Transcript Longus colli tendinitis mimicking a retropharyngeal

Longus colli tendinitis mimicking a
retropharyngeal abscess in a 12
year old girl.
CA Hilditch1, S Biswas2, S Mathur1
1. Departments of Neuroradiology
Lancashire Teaching Hospitals NHS Foundation Trust
Preston, UK
2. The Walton Centre, NHS Foundation Trust
Liverpool, UK
Purpose
• To demonstrate the diagnostic dilemma
caused by a rare case of longus colli tendinitis
presenting as a retropharyngeal abscess with
unique imaging features
Case report: Clinical
• A 12 year old girl with no significant past medical
history presented to the emergency department
complaining of severe neck pain
• On examination:
–
–
–
–
Marked restriction of neck movements with severe pain
Pyrexia
Redness and swelling of the left side of the neck
Mild trismus and swallowing difficulty due to pain
• Blood biochemistry showed raised inflammatory
markers and a neck ultrasound demonstrated reactive
lymphadenopathy
Plain film
Plain films of the neck show some prevertebral soft tissue swelling but no
evidence of calcification
Ultrasound
Ultrasound scanning of the neck showed reactive lymphadenopathy
only
Axial & Coronal T2W MRI Neck
Urgent neck MRI showed an inflammatory collection in the left prevertebral soft tissues,
confined to the left longus colli muscle
MRI Neck T1W
Irregular thick walled fluid collection in the left longus colli muscle
MRI Neck T1+C
Fat saturated T1 post contrast MRI showed a large irregular rim enhancing
inflammatory mass in the prevertebral soft tissues within the left long colli muscle
Initial diagnosis
• Retropharyngeal abscess
Further investigations & management
• Surgical neck exploration
– No drainable abscess identified
• Biopsy of the post nasal space
– Reactive hyperplasia
• Commenced on IV antibiotics
• Remained an inpatient for 10 days
• Clinical improvement and discharged home
with a course of oral antibiotics
Follow-up MRI at 1 month
Axial fat saturated T1 pre and post contrast demonstrates marked
improvement with some mild residual enhancement in the left longus colli
muscle
Longus colli tendinitis
• Acute calcific tendinitis of the longus colli muscle
is a rare condition that causes severe neck pain
(1).
• Calcium hydroxyapatite crystals are deposited
causing acute inflammatory changes in the
muscle.
• Benign condition that usually mimics more
serious causes of acute neck pain such as
retropharyngeal abscess, meningitis and
infectious spondylitis (2).
Longus colli tendinitis
• Classic imaging findings of calcification in the prevertebral soft tissues on
CT and plain film may not be present (3).
• Longus colli tendinitis can present with a retropharyngeal effusion/fluid
collection which can mimic retropharyngeal abscess (4, 5)
• To our knowledge this is the first case diagnosed in a child and with a fluid
collection displaying a thickened irregularly enhancing wall confined to the
longus colli muscle
• Longus colli tendinitis is an important condition to recognise as it can be
treated conservatively and usually will resolve with symptomatic
treatment after 1 to 2 weeks.
• Early diagnosis can prevent unnecessary invasive management or
investigations such as neck surgery and biopsy
• Longus colli tendinitis can have a range of imaging appearances and
should be suspected in cases of lesions confined to the longus colli muscle
Longus colli tendinitis; classic imaging
findings (6)
Foci of amorphous calcification within the superior fibres of the longus colli tendon are typical.
Non contrast enhanced CT is the imaging modality of choice.
Images taken from; OFFIAH CE, HALL E. Acute calcific tendinitis of the longus colli muscle:
spectrum of CT appearances and anatomical correlation. British Journal of Radiology 2009
June;82(978):e121.
Take home points
• Longus colli is a rare condition which can mimic serious causes of
neck pain and stiffness
• Classic calcifications in the superior fibres of the longus colli muscle
tendon may not be present
• The finding of a retropharyngeal fluid collection smoothly enlarging
the retropharyngeal space should prompt the radiologist to search
for calcifications in the longus colli tendon (4)
• The diagnosis should be considered when there is absence of
compelling imaging or clinical evidence of acute bacterial infection
(4)
• Early recognition can prevent unnecessary invasive surgery
• The condition usually settles within weeks with conservative
management with anti-inflammatory medications
References
•
•
•
•
•
•
1) Estimable K, Rizk C, Pujalte GGA. A rare case of neck pain: acute longus colli
calcific tendinitis in a possibly immunocompromised individual. Journal of the
American Board of Family Medicine : JABFM 2015 January;28(1):146-150.
(2) Shin D, Ahn C, Choi J. The Acute Calcific Prevertebral Tendinitis: Report of Two
Cases. Asian Spine Journal 2010 December 1;4(2):123-127.
(3) Kang C, Son ES, Kim DH, Jang H. Acute Longus Colli Tendinitis without
Calcification. Journal of the Korean Orthopaedic Association 2015 June
1;50(3):264-267
(4) Eastwood JD, Hudgins PA, Malone D. Retropharyngeal effusion in acute calcific
prevertebral tendinitis: diagnosis with CT and MR imaging. American Journal of
Neuroradiology 1998 October 1;19(9):1789.
(5) Ronak Rahmanian, Chris Diamond. Calcific Tendonitis of the Longus Colli
Muscle: A Noninfectious Cause of Retropharyngeal Fluid Collection. Case reports in
otolaryngology 2014;2014:286190.
(5) OFFIAH CE, HALL E. Acute calcific tendinitis of the longus colli muscle: spectrum
of CT appearances and anatomical correlation. British Journal of Radiology 2009
June;82(978):e121