Hye Kyung Chang, JungHye Kyung Chang, JungHye Kyung Chang, JungHye Kyung Chang, Jung----TakTakTakTak Oh, Oh, Oh, Oh, SeungSeungSeungSeung HoonHoonHoonHoon Choi, Choi, Choi, Choi, SeokSeokSeokSeok JooJooJooJoo HanHanHanHan

Division of Pediatric Surgery, Department of Surgery,Division of Pediatric Surgery, Department of Surgery,Division of Pediatric Surgery, Department of Surgery,Division of Pediatric Surgery, Department of Surgery,Yonsei University College of MedicineYonsei University College of MedicineYonsei University College of MedicineYonsei University College of Medicine

Recurrent Retropharyngeal AbscessRecurrent Retropharyngeal AbscessRecurrent Retropharyngeal AbscessRecurrent Retropharyngeal Abscesswith Esophageal Perforationwith Esophageal Perforationwith Esophageal Perforationwith Esophageal Perforation

due to Chopstick Injurydue to Chopstick Injurydue to Chopstick Injurydue to Chopstick Injury

Case PresentationCase PresentationCase PresentationCase Presentation

1111----yearyearyearyear----old girl old girl old girl old girl

C/C : recurrent retropharyngeal abscess and feverC/C : recurrent retropharyngeal abscess and feverC/C : recurrent retropharyngeal abscess and feverC/C : recurrent retropharyngeal abscess and fever

transferred to our hospital transferred to our hospital transferred to our hospital transferred to our hospital due to recurrent retropharyngeal abscess and feverdue to recurrent retropharyngeal abscess and feverdue to recurrent retropharyngeal abscess and feverdue to recurrent retropharyngeal abscess and feverin spite of in spite of in spite of in spite of 1) three times of incision and drainage of cervical/thoracic ab1) three times of incision and drainage of cervical/thoracic ab1) three times of incision and drainage of cervical/thoracic ab1) three times of incision and drainage of cervical/thoracic abscessscessscessscess2) repair of suspicious esophageal perforation site2) repair of suspicious esophageal perforation site2) repair of suspicious esophageal perforation site2) repair of suspicious esophageal perforation site3) intravenous antibiotics treatment for 6 months in other hosp3) intravenous antibiotics treatment for 6 months in other hosp3) intravenous antibiotics treatment for 6 months in other hosp3) intravenous antibiotics treatment for 6 months in other hospitalitalitalital

bloodbloodbloodblood----stained chopstick was found beside her a few daysstained chopstick was found beside her a few daysstained chopstick was found beside her a few daysstained chopstick was found beside her a few daysbefore she presented fever and was admitted in the other hospitbefore she presented fever and was admitted in the other hospitbefore she presented fever and was admitted in the other hospitbefore she presented fever and was admitted in the other hospital al al al

Neck & Chest CTNeck & Chest CTNeck & Chest CTNeck & Chest CT---- First presentation First presentation First presentation First presentation ----

Neck CT, Chest CTNeck CT, Chest CTNeck CT, Chest CTNeck CT, Chest CT---- 7 days after 17 days after 17 days after 17 days after 1stststst drainage drainage drainage drainage ----

Neck & Chest CTNeck & Chest CTNeck & Chest CTNeck & Chest CT---- 1 month after 11 month after 11 month after 11 month after 1stststst drainage drainage drainage drainage ----

Recurrence on CTRecurrence on CTRecurrence on CTRecurrence on CT- 1.5 month after1.5 month after1.5 month after1.5 month after1111stststst discharge discharge discharge discharge ----

Neck & Chest CTNeck & Chest CTNeck & Chest CTNeck & Chest CT---- 2 weeks after 22 weeks after 22 weeks after 22 weeks after 2ndndndnd drainage drainage drainage drainage ----

Recurrence on CTRecurrence on CTRecurrence on CTRecurrence on CT---- 1 month after1 month after1 month after1 month after2222ndndndnd discharge discharge discharge discharge ----

EsophagographyEsophagographyEsophagographyEsophagography---- 10 days after 310 days after 310 days after 310 days after 3rdrdrdrd drainage drainage drainage drainage ----

Transfer to our hospital 1 month after 2Transfer to our hospital 1 month after 2Transfer to our hospital 1 month after 2Transfer to our hospital 1 month after 2ndndndnd recurrencerecurrencerecurrencerecurrence

ImpressionImpressionImpressionImpression: Retropharyngeal abscess and : Retropharyngeal abscess and : Retropharyngeal abscess and : Retropharyngeal abscess and mediastinitismediastinitismediastinitismediastinitis

due to chopstick injurydue to chopstick injurydue to chopstick injurydue to chopstick injury

WorkWorkWorkWork----ups to Find the Perforated Siteups to Find the Perforated Siteups to Find the Perforated Siteups to Find the Perforated SiteNeck CTNeck CTNeck CTNeck CT

EsophagographyEsophagographyEsophagographyEsophagographyFistulographyFistulographyFistulographyFistulographyLaryngoscopyLaryngoscopyLaryngoscopyLaryngoscopy

EsophagoscopyEsophagoscopyEsophagoscopyEsophagoscopy: No evidence of perforation of : No evidence of perforation of : No evidence of perforation of : No evidence of perforation of parynxparynxparynxparynx or esophagusor esophagusor esophagusor esophagus

Treatment PlanTreatment PlanTreatment PlanTreatment PlanLongLongLongLong----term conservative management with intravenous antibiotics at term conservative management with intravenous antibiotics at term conservative management with intravenous antibiotics at term conservative management with intravenous antibiotics at

home via home via home via home via BroviacBroviacBroviacBroviac catheter to control residual abscess and fevercatheter to control residual abscess and fevercatheter to control residual abscess and fevercatheter to control residual abscess and fever

Neck Lat. XNeck Lat. XNeck Lat. XNeck Lat. X----ray & CTray & CTray & CTray & CT EsophagographyEsophagographyEsophagographyEsophagography

after 20 days of IV antibiotics after 20 days of IV antibiotics after 20 days of IV antibiotics after 20 days of IV antibiotics TxTxTxTx. . . . at home via CVC

poor oral intake, fever and Lt. lat. neck swellingpoor oral intake, fever and Lt. lat. neck swellingpoor oral intake, fever and Lt. lat. neck swellingpoor oral intake, fever and Lt. lat. neck swelling

palpable abscess pocket palpable abscess pocket palpable abscess pocket palpable abscess pocket in her Lt. lat. neck: about 2 x 3 cm in size

radio-opaque dye was injected into the1) abscess cavity and

2) esophagusto find suspected fistula,

butno evidence of fistula no evidence of fistula no evidence of fistula no evidence of fistula was detected.

2222ndndndnd AdmissionAdmissionAdmissionAdmission

I.I.I.I. Incision and drainageIncision and drainageIncision and drainageIncision and drainage- hockey stick incision on Lt. lateral cervical area- hemovac drainage catheter insertion

II.II.II.II. PicibanilPicibanilPicibanilPicibanil injection to the abscess cavity injection to the abscess cavity injection to the abscess cavity injection to the abscess cavity after the abscess was subsidedvia drainage cathetertwice injection of picibanil for 5 daysno symptomatic change or discharge

after picibanil injection

discharge after removal of the catheter

Treatments on 2Treatments on 2Treatments on 2Treatments on 2ndndndnd AdmissionAdmissionAdmissionAdmission

10 days after second discharge

pus discharge from cervical incision site

Treatment PlansTreatment PlansTreatment PlansTreatment Plans

I. control of inflammation and perifistula edemaby IV antibiotics treatmentIV antibiotics treatmentIV antibiotics treatmentIV antibiotics treatment

II. delayed evaluation of fistuladelayed evaluation of fistuladelayed evaluation of fistuladelayed evaluation of fistulaafter control of inflammation

and decrease of perifistula edemato make the fistula visible

3333rdrdrdrd AdmissionAdmissionAdmissionAdmission

IV antibiotics treatment for 1 week

FistulographyFistulographyFistulographyFistulography

: injection of dye to the abscess cavity

⇒ drainage of dye to the esophagus

EsophagoscopyEsophagoscopyEsophagoscopyEsophagoscopy

: injection of air to the abscess cavity

⇒ leakage of air bubble into esophagus

WorkWorkWorkWork----ups on 3ups on 3ups on 3ups on 3rdrdrdrd Adm.Adm.Adm.Adm.

Tube feeding for one monthTube feeding for one monthTube feeding for one monthTube feeding for one monthto heal the injured esophageal site

with IV antibiotics treatment

oral feeding of diet mixed with gentian violet dye

7 days

violet color tinged at the end of drainage catheter

Treatment on 3Treatment on 3Treatment on 3Treatment on 3rdrdrdrd admadmadmadm. (I). (I). (I). (I)

Neck explorationNeck explorationNeck explorationNeck explorationsealing of oral cavity, one nostril, and both ears

to prevent leakage to other airways

air shooting through the catheterinserted via another nostril to esophagus

detection of air leakage on posterior wall of inlet of upper cervical esophagus

repair of esophageal perforation

Treatment on 3Treatment on 3Treatment on 3Treatment on 3rdrdrdrd admadmadmadm. (II). (II). (II). (II)

postoperative course : uneventful

discharge on POD #7

no recurrent symptom for 2 months after discharge

ConclusionConclusionConclusionConclusionRetropharyngealRetropharyngealRetropharyngealRetropharyngeal abscess with fistula tractabscess with fistula tractabscess with fistula tractabscess with fistula tract

Abscess can recur without the control of fistula.Remaining fistula should be considered in the case

ofrecurrent abscess.

Difficulty in control of the abscess is attributable tothe difficulty in detection of fistula tract.

Control of the perifistula inflammation should precede

the effort to detect the fistula tract, and every efforts

should be done to find and close the fistula tract.