation. A salivary bypass was placed and the patient treated with a full course of antibiotics. The patient did well postoperatively. Subsequently, the tracheotomy and salivary bypass were removed and the patient sent home on a regular diet.
Case 2 A 3-year-old male presented to our service with complaints of odynophagia, drooling, and fever of 38.38C. Examination revealed a febrile, irritable child who was unable to control his secretions. The rest of the physical findings were within normal limits. From the routine chest radiograph the suspicion was made of a foreign body in the oro-pharyngeal region. Neck radiographs confirmed the presence of a foreign body in the pharynx, with accompanying retropharyngeal cellulitis. A fish bone was removed intra-operatively, following which the patient was discharged after 10 days of antibiotic therapy.
Fig. 1 – Lateral roentgenogram of the neck showing the presence of air and widening of the retropharyngeal space.
Case 3 A 53-year-old female with a history of acquired immunodeficiency syndrome presented 6 h after a fish meal with a sensation of foreign body in the throat. Radiographic examination confirmed the presence of a foreign body and the patient underwent endoscopic removal of it (Fig. 3). However, the patient developed persistent fever (38.88C) during the post-operative period and antibiotic therapy was started. On the fourth postoperative day, the patient complained of worsening odynophagia, neck pain, and mild dyspnea. Fiberoptic examination showed bulging of the posterior pharyngeal wall with mild supraglottic oedema. CT scan showed the presence of a retropharyngeal abscess. The patient responded well to drainage and antibiotic therapy, and was discharged home on the eighteenth post-operative day. Case 4 A 26-year-old male with Down’s syndrome, associated with severe mental retardation, presented to our service with a 5-day history of anorexia, an accompanying fever (38.88C) and lethargy. Neither the patient nor the home staff could give any more information. At presentation, the patient was in mild distress, with a fever of 38.68C and an inability to control his secretions. Fibreoptic examination revealed a tear on the posterior pharyngeal wall. CT scan (Fig. 2) revealed the presence of a retropharyngeal abscess, with the detection of a pen refill in the abdomen on routine chest roentgenogram. The patient was taken to the operating room, where tracheotomy was performed under local anaesthesia, followed by external drainage. The symptoms resolved completely with aggressive wound care and intravenous antibiotics and the
Fig. 2 – Computerized tomograph at the level of seventh cervical vertebra showing the presence of air inclusion in the soft tissue.
Retropharyngeal abscess secondary to penetrating foreign bodies 245
Fig. 3 – Endoscopy showing a foreign body (bone) perforating the cervical oesophagus.
patient was discharged home on the fourteenth postoperative day. DISCUSSION Although rare, the presence of a perforating foreign body can be associated with life-threatening complications. The older literature suggests that vascular complications are most common (Remsen et al., 1983), involving fistula formation between oesophagus and aorta, innominate artery, or carotid artery. Other rare vascular complications included formation of pericardio-oesophageal fistula, carotid rupture or thrombosis, stroke, cardiac tamponade and exsanguination. The mortality associated with vascular complications was reported to be close to 100% (Remsen et al., 1983). Infectious complications associated with perforating foreign bodies were less commonly reported with diffuse thoracic infections, especially mediastinitis and pericarditis being the most frequent (Remsen et al., 1983). Localized abscess formation was rarely reported, but a diversity of locations could be involved, including the parapharyngeal or retropharyngeal spaces, as well as the thyroid, parotid, and submaxillary gland (Remsen et al., 1983). Our reports combined with recent reports in the literature suggest that a shift in penetrating foreign body-associated complications had occurred (Singh et al., 1997; Bizakis et al., 1993; Sethi and Chew, 1991; Barratt et al., 1984). In fact, all of the complications in our series were infectious in nature. The majority of these were localized abscesses and developed in adults most frequently as a consequence of fish bone ingestion. The change in the types of complications is likely related to improvement in diagnostic measures with resultant decrease in chronic erosive type complications, which are more likely to lead to vascular involvement. Overall, retropharyngeal abscesses are rarely caused by localized trauma due to foreign body
ingestion. Studies showed that 96% of retropharyngeal abscesses in children occurred as a complication of lymphatic infection (Brown, 1919). However, by the age of 3–4 years, the lymphatic tissues in the retropharyngeal space undergo atrophy. The contribution of lymphatic suppuration as a cause of retropharyngeal abscesses decreases, with increasing contribution from spread of dental infection, endotracheal intubation (Heath and Pierce, 1977; Wong and Novotny, 1978) endoscopic procedures (Heller et al., 1978), external penetrating injuries, vertebral fractures (Levitt, 1970), tuberculosis, and blunt neck trauma (Husaru and Nedzelski, 1979). More recent series show that penetrating foreign bodies are among the most common cause of retropharyngeal abscesses in adults (Singh et al., 1997; Pontell et al., 1995; Sethi and Chew, 1991). Including all cases found in the literature where age was reported, the majority occurred in patients under 12 or over 50 years of age (Singh et al., 1997; Remsen et al., 1983; Barratt et al., 1984; Sethi and Chew, 1991; Bizakis et al., 1993). The average age was 34, with male to female ratio of 3 : 1 in cases where gender was reported. The most commonly reported symptoms at presentation included odynophagia, pain, fever and dyspnoea. In severe cases, acute respiratory embarrassment requiring tracheostomy can also occur. Patients reported in the literature presented an average of 7.8 days after foreign body ingestion, ranging from 5 h to 104 days. Surprisingly, no deaths were reported as a consequence of foreign body associated retropharyngeal abscess (Singh et al., 1997; Remsen et al., 1983; Barratt et al., 1984; Bizakis et al., 1993). The management is well described and revolves around surgical drainage and antibiotic therapy (Bizakis et al., 1993). In severe cases, external drainage must be contemplated along with the placement of a tracheotomy for airway protection. However, the diagnosis of retropharyngeal abscess in cases of perforating foreign body may be delayed by the inability of the patient to give a history, as illustrated in cases 2 and 4. Accordingly, in adult patients presenting with retropharyngeal abscess and unable to give a history, the performance of laryngoscopy and oesophagoscopy should be considered, even in the absence of radiographic evidence of a foreign body. Furthermore, as illustrated in case 3, in immuno-compromised individuals, delayed abscess formation is possible, even after timely removal of the foreign body. This necessitates that immuno-compromised patients be followed closely even after uneventful management of trauma to the upper aerodigestive tract.
References Barratt GE, Koopmann CF, Coulthard SW, Tucson AZ: Retropharyngeal abscess – A ten-year experience. Laryngoscope 94: 455–463, 1984 Bizakis JG, Segas J, Skoulakis H et al.: Retropharyngeal abscess associated with a swallowed bone. Am J Otolaryngol 14: 354–357, 1993
246 Journal of Cranio-Maxillofacial Surgery Brown JM: Acute retropharyngeal abscess in children. Laryngoscope 29: 9–12, 1919 Heath LK, Pierce TH: Retropharyngeal abscess following endotracheal intubation. Chest 72: 776–777, 1977 Heller AM, Hohl R, Madhavan T, Wong K: Retropharyngeal abscess after endoscopic cholangiopancreatography: an uncommon but potentially fatal complication. South Med J 71: 219–221, 1978 Husaru AD, Nedzelski JM: Retropharyngeal abscess and upper airway obstruction. J Otolaryngol 8: 443–447, 1979 Jackson C, Jackson CL: Diseases of the air and food passages of foreign body origin. Philadelphia: Saunders, 1936 Levitt GW: Cervical fascia and seep neck infections. Laryngoscope 80: 409–435, 1970 Pontell J, Har-El G, Lucente FE: Retropharyngeal abscess: clinical review. Ear Nose Throat J 74: 701–704, 1995 Remsen K, Lawson W, Biller HF, SomLM: Unusual presentations of penetrating foreign bodies of the upper aerodigestive tract. Ann Otol Rhinol Laryngol Suppl 105: 32–44, 1983 Sethi DS, Chew CT: Retropharyngeal abscess – The foreign body connection. Ann Acad Med Singapore 20: 581–588, 1991
Singh B, Kantu M, Har-El G, Lucente FE: Complications associated with 327 foreign bodies of the pharynx, larynx, and oesophagus. Ann Otol Rhinol Laryngol 106: 301–304, 1997 Wong YK, Novotny GM: Retropharyngeal space – A review of anatomy, pathology, and clinical presentation. J Otolaryngol 7: 528–553, 1978
Bhuvanesh Singh MD 1275 York Avenue New York New York 10021 USA Tel: +1 212 639 2024 Fax: +1 212 717 3302 E-mail: [email protected] Paper received 27 September 1999 Accepted 27 June 2000
Retropharyngeal abscess secondary to penetrating foreign bodies Ashok Poluri, Bhuvanesh Singh, Neil Sperling, Gady Har-El, Frank E. Lucente Department of Otolaryngology, State University of New York, Health Science Center at Brooklyn, Brooklyn, New York, USA SUMMARY. A retrospective study was conducted on patients with upper aerodigestive tract foreign bodies requiring operative intervention over a 12-year period to aid in the recognition and management of foreign body associated complications. Oesophagoscopies were performed for the removal of foreign bodies in 37 patients, age one to 82 years with a male to female ratio of 1.2 : 1. Retropharyngeal abscesses accounted for eight of 11 foreign body-associated complications. Fish bones were the cause in six cases, chicken bone and a pen refill in one case each. An abscess was already present at the time of initial procedure in six cases and developed in two cases after successful removal of the foreign body. A high level of suspicion for a retropharyngeal abscess should be maintained in cases with perforation, and in patients with immunodeficiency. # 2000 European Association for CranioMaxillofacial Surgery
the duration and types of symptoms, diagnostic work-up, treatment required, and outcome. Radiographic examinations, when available, were reviewed as well.
INTRODUCTION Most foreign bodies pass through the alimentary tract spontaneously. However, large or sharp ones may become lodged in the aerodigestive tract causing trauma and leading to severe complications. Death may ensue if prompt intervention is not provided. Early detection and removal of the foreign body is mandatory. Rarely, foreign bodies perforate the digestive tract to cause complications involving surrounding structures. In the review of 2902 cases, Jackson and Jackson (1936) identified only 31 cases and Remsen et al. (1983) found a total of 321 penetrating foreign bodies in his review, the majority of which occurred in children. The formation of an abscess as a complication of perforating foreign body is especially rare. Remsen et al. identified only 10 of these in the medical literature. We found 33 additional cases reported in the literature since then (Bizakis et al., 1993; Barratt et al., 1984; Sethi and Chew, 1991). We have had experience with eight cases of retropharyngeal abscesses as the consequence of a perforating foreign body. Our approach to diagnosis and management of this condition is presented.
RESULTS During the study period, 37 esophagoscopies were performed for the removal of foreign bodies from the upper aerodigestive tract. These patients ranged in age from one to 82 years, with a male to female ratio of 1.2 : 1. Animal bones were present in 24 cases (fish=21; chicken=2; ox tail=1), lodged meat, a partial denture, and a pen refill in one case each. Coins were recovered in the remaining 10 cases. Complications associated with perforations were seen in 11 cases, all of which were infectious in nature. Out of the 11 cases, eight were retropharyngeal abscesses, with fish bones being the cause in six cases, and chicken bones and a pen refill in one case each. The abscesses were present in six cases at the time of initial procedure for foreign body removal, and developed after the successful removal in two cases. Four of the six patients presenting already with a retropharyngeal abscess had sought medical treatment for the presence of a foreign body within one week prior to presentation. Radiographic and fiberoptic examination performed at the initial presentation in four and three cases respectively had not shown evidence of the presence of foreign body at that time.
MATERIAL AND METHODS A retrospective review of all patients presenting with upper aerodigestive tract foreign bodies requiring operative treatment over a 12-year period was performed. It covered all such patients of our institution from January 1983 to June 1995. The records were reviewed to identify the demographic information, symptoms at presentation, diagnostic evaluation, and type of foreign body and associated complications. The medical records of patients with retropharyngeal abscesses as a consequence of foreign body were further reviewed to identify
CASE REPORTS Case 1 A 41-year old black male presented to our service five days after initial presentation to his primary 243
244 Journal of Cranio-Maxillofacial Surgery
physician with a sensation of a foreign body in his throat after a fishmeal. At the time of presentation, a thorough physical and radiologic examination of his primary physician failed to reveal the presence of a foreign body or upper aerodigestive tract injury. The patient was sent home on oral antibiotics with instructions to return if symptoms persisted or worsened. At the time of presentation to our service, the patient was in obvious distress. He was complaining of fever, chills, and progressive dysphagia for both solids and liquids in addition to drooling. Fibreoptic laryngoscopy revealed a bulging posterior pharyngeal wall with a small laceration in the lateral aspect. Radiographic examination (Fig. 1) revealed the presence of a retropharyngeal abscess. Computerized tomography confirmed the presence of pus collection. The patient underwent tracheotomy under local anaesthesia, with external drainage of the abscess. A necrotic area on the posterior pharyngeal wall was noted corresponding to the area of perforation. A salivary bypass was placed and the patient treated with a full course of antibiotics. The patient did well postoperatively. Subsequently, the tracheotomy and salivary bypass were removed and the patient sent home on a regular diet.
Case 2 A 3-year-old male presented to our service with complaints of odynophagia, drooling, and fever of 38.38C. Examination revealed a febrile, irritable child who was unable to control his secretions. The rest of the physical findings were within normal limits. From the routine chest radiograph the suspicion was made of a foreign body in the oro-pharyngeal region. Neck radiographs confirmed the presence of a foreign body in the pharynx, with accompanying retropharyngeal cellulitis. A fish bone was removed intra-operatively, following which the patient was discharged after 10 days of antibiotic therapy.
Fig. 1 – Lateral roentgenogram of the neck showing the presence of air and widening of the retropharyngeal space.
Case 3 A 53-year-old female with a history of acquired immunodeficiency syndrome presented 6 h after a fish meal with a sensation of foreign body in the throat. Radiographic examination confirmed the presence of a foreign body and the patient underwent endoscopic removal of it (Fig. 3). However, the patient developed persistent fever (38.88C) during the post-operative period and antibiotic therapy was started. On the fourth postoperative day, the patient complained of worsening odynophagia, neck pain, and mild dyspnea. Fiberoptic examination showed bulging of the posterior pharyngeal wall with mild supraglottic oedema. CT scan showed the presence of a retropharyngeal abscess. The patient responded well to drainage and antibiotic therapy, and was discharged home on the eighteenth post-operative day. Case 4 A 26-year-old male with Down’s syndrome, associated with severe mental retardation, presented to our service with a 5-day history of anorexia, an accompanying fever (38.88C) and lethargy. Neither the patient nor the home staff could give any more information. At presentation, the patient was in mild distress, with a fever of 38.68C and an inability to control his secretions. Fibreoptic examination revealed a tear on the posterior pharyngeal wall. CT scan (Fig. 2) revealed the presence of a retropharyngeal abscess, with the detection of a pen refill in the abdomen on routine chest roentgenogram. The patient was taken to the operating room, where tracheotomy was performed under local anaesthesia, followed by external drainage. The symptoms resolved completely with aggressive wound care and intravenous antibiotics and the
Fig. 2 – Computerized tomograph at the level of seventh cervical vertebra showing the presence of air inclusion in the soft tissue.
Retropharyngeal abscess secondary to penetrating foreign bodies 245
Fig. 3 – Endoscopy showing a foreign body (bone) perforating the cervical oesophagus.
patient was discharged home on the fourteenth postoperative day. DISCUSSION Although rare, the presence of a perforating foreign body can be associated with life-threatening complications. The older literature suggests that vascular complications are most common (Remsen et al., 1983), involving fistula formation between oesophagus and aorta, innominate artery, or carotid artery. Other rare vascular complications included formation of pericardio-oesophageal fistula, carotid rupture or thrombosis, stroke, cardiac tamponade and exsanguination. The mortality associated with vascular complications was reported to be close to 100% (Remsen et al., 1983). Infectious complications associated with perforating foreign bodies were less commonly reported with diffuse thoracic infections, especially mediastinitis and pericarditis being the most frequent (Remsen et al., 1983). Localized abscess formation was rarely reported, but a diversity of locations could be involved, including the parapharyngeal or retropharyngeal spaces, as well as the thyroid, parotid, and submaxillary gland (Remsen et al., 1983). Our reports combined with recent reports in the literature suggest that a shift in penetrating foreign body-associated complications had occurred (Singh et al., 1997; Bizakis et al., 1993; Sethi and Chew, 1991; Barratt et al., 1984). In fact, all of the complications in our series were infectious in nature. The majority of these were localized abscesses and developed in adults most frequently as a consequence of fish bone ingestion. The change in the types of complications is likely related to improvement in diagnostic measures with resultant decrease in chronic erosive type complications, which are more likely to lead to vascular involvement. Overall, retropharyngeal abscesses are rarely caused by localized trauma due to foreign body
ingestion. Studies showed that 96% of retropharyngeal abscesses in children occurred as a complication of lymphatic infection (Brown, 1919). However, by the age of 3–4 years, the lymphatic tissues in the retropharyngeal space undergo atrophy. The contribution of lymphatic suppuration as a cause of retropharyngeal abscesses decreases, with increasing contribution from spread of dental infection, endotracheal intubation (Heath and Pierce, 1977; Wong and Novotny, 1978) endoscopic procedures (Heller et al., 1978), external penetrating injuries, vertebral fractures (Levitt, 1970), tuberculosis, and blunt neck trauma (Husaru and Nedzelski, 1979). More recent series show that penetrating foreign bodies are among the most common cause of retropharyngeal abscesses in adults (Singh et al., 1997; Pontell et al., 1995; Sethi and Chew, 1991). Including all cases found in the literature where age was reported, the majority occurred in patients under 12 or over 50 years of age (Singh et al., 1997; Remsen et al., 1983; Barratt et al., 1984; Sethi and Chew, 1991; Bizakis et al., 1993). The average age was 34, with male to female ratio of 3 : 1 in cases where gender was reported. The most commonly reported symptoms at presentation included odynophagia, pain, fever and dyspnoea. In severe cases, acute respiratory embarrassment requiring tracheostomy can also occur. Patients reported in the literature presented an average of 7.8 days after foreign body ingestion, ranging from 5 h to 104 days. Surprisingly, no deaths were reported as a consequence of foreign body associated retropharyngeal abscess (Singh et al., 1997; Remsen et al., 1983; Barratt et al., 1984; Bizakis et al., 1993). The management is well described and revolves around surgical drainage and antibiotic therapy (Bizakis et al., 1993). In severe cases, external drainage must be contemplated along with the placement of a tracheotomy for airway protection. However, the diagnosis of retropharyngeal abscess in cases of perforating foreign body may be delayed by the inability of the patient to give a history, as illustrated in cases 2 and 4. Accordingly, in adult patients presenting with retropharyngeal abscess and unable to give a history, the performance of laryngoscopy and oesophagoscopy should be considered, even in the absence of radiographic evidence of a foreign body. Furthermore, as illustrated in case 3, in immuno-compromised individuals, delayed abscess formation is possible, even after timely removal of the foreign body. This necessitates that immuno-compromised patients be followed closely even after uneventful management of trauma to the upper aerodigestive tract.
References Barratt GE, Koopmann CF, Coulthard SW, Tucson AZ: Retropharyngeal abscess – A ten-year experience. Laryngoscope 94: 455–463, 1984 Bizakis JG, Segas J, Skoulakis H et al.: Retropharyngeal abscess associated with a swallowed bone. Am J Otolaryngol 14: 354–357, 1993
246 Journal of Cranio-Maxillofacial Surgery Brown JM: Acute retropharyngeal abscess in children. Laryngoscope 29: 9–12, 1919 Heath LK, Pierce TH: Retropharyngeal abscess following endotracheal intubation. Chest 72: 776–777, 1977 Heller AM, Hohl R, Madhavan T, Wong K: Retropharyngeal abscess after endoscopic cholangiopancreatography: an uncommon but potentially fatal complication. South Med J 71: 219–221, 1978 Husaru AD, Nedzelski JM: Retropharyngeal abscess and upper airway obstruction. J Otolaryngol 8: 443–447, 1979 Jackson C, Jackson CL: Diseases of the air and food passages of foreign body origin. Philadelphia: Saunders, 1936 Levitt GW: Cervical fascia and seep neck infections. Laryngoscope 80: 409–435, 1970 Pontell J, Har-El G, Lucente FE: Retropharyngeal abscess: clinical review. Ear Nose Throat J 74: 701–704, 1995 Remsen K, Lawson W, Biller HF, SomLM: Unusual presentations of penetrating foreign bodies of the upper aerodigestive tract. Ann Otol Rhinol Laryngol Suppl 105: 32–44, 1983 Sethi DS, Chew CT: Retropharyngeal abscess – The foreign body connection. Ann Acad Med Singapore 20: 581–588, 1991
Singh B, Kantu M, Har-El G, Lucente FE: Complications associated with 327 foreign bodies of the pharynx, larynx, and oesophagus. Ann Otol Rhinol Laryngol 106: 301–304, 1997 Wong YK, Novotny GM: Retropharyngeal space – A review of anatomy, pathology, and clinical presentation. J Otolaryngol 7: 528–553, 1978
Bhuvanesh Singh MD 1275 York Avenue New York New York 10021 USA Tel: +1 212 639 2024 Fax: +1 212 717 3302 E-mail: [email protected] Paper received 27 September 1999 Accepted 27 June 2000