European Journal of Radiology 85 (2016) 1247–1256

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Fluid collection in the retropharyngeal space: A wide spectrum of

various emergency diseases
Hayato Tomita a,∗ , Tsuneo Yamashiro a,b , Hirotaka Ikeda a , Atsuko Fujikawa a ,
Yoshiko Kurihara a , Yasuo Nakajima a
a
Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
b
Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa 903-0215, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Fluid collections in the retropharyngeal space (RPS) result from a wide spectrum of diseases, including
Received 23 October 2015 retropharyngeal abscess, cervical osteomyelitis, and calcific tendinitis of the longus colli muscle. These
Received in revised form 27 March 2016 conditions should be managed by different specialties; beginning with care in the emergency room,
Accepted 5 April 2016
physicians from orthopedics, pediatrics, otolaryngology, and oncology are in charge of the treatment.
Since these diseases demonstrate similar fluid collections in the RPS on computed tomography (CT) and
Keywords:
magnetic resonance imaging (MRI), the radiologist’s diagnosis based on the characteristic imaging find-
Retropharyngeal space
ings is very important to identify the primary disease. Also, since some of the diseases require immediate
Fluid collection
Retropharyngeal abscess
surgical intervention to avoid life-threatening mediastinitis or airway obstruction, radiologists must dis-
CT tinguish these diseases correctly and provide recommendations for their management to physicians.
MRI Understanding clinical features and imaging findings of these fluid collections in the RPS is crucial for the
best care.
© 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction rapidly and require immediate surgical interventions in order to

Fluid collection in the retropharyngeal space (RPS) is a mani-
festation of various diseases, which are treated by physicians in
different clinical departments. Although patients present with less
specific symptoms, such as dysphagia, sore throat, fever, neck pain,
and stiffness, this condition is caused by a wide variety of dis-
eases including retropharyngeal edema, abscess, or hemorrhage.
The retropharyngeal edema results from an increased permeabil-
ity of capillaries and obstruction of lymphatic and venous drainage,
as well as a sudden onset of calcific tendinitis of the longus colli
muscle. Infections in the neck, such as peritonsillar abscesses and
suppurative lymphadenitis, trigger retropharyngeal abscesses [1].
Trauma and fracture of the cervical spine cause retropharyngeal
hemorrhage. The RPS has loose areolar tissue [2]. Inflammation that
spreads to the mediastinum by gravity causes mediastinitis. The
fluid collection within the RPS that displaces the trachea anteriorly
results in airway obstruction. Although some diseases can be man-
aged with conservative treatment, fluid collections in the RPS are
observed in various emergency conditions that must be diagnosed
∗ Corresponding author.
E-mail address: m04149@yahoo.co.jp (H. Tomita).
avoid life-threatening mediastinitis and airway obstruction.
Radiographs have a limited role in predicting the presence of
retropharyngeal diseases. Computed tomography (CT) and mag-
netic resonance imaging (MRI) are the best imaging modalities to
identify diseases in the RPS [1,3–5]. The imaging findings of a fluid
collection in the RPS on CT and MRI are often non-specific. However,
some of them often show characteristic imaging findings if radiolo-
gists fully notice their characteristics. For example, retropharyngeal
abscess, which results from peritonsillar abscesses, pyogenic lym-
phadenitis, foreign bodies ingestion, and cervical osteomyelitis,
typically appears a fluid collection in the RPS with rim enhancement
on contrasted CT and MRI. In addition, CT is useful to detect foreign
bodies, calcification of the longus colli muscle, and bony destruction
caused by osteomyelitis. MRI can also reveal the correct extent of
fluid collections in the RPS and pyogenic osteomyelitis. Radiologists
are required to make a correct diagnosis and to determine clinical
departments that should care for the condition to facilitate treat-
ment. To the best of our knowledge, there is no previous review
that provides an overview of these conditions and demonstrates
imaging findings of fluid collections in the RPS.
We strongly believe that learning the variety of these diseases
and their characteristic imaging findings is essential for radiolo-
gists to distinguish various diseases that cause fluid collections in

http://dx.doi.org/10.1016/j.ejrad.2016.04.001
0720-048X/© 2016 Elsevier Ireland Ltd. All rights reserved.
1248 H. Tomita et al. / European Journal of Radiology 85 (2016) 1247–1256

Fig. 1. Normal anatomy of the RPS. Axial images containing CT show visceral fascia (black line), prevertebral fascia (green line), the carotid sheath (blue line), and the
alar fascia (purple dashed line) (A). A sagittal image shows RPS (yellow area), and the danger space (red area) (B). Medial retropharyngeal nodes (arrowhead) and lateral
retropharyngeal nodes (arrow) are shown in the RPS (C).

Fig. 2. A practical approach for differential diagnosis of fluid collections in the RPS. Radiologists are required to identify the diseases in the RPS and to determine the clinical
department that is appropriate for rendering treatment.

the RPS. In this review, the following diseases are demonstrated and
discussed: retropharyngeal abscess due to peritonsillar abscesses
and cervical lymphadenitis, foreign body ingestion, osteomyelitis,
calcific tendinitis of the longus colli muscle, Kawasaki disease, pyri-
form sinus cyst, lymphatic malformation, malignant lymphoma,
angioedema, and retropharyngeal hematoma. We hope that read-
ers recognize the major imaging findings of these diseases and
avoid their over- or underdiagnosis.
2. Anatomy of the RPS
impossible to differentiate the danger space from the RPS because
the alar fascia is very thin and the RPS itself occupies such a small
space.
The RPS contains lymph nodes, small vessels and fatty tissue.
The medial retropharyngeal nodes, which receive the lymphatic
drainage from the pharynx, atrophy before puberty, making chil-
dren susceptible to lymphadenitis with subsequent pharyngitis.
The lateral retropharyngeal nodes remain in adults and are com-
mon sites of lymph node metastasis from nasopharyngeal cancer.
The fatty tissue in the RPS can be a pathway for infection that
spreads inferiorly from the neck to the chest causing mediastinitis.

The RPS is located posterior to the pharynx and anterior to the

prevertebral muscles and surrounded anteriorly by the visceral
fascia, posteriorly by the prevertebral fascia, and laterally by the
carotid sheath [6–8] (Fig. 1). The RPS is divided into the true RPS
and the “danger space” by the deep layer of the deep cervical fas-
cia, called the alar fascia [6,8]. The true RPS extends from the skull
base to the upper thoracic spine (T1–T6) where the alar fascia fuses
with the visceral fascia [7,8]. The danger space runs more inferiorly
towards the mediastinum at the level of the diaphragm. It is almost
3. an overview for diseases demonstrating fluid collections
in the RPS
Table 1 demonstrates the differential diagnosis of diseases
resulting in a fluid collection within the RPS. Fig. 2 shows a basic
category of diseases that demonstrate fluid collections in the RPS.
Based on the clinical features of the diseases, they can be cat-
egorized by the presence of infection and by the possibility of
 H. Tomita et al. / European Journal of Radiology 85 (2016) 1247–1256 1249

Table 1
Differential diagnosis of diseases resulting in a fluid collection within the RPS.

Disease Infection Emergency Clinical department Key finding Note

Retropharyngeal abscess Yes Yes otolaryngology Fluid collecion in the RPS with Mediastinitis
rim enhancement
Foreign body ingestion Yes Yes otolaryngology Fluid collecion in the RPS with Mediastinitis
a trigger
Osteomyelitis Yes Yes Orthopedics Destructive changes in the Mediastinitis
cervical spine
Calcific tendinitis of the longus No No Orthopedics Calcifications of the longus Often misdiagnosed as abscess
colli muscle colli muscle
Kawasaki disease No Yes Pediatrics Fluid collecion in the RPS with Specific criteria
other symptoms
Pyriform sinus cyst Both Yes Pediatrics or surgeon Fistula and suppurative Airway obstruction
thyroiditis
Lymphatic malformation No No Pediatrics or otolaryngology Well-defined smooth or –
lobular mass
Malignant lymphoma No No Hematology or radiation Large lymphadenopathy –
oncology
Angioedema No Yes Emergency medicine or Fluid collecion in the RPS with Airway obstruction
otolaryngology a trigger
Retropharyngeal hematoma No Yes Emergency medicine or Cervical fracture or bleeding Airway obstruction
Orthopedics

being treated as an emergency condition. Determining physicians
in charge of caring for patients is also very important for effective
clinical management since different clinical departments, such as
orthopedics, pediatrics, otolaryngology, and oncology, are respon-
sible for diseases showing fluid collections in the RPS. In other
words, if radiologists misdiagnose the disease, physicians in an
inappropriate clinical department may be forced to manage the
patient with inappropriate treatment options.
ment for suppurative retropharyngeal nodes is antibiotics, whereas
retropharyngeal abscesses are treated with surgical drainage
[1]. A contrast-enhanced CT of an abscess in the RPS demon-
strates the characteristic images of the retropharyngeal fluid with
rim enhancement, while the retropharyngeal fluid without rim
enhancement and the nodule with rim enhancement around an
area of central low attenuation are seen in suppurative lym-
phadenitis [1,5,13] (Figs. 3 and 4).

4. Diseases causing fluid collections in the rps

4.1. Retropharyngeal abscess—the most dangerous condition

Retropharyngeal abscess can be caused by a cervical infection

that involves the lymphatic drainage pathway in the pharynx,
paranasal sinuses, middle ear, or the prevertebral space [9].
Retropharyngeal abscesses are most commonly caused by periton-
sillar abscesses and pyogenic lymphadenitis and less commonly by
foreign body ingestion and osteomyelitis of the cervical spine (See
the following chapters). A retropharyngeal abscess more frequently
occurs in patients with an immunocompromised status [10]. The
symptoms of the abscess, such as fever, sore throat, and dysphagia,
are not specific for making the diagnosis. The infected retropha-
ryngeal lymph nodes surrounding the abscess often enlarge,
indicating the infection. The nodes sometimes become edematous
and necrotic, reflecting severe infection [1]. Staphylococcus aureus
and group A Streptococcus (GAS) infections are the most common
cause of cervical lymphadenitis [5]. Fusobacterium necrophorum
is an anaerobic bacteria identified in the majority of peritonsil-
lar abscesses [11]. A retropharyngeal abscess also results from
Lemierre’s syndrome, in which septic thrombophlebitis of the
internal jugular vein develops following a primary oropharyngeal
infection [12]. When an abscess in the RPS is observed, it is essential
to evaluate for mediastinal extension, central airway obstruction,
and vascular complications (i.e. internal jugular thrombosis, inter-
nal carotid artery stenosis and pseudoaneurysm). An infection in
the danger space more quickly spreads into the mediastinum by
gravity, resulting in mediastinitis and empyema.
The role of diagnostic imaging is very important for mak-
ing a correct diagnosis of retropharyngeal abscesses when the
etiologies above are seen. Radiologists are required to differ-
entiate suppurative retropharyngeal nodes and retropharyngeal
edema from retropharyngeal abscess because the current treat-
4.2. Foreign body ingestion
Foreign body ingestions in children account for 80% of all cases
[14]. Foreign bodies swallowed by children include coins, batter-
ies, pens, and toys. Oropharyngeal injuries occur accidentally in
children who fall down when they are holding an object such as a
toy, stick, or toothbrush in their mouths. Batteries must be distin-
guished from other foreign bodies because they can result in serious
damage such as tracheoesophageal fistula, esophageal perforation,
and mediastinitis just two hours after ingestion [15]. Ingestions
related to foods usually occur in older children and adults. Most for-
eign bodies pass through the gastrointestinal tract; however, items
>20 mm in diameter become lodged within the esophagus and 20%
of patients require treatment, while <1% require surgery [14–17].
Migrating or penetrating foreign bodies cause local infection or tis-
sue damage in the pharyngeal wall, resulting in fluid collections or
abscesses in the RPS [18]. Radiographs of the neck and chest in both
anteroposterior and lateral views are performed to detect the for-
eign body [15,19]. Button batteries appear to form a double ring sign
on radiographs (Fig. 5). However, 80% of foreign bodies are radiolu-
cent [13]. A radiograph is able to detect metal objects and dense
bones, but it cannot rule out glass, wood, and thin metal objects
[14]. It is important to look for foreign bodies and secondary ede-
matous lesions using multiple reconstructed images [20] (Fig. 6). A
3-dimensional reconstruction CT scan has high sensitivity to iden-
tify foreign bodies, although there is a sensitivity of only 36% using
a radiograph [14,21,22]. In cases of delayed diagnosis of battery
ingestion, a contrast-enhanced CT should be performed to exclude
serious complications in the esophagus [15].
1250 H. Tomita et al. / European Journal of Radiology 85 (2016) 1247–1256

Fig. 3. Retropharyngeal abscess. A 57 years old female presented to the ENT outpatient clinic with a history of progressive throat pain, hoarseness, and fever for four days.
Contrast-enhanced axial CT images show ill-defined fluid collections with rim enhancement adjacent to the left tonsil (A) and in the RPS (arrows) (B). Contrast-enhanced
sagittal CT image shows the abscess tracks caudally, resulting in pyogenic mediastinitis (long arrows) (C).

Fig. 4. Cervical lymphadenitis. A 3 years old boy presented with fever and lymphadenopathy. Group A Streptococci was detected from a throat swab test. A fluid collection
in the RPS without rim enhancement (arrow), a necrotic lymph node (ovoid circle), and tonsil swelling (arrowhead) are demonstrated on contrast-enhaced axial and sagittal
CT images (A, B).

5. Osteomyelitis—another cause of retropharyngeal abscess
that should not be treated by otolaryngologists
Osteomyelitis accounts for 1–7% of all bone infections [23].
Cervical osteomyelitis is a rare disease occurring in 3–6% of the
entire spinal osteomyelitis population [23]. Cervical osteomyeli-
tis is defined as the inflammation of bone or bone marrow caused
by bacteria, resulting from an indirect spread of hematogenous
infection to other sites [24]. Patients with diabetes, alcoholism,
drug abuse, tuberculosis, and radiotherapy easily present with cer-
vical osteomyelitis [25,26]. Radiation for head and neck cancer
causes a fluid collection in the RPS after 4–6 weeks. Also, mucosal
necrosis and reduced resistance to infection sometimes result in
osteomyelitis [7,27].
Osteomyelitis can spread along the anterior longitudinal liga-
ment, causing abscesses in the RPS that are confirmed as a fluid
collection with rim enhancement on contrast-enhanced CT and MRI
[28,29]. Paraspinal soft tissue swelling or destructive changes in the
cervical spine are key findings that raise suspicion for osteomyelitis
on CT and MRI (Fig. 7). If these conditions are misdiagnosed, exten-
sive bony destruction and cervical epidural abscess could lead to
neurological disorder caused by a spinal cord compression that is
treated not by an otolaryngologist but by an orthopedist. Radiolo-
gists should consider osteomyelitis when an abscess in the RPS is
not accompanied by an obvious peritonsillar abscess or other neck
infectious lesions.
6. Calcific tendinitis of the longus colli muscle—frequently
misdiagnosed as a retropharyngeal abscess
Calcific tendinitis of the longus colli muscle is caused by deposi-
tion of calcium hydroxylase apatite crystals at the C1-C2 and rarely
C5-C6 vertebral levels in the 3rd to 6th decades [30,31]. Patients
are often misdiagnosed with retropharyngeal abscesses because
they have similar symptoms and imaging findings; however, cal-
cific tendinitis of the longus colli muscle often develops suddenly.
Nonsteroidal anti-inflammatory drugs or a brief course of steroids
are treatment options.
 H. Tomita et al. / European Journal of Radiology 85 (2016) 1247–1256 1251

Fig. 5. Foreign body (button battery) ingestion in a child. A 1 years old boy swallowed a button battery. A lateral radiograph shows the battery (arrowhead) (A). After the
battery was removed, a fluid collection in the RPS (arrows) was observed on contrast-enhanced axial CT image (B).

Fig. 6. Foreign body (fish bone) ingestion. A 40 years old female presented to the ER with a history of odynophagia after fish intake. A high density area at the left pyriform
sinus (arrow) with a fluid collection in the RPS (arrowhead) is seen in an axial CT image (A). A foreign body (fish bone) stuck at the left pyriform sinus can be identified in a
sagittal CT image (arrow) (B).

CT may provide a more accurate estimate of the calcific tendini-
tis of the longus colli muscle [30,32]. The characteristic findings on
CT are a fluid collection in the RPS without rim enhancement and
with amorphous calcifications of the longus colli muscle at the C1-
C2 levels [30,31] (Fig. 8). Understanding these conditions and CT
images leads to prevention of unnecessary antibiotics and surgical
intervention. MRI can detect the diffuse edema in the RPS, while it
is difficult to show the calcific deposition.
7. Kawasaki disease—mimicking retropharyngeal abscess
and lymphadenitis
Kawasaki disease is an acute vasculitis of undetermined etiology
that occurs predominantly in children younger than 5 years old. The
diagnosis of Kawasaki disease is based on the presence of a fever
persisting at least 5 days and 4 of 5 principal criteria as follows: 1)
changes in extremities including erythema and edema, 2) changes
in the lips or oral cavity, 3) nonpurulent conjunctivitis, 4) poly-
morphous exanthema, and 5) cervical lymphadenopathy greater
than 1.5 cm in diameter [33,34]. High doses of immunoglobulin and
aspirin are used to prevent coronary artery aneurysms and relieve
the symptoms.
Retropharyngeal fluid collection (retropharyngeal edema) in
Kawasaki disease occurs in 64% of cases [35]. Vasculitis of microves-
sels with tissue edema and inflammation is considered as the major
mechanism of low density without rim enhancement in the RPS on
contrast-enhanced CT [36,37] (Fig. 9). Kawasaki disease could be
misdiagnosed because the symptoms are similar to those of deep
neck infections. The lack of enhancement around the fluid collec-
tion in the RPS may be helpful to distinguish the retropharyngeal
abscess with rim enhancement [33,38]. However, if the fluid collec-
tion is accompanied by necrotic lymphadenopathy, it is difficult to
1252 H. Tomita et al. / European Journal of Radiology 85 (2016) 1247–1256

Fig. 7. Osteomyelitis. A 34 years old male presented to the hospital with a 2-day history of posterior cervical pain and fever. Soft tissue swelling (black arrow) is seen at the
C5–C7 levels and destructive changes at the superior endplate of C6 on contrast-enhanced sagittal CT images (arrow) (A, B). Osteomyelitis (arrow) at the C5–C6 levels with
an epidural abscess (arrowhead) is seen on sagittal STIR (C). Retropharyngeal edema remained.

Fig. 8. Calcific tendinitis of the longus colli muscle. A 35 years old male presented to the hospital with a history of progressive, severe neck pain and odynophagia for three
days. Fluid collection in the RPS without rim enhancement (arrow) and a calcification anterior to the C2 vertebral body (arrowhead) are seen on contrast-enhanced axial and
sagittal CT images (A, B).

Fig. 9. Kawasaki disease. A 9 months old boy presented with a high fever for 3 days. He had been diagnosed with cervical lymphadenitis and tonsillitis. The symptoms did
not improve with antibiotics. Contrast-enhanced axial and sagittal CT images show a low-density fluid collection without rim enhancement in the RPS (arrows) (A, B).
 H. Tomita et al. / European Journal of Radiology 85 (2016) 1247–1256
distinguish Kawasaki disease and retropharyngeal abscess caused
by pyogenic lymphadenitis.
8. Pyriform sinus cyst
A pyriform sinus fistula originates from a developmental
anomaly of the third or fourth branchial pouch [39]. An infection
extending from the apex of the pyriform sinus to the thyroid gland
via this fistula is recognized as the cause of suppurative thyroiditis
[40,41]. The prevalence of suppurative thyroiditis is 83% left-sided
[42]. The fourth branchial artery on the left side becomes a part of
the aortic arch while the one on the right side becomes the right
subclavian artery [39]. The embryologic asymmetry may be associ-
ated with the left-sided predominance. Surgical excision is the only
radical treatment.
Although a pyriform sinus fistula is usually identified with a bar-
ium swallow study, CT or MRI are also available to detect the tract
and its complications [39,43,44] (Fig. 10). The diagnosis using CT
or MRI is accomplished by detecting the tract and suppurative thy-
roiditis [39]. Infection of the pyriform sinus fistula spreading from
the parapharyngeal space to the RPS might form a retropharyngeal
abscess [45]. The characteristic findings of the pyriform sinus fis-
tula on CT or MRI would play a role in identifying the cause of the
retropharyngeal abscess.
9. Lymphatic malformation
Lymphatic malformation develops from a congenital malforma-
tion of the lymph system, which is frequently diagnosed before
the age of 2 years, whereas the onset in adults is extremely rare
[46]. Lymphatic malformation accounts for 5% of benign tumors in
children, and 45–52% occur in the head and neck [47,48]. The mal-
formation in the head and neck results from abnormal development
of the embryonic lymphatics and lymphatic jugular sacs that con-
nect to lymphatic channels [48,49]. Lymphatic malformations are
categorized into three morphologic types: macrocystic, microcys-
tic, and mixed [48,49]. The macrocystic lesions have larger cysts
than microcystic lesions consisting of multiple cysts smaller than
2 mm [50,51]. The treatments range from non-invasive therapy to
surgery because sufficient evidence has not yet been established
[47,48]. Treatments of the localized lesions are sclerotherapy, laser
therapy, and surgery. The conditions of airway obstruction, active
bleeding, and cosmetic problems would require an intervention.
The diagnosis of lymphatic malformation is usually based on
the physical examination and medical history. However, CT and
MRI have a key role in excluding other vascular malformations and
assessing the extent of the lesions and the presence of inflammation
[47,52]. Lymphatic malformation is a benign cause of fluid collec-
tions in the RPS [52]. The imaging findings on MRI are shown as a
well-defined smooth or lobular mass, hyperintense on T2 weighted
images (T2WI) (Fig. 11). Additionally, the cysts do not demonstrate
the enhancement, with minimal enhancement of the septa of vari-
able thickness after administration of gadolinium-based contrast
material on MRI. Contrast-enhanced CT would be helpful to recog-
nize the extent of displacement or involvement of adjacent vessels
and surrounding structures [47,53].
10. Malignant lymphoma—the largest entity of
retropharyngeal edema
Malignant lymphoma is involved in approximately 5% of malig-
nant neoplasms in the head and neck [54]. The diagnosis of the
malignant lymphoma and detection of the difference between the
subtypes requires a biopsy of the lymph node.
1253
To the best of our knowledge, no previous literature has reported
the cause of a fluid collection in the RPS resulting from malignant
lymphoma. Malignant lymphoma may cause necrosis in lymph
nodes, which mimics lymphadenitis. Stenosis or obstruction of the
cervical lymphatic tract can occur in the lymphatic system due to
swelling of lymph nodes. The increase in venous hydrostatic pres-
sure may cause the fluid collection to extend into the interstitial
space, as in Kawasaki disease.
CT and MRI show one or more enlarged cervical lymph nodes
that may not be specific in neck diseases. The imaging appear-
ance of fluid collection in the RPS on contrast-enhanced CT is low
attenuation without rim enhancement (Fig. 12).
11. Angioedema—causing airway obstruction
Angioedema, an immunologic disorder, represents the swelling
of the mucosa and subcutaneous tissues due to the leak of small
blood vessels. Angioedema is classified as hereditary, allergic, and
idiopathic. Hereditary angioedema is a recurrent inherited disorder
resulting from C1 esterase inhibitor deficiency or dysfunction [55].
The triggers of allergic angioedema include medications, foods, and
a physical reaction such as pressure [55]. Airway management is
the priority in anaphylaxis patients because the edema produces
upper airway obstruction that may be life-threatening.
CT or MRI allows detailed assessment of the edematous change
and fluid in the RPS without enhancement (Fig. 13). Radiologists
should evaluate the airway and inform the involved doctor if any
airway compromise is suspected based on the clinical information
and images.
12. Retropharyngeal hematoma—importance of careful
observation on CT and MRI
Retropharyngeal hematoma occurs in trauma, rupture of the
carotid artery, foreign body ingestion, hemorrhagic complication
with anticoagulation, and cerebral angiography [4]. The diagnosis
may be difficult because the hematoma in the RPS has non-specific
symptoms similar to those of pharyngitis. However, delayed diag-
nosis could lead to airway obstruction arising from compression
of the laryngopharynx and trachea [56,57]. Isolated C1 and C2
fractures are reported to cause airway obstruction 4.9% of the
time, which is frequently due to retropharyngeal hematoma [58].
Patients with a small hematoma in the RPS are managed con-
servatively. Surgical intervention would be necessary in cases of
expanding hematomas and airway obstruction.
Lateral radiographs may provide information about the prever-
tebral soft tissue thickness [4]. CT and MRI are useful methods to
identify the hematoma and the extent even in the acute phase
(Fig. 14). Dynamic contrast-enhanced CT can also estimate the
active bleeding in the RPS. Contrast-enhanced CT findings show
the hematoma with non-enhancement in the acute stage, with
rim enhancement in the subacute stage and with solid-nodular
enhancement in the chronic stage [59]. Rim enhancement is
related to the perivascular inflammatory reaction of the hematoma,
while solid-nodular enhancement involves the angiogenic collagen
matrix [59]. The CT appearance of the rim-enhanced hematoma
may mimic an abscess; however, clinical information and MRI
would be helpful. Hematoma in the acute phase reveals hyper-
intensity on both T1WI and T2WI [60]. Hemosiderin shows as a
hypointensity on gradient-echo MRI but is not identified on CT [61].
13. Other diseases causing fluid collections in the RPS
Although they are extremely rare conditions, there are some
case reports that have demonstrated fluid collections in the RPS.
1254 H. Tomita et al. / European Journal of Radiology 85 (2016) 1247–1256

Fig. 10. Pyriform sinus cyst. Based on routine prenatal US, a newborn baby was suspected of having a large fluid collection in the neck, which narrowed the upper airway.
Axial T2WI shows a high intensity mass in the widened RPS (A). The fluid expands from the lateral neck into the RPS on coronal T2WI (B). A sagittal CT image (18 days after
the MRI) demonstrates that air replaces the fluid collection and extends into the RPS (arrows) (C).

Fig. 11. Lymphatic malformation. A 54 years old female with a past medical history of multiple sclerosis underwent MRI to evaluate cervical spinal lesions. There is a high
intensity lesion at the right side of the RPS from C2 to C3 on T2WI (A, B).

Fig. 12. Malignant lymphoma. A 17 years old female was noted to have cervical swelling at a medical check-up. Contrast-enhanced CT was performed to evaluate the cause
of the cervical swelling. Contrast-enhanced axial CT images show the swelling of the lateral retropharyngeal nodes and internal jugular nodes with necrosis (arrowheads)
(A, B). There is a fluid collection in the RPS without rim enhancement (arrows) (B).
 H. Tomita et al. / European Journal of Radiology 85 (2016) 1247–1256 1255

Fig. 13. Angioedema. A 43 years old female presented to the ER with a history of progressive shortness of breath after eating mango. There is a swelling of the uvula (arrow),
retropharyngeal edema (arrowhead), and diffuse edema in the cervical soft tissues (ovoid circles) on axial CT images (A, B). A smoothly defined fluid collection in the RPS is
seen.

Fig. 14. Retropharyngeal hematoma. A 74 years old male presented to the ER with head trauma after a fall. There is a fluid collection within the RPS on the axial CT image
(arrowhead) (A). An odontoid fracture is seen on the sagittal CT image (arrow) (B).

Bhandarkar et al. reported a case of retropharyngeal abscess, which are required to differentiate the etiology and to recommend referral
was caused by infection to pancreatic pseudocysts that extended to the appropriate department.
through the mediastinum [62]. Also, it was reported by Chrobok
et al. and Yung et al. that infectious thyroiditis leads to retropha- Conflicts of interest
ryngeal abscess [63,64]. These conditions should also be considered
as atypical causes of retropharyngeal abscess. None.

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