Age: 50
Sex: Male
Indication: Neck pain, fever
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Case #7
Findings
- Large peripherally enhancing retropharyngeal fluid collection extending from the skull base to the level of the C2-C3 disc space. Associated mass effect with partial effacement of the nasopharynx and oropharynx
- Mass effect on the left internal jugular vein with occlusive thrombus in the left internal jugular vein extending cranially from the level of C1-C2 into the imaged portions of the left sigmoid and transverse sinsuses
- Soft tissue thickening and possible thin peripherally enhancing fluid collection along the posterior margin of the C1 and C2 vertebral bodies
- Nodularity in the left greater than right lung apices
Diagnosis
- Retropharyngeal abscess
- Left internal jugular vein thrombosis with intracranial extension and likely septic pulmonary emboli
- Possible epidural abscess
Sample Report
Large retropharyngeal abscess measuring 6 by 3 by 5 cm with mass effect on and partial effacement of the nasopharynx and oropharynx. The abscess extends inferiorly to the level of C2-C3 without findings to suggest descending mediastinitis at present.
Associated compression of the left internal jugular vein with occlusive thrombus extending cranially from the level of C1-C2 into the visualized portions of the left sigmoid and transverse sinuses. Recommend brain MRI with and without contrast for further assessment.
Soft tissue thickening and possible thin peripherally enhancing fluid collection in the ventral epidural space at the level of C1-C2, which is concerning for epidural abscess. Recommend C spine MRI with and without contrast for further assessment.
Nodular opacities in the left greater than right lung apices are concerning for septic emboli, particularly in the setting of left internal jugular vein thrombosis. Recommend chest CT for further assessment.
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