Medical Malpractice Insights: It may be more than “just a sore throat”

Here’s another case from from Medical Malpractice Insights – Learning from Lawsuits, a free monthly opt-in email newsletter. The goal of MMI-LFL is to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits.

Author: Chuck Pilcher MD, FACEP; Editor, Med Mal Insights

It may be more than “just a sore throat”

Retropharyngeal abscesses may be subtle

Facts: A 34 yo female presents to the ED with severe sore
throat and dysphagia of 2 days duration. She is anxious and
crying. Examination shows no tonsillar exudates, no lymphadenopathy, and no fever. Rapid strep test is negative. She is given Decadron, viscous lidocaine, and a prescription for Lortab elixir. She returns the next day appearing ill, and the exam is unchanged. Supportive therapy is continued. Two days later she is seen by her PCP at an Urgent Care center, still afebrile, but with trismus and muffled speech. Her neck is “too tender to touch.” A CT is done and reported the next morning as a likely retro- and para-pharyngeal abscess. She is started on serial IV antibiotics as an outpatient, after a telephone consult with an ENT at a tertiary hospital. She improves slightly, but a f/u CT a week later shows spread of the infection. She is sent to the tertiary hospital for surgery. She develops chronic post-operative pain over the next year and consults an attorney.

Plaintiff: You should have made the diagnosis earlier. If I had re- ceived antibiotics earlier, I would not have needed surgery, and I would not be in pain now.
Defense: A retropharyngeal abscess is rarely obvious early. You didn’t even have a fever. Antibiotics are appropriate initially; surgi- cal drainage should be delayed until there is frank pus. Earlier an- tibiotics might not have made any difference.

Result: After expert review of the medical record, plaintiff attorney elected not to file a lawsuit.

Takeaways:

1. Symptoms of retro- or parapharyngeal abscess include fever, dysphagia (difficulty swallowing), odynophagia (pain with swallowing), neck tenderness, and sometimes dyspnea.
2. Neck stiffness and swelling are more common in infants and children.
3. Because this is uncommon, one must remember to think of it in any case of severe sore throat, especially when the “throat” itself looks normal.
   

   References:

   Retropharyngeal Abscess. Kahn JH. Medscape eMedicine, up- dated Jan 27, 2017.

   Deep neck space infections. Chow AW. UpToDate Online, up- dated Jul 16, 2015.

   “Good judgment comes from experience. Experience comes from bad judgment.”