a20 yr old down's syndrome girl with uncontrolled epilepsy was brought by her family for rapidly progressing neck pain and dysphagia. endoscopy very edematous pharynx and larynx. xray neck showed prevertebral widening with gas formation, straightening of cervical vertebrae and suspected foreign body at post cricoid level. ? large retropharyngl abcess on questioning the parents they give history that she hurriedly had fish a few days ago. As it was a high risk condition she wasn't taken up at many places. it was heart wrenching looking at her , she's unable to understand what's happening to her all that she wasn't able to swallow anything and had excruciating pain. she was taken up for exploration under GA under high risk thanks to my anaesthetist who dared to give her anesthesia. intra op big sharp fish bone was found at post cricoid region anteriorly abutting laryngeal mucosa posteriorly piercing pharyngeal mucosa, after it's removal 20 ml of foul smelling pus evacuated. it was very difficult to make her retain her ryles tube post surgery, with a lot of her mischief we managed to keep it for 4 days and she made a good diet speedy recovery. *parents of MR children should never leave them unattended when they are consuming food with Sharp particles like meat, and small round food items (can cause aspiration). *we have to take calculated risks *retropharyngeal abcess should be managed before they turn into near fatal mediastinitis.

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I didn't understand the need for a tracheostomy here?? it's not at all needed here. we have to do a trac if there is massive laryngeal and pharyngeal edema where intubation is not feasible. post surgery we kept the tube in situ for a day and deeply sedated with ventilator on stand by her for the edema to come . she pulled out her RT tube after coming out of sedation and extubation thrice. imagine what would happened if she pulled out her trac tube. tracheostomy wasn't needed at all in this case. aspiration of what and when. she's on RT feeds and nil oral for 4 days. where's the chance of aspiration when we aren't feeding her by mouth?? and serial x-rays Ap lateral were taken I just didn't post them here. and there wasn't any other space involvement. and we use 30cm optical forceps for all our endoscopic procedures and we incise and drain the abcess endoscopically. and give betadine and h2o2 washes too. more than aspiration we should be worried about recurrence of the abcess as there is an opening in the mucosa so the NPO and RT feeds. I will post another case where a tracheostomy was needed and then we proceeded with open and endoscopic drainage.

@ Dr Shaib Shankar Roy
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Dr siddharth, a very good job, for managing a fb induced retropharyngeal abscess!!! Onething i want to add within ur management!! Don't only deal with the site of impaction in case of any space abscess, u have to manage other pockets too, go for serial x ray soft tissue neck ap and lateral view, as i can see u haven't consider the chance of tracheostomy requirement during the ot procedure!! For this case u required incision along the both sides of the median raphe and definitely a tracheostomy is required, coz the patient is MR case, aspiration difficulty cannot be predicted from this retarded case!! Anyway, thank u for sharing it..

Wonderful enlightening post on FBs in MR Mentally Retarded Children. It's an eye opener for all doctors and parents and attendants of MR Children like Down's Syndrome. Wonderful job dear Siddharth and special thanks to the Anaesthetist who dared to give anaesthesia at a critical juncture. I know your dynamism Siddharth. Hats off to your skills that saved a life. Keep going on and on. All the best in all your endeavors.

Thanks sirji
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sir, thank you for highlighting such a case. very informative

thanks future doc
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very well conducted .but why RT was kept for 4days?

there is a big opening of the the pharyngeal mucosa by this forgin body. it's through this opening that her own saliva and food contents entered the retropharyngeal space and have formed an abcess so if we just remove the foreign body, drain the abcess and let them have oral feeds the feeds will again enter the retropharyngeal space and the vicious cycle repeats. so RT is placed for feeding till the opening in mucosa heals.
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good job

thanks doc
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Good job doctor... commendable approach for treatment of MR patient... helpful for us also in treating such patients..do keep posting such good cases

thanks doc and will be posting more.
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Yes definitely well managed case and an eye opener for others

thanks doctor
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retropharyngeal abscess can be drained under G .A .

it was done under GA
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Congratulations Sir! Congratulations both of you!!

thanks doc without you guys we can't do anything big
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