Pharyngeal abscess presenting with upper airway obstruction and atlanto‐axial subluxation in a small infant

Abstract

SummaryWe describe an infant who presented with a combination of upper airway obstruction and atlantoaxial subluxation, secondary to a pharyngeal abscess resulting from cosmetic ear piercing. This combination posed a number of dif®culties for the anaesthetist and a detailed plan was formulated to prepare the child for anaesthesia.Keywords Complications: pharyngeal abscess; atlanto-axial subluxation. Intubation: tracheal; dif®cult. Anaesthesia: paediatric. Parapharyngeal abscess is rare in the early infant period and the association of subluxation of the cervical spine with pharyngeal abscess is rare at any age [1].This combination of conditions poses a number of problems for the anaesthetist; the possibility of dif®cult intubation, worsened by the inability to¯ex or extend the cervical spine, the presence of atlanto-axial subluxation and the potential of damage to the spinal cord, and the age of the child, which would make awake ®breoptic intubation extremely dif®cult. Case historyThree weeks after cosmetic piercing of both ear lobes, a 6-month-old 8.8 kg baby was admitted to a local hospital with a 3-week history of swelling of the right side of his neck, pyrexia and malaise. He was transferred to The Birmingham Children's Hospital when he developed an expiratory wheeze, inspiratory stridor and intercostal recession, requiring supplementary oxygen therapy.On examination, the infant was apyrexial and there was a tender cystic mass measuring 7 cm in diameter in the right lateral cervical area (Fig. 1). The inspiratory stridor and intercostal recession were minimal at rest and he did not require supplementary oxygen. The patient preferred to have his head positioned looking to the left, although he would move it into the neutral position. Investigations revealed a reactive leucocytosis (white cell count 54.41 0 9 .l À1 ). A chest radiograph indicated changes consistent with bronchiolitis and a lateral X-ray of the cervical spine demonstrated a large parapharyngeal mass associated with gross atlanto-axial subluxation.An ultrasound of the neck con®rmed the large pharyngeal mass (6.8´4.5´4.9 cm), suggestive of suppurative lymphadenitis. An examination by a neurosurgeon did not show any neurological signs, and a magnetic resonance imaging (MRI) scan was requested to look for compression of the spinal cord. A consultant ear nose and throat (ENT) surgeon requested general anaesthesia to drain the mass.At a pre-operative visit we con®rmed the absence of neurological signs, and the child's ability to move his head into the neutral position spontaneously. Although his stridor, while present at rest, was minimal, we felt that an MRI scan was necessary before attempting tracheal intubation, to establish the degree of laryngeal or tracheal compression by the mass. The child was therefore sedated with chloral hydrate and transferred to the MRI suite, accompanied by two anaesthetists.During the MRI scan the child was monitored with pulse oximetry, noninvasive blood pressure and electrocardiograph. The scan proceeded uneventfull...

Retropharyngeal abscess presenting with upper airway obstruction

“…A pharyngeal abscess usually presents in children with fever, upper respiratory tract infections, irritability and poor oral intake. This progresses to torticollis, neck pain and finally signs of upper airway obstruction [3]. In our case, we feel that the diagnosis was delayed because of the absence of respiratory compromise until late in the disease.…”