Spontaneous Cervical Swelling

Abstract

A 56-year-old patient with no medical history presented spontaneously to the emergency department of our university hospital (Assistance Publique Hôpitaux de Paris) for bilateral neck swelling that had developed over 24 hours. The patient had no traumatic or iatrogenic triggers. He reported an edema of the lower lip that resolved spontaneously the day before. He had no dyspnea nor dysphagia, but did have a discrete dysphonia. He had no fever. Neck swelling was global, bilateral, and painless, and was most severe on the left side. There was a rash, the border of which was marked with a felt pen. Nasofibroscopy results showed a normal airway with a posterior pharyngeal wall bulging. Oropharyngeal and oral cavity examination results were normal, with no trismus.A contrast-enhanced computed tomography (CT) scan showed a large retropharyngeal fluid accumulation of 2 × 10 × 6 cm that extended laterally to the vascular spaces, especially on the left side (Figure , A and B). This was associated with infiltration of the mediastinal fat and a thin left pleural effusion. There was no vascular thrombosis or dental abnormality. Hyperleukocytosis levels were 12 000/mL. We did not have the result of the C reactive protein assay. Diagnosis B. Spontaneous lymphorrheaBecause of the rash, acute neck swelling, large cervical fluid accumulation with mediastinal infiltration, and hyperleukocytosis, we treated the patient as if he had cervical necrotizing fasciitis. He immediately underwent an operation. Orotracheal intubation was easily performed. The left cervicectomy and opening of the superficial fascia revealed a milky fluid that was coming from all the soft tissues. The introduction of the surgeon's finger allowed an easy and large retropharyngeal and retroesophageal dissection from the skull base to the posterior mediastinum.Samples were sent to bacteriology, mycobacteriology, anatomopathology, and biochemistry laboratories. Two lavage modules