CASE REPORT

Neck swelling: Unusual manifestation

of Potts spine
D. Deviprasad
a,
*
, Ashok Shetty
b
, M. Panduranga Kamath
a
, Kiran Bhojwani
a
,
Mariam Kuriakose Supriya
a
a
Department of ENT and Head and Neck Surgery, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
b
Department of Cardio Thoracic Vascular Surgery, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
Received 19 November 2013; accepted 13 December 2013
Available online 8 January 2014
KEYWORDS
Neck swelling;
Tuberculosis: Potts spine
Abstract Tuberculosis (TB) of the skeletal system constitutes only 13% of extrapulmonary TB
and usually involves the thoracic spine. These patients usually present with malaise, weight loss,
night sweats, muscle spasms, paraspinal swellings or neurological decits. We report a case of tuber-
culosis of the spine, which had an unusual presentation only as a painless neck swelling, without any
neurological complications. The patient did not respond well to antitubercular therapy (ATT),
necessitating thoracotomy and drainage of pus. Then his ATT was continued for 1 year and is
asymptomatic during 1 year of follow up thereafter.
2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and
Allied Sciences.
1. Introduction
Tuberculosis (TB) still remains one of the commonest chronic
granulomatous infections, especially in the developing world.
The commonest organs affected are the lungs but extrapulmo-
nary TB is also encountered in day to day practice. Among the
patients with extrapulmonary TB, skeletal TB constitutes only
13%, of which spine is involved in half of the cases.
1
TB spine
commonly involves the thoracic spine.
2
TB spine if not treated
adequately can have serious sequelae.
3
We report a case of
tuberculosis of the spine, which had an unusual presentation
as a painless neck swelling but without any neurological
complications.
2. Case report
A 25 year old male presented to our hospital with complaints
of a painless swelling on the left side of the neck for 2 months
duration. Patient gave history of fever, on and off in the past
few months. He also gave history of low grade back pain
for the past 1 year for which he was not taking any treat-
ment. On examination, there was a 5 7 cm soft, uctuant
swelling on the left side of the neck, deep and lateral to the
*
Corresponding author. Address: Department of ENT and Head
and Neck Surgery, Kasturba Medical College, Manipal University,
Mangalore 575001, Karnataka, India. Tel.: +91 9900135975.
E-mail address: dr.deviprasad@yahoo.co.in (D. Deviprasad).
Peer review under responsibility of Egyptian Society of Ear, Nose,
Throat and Allied Sciences.
Production and hosting by Elsevier
Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2014) 15, 135137
Egyptian Society of Ear, Nose, Throat and Allied Sciences
Egyptian Journal of Ear, Nose, Throat and Allied
Sciences
www.ejentas.com
2090-0740 2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
http://dx.doi.org/10.1016/j.ejenta.2013.12.004
sternocleidomastoid, with fullness of the neck on the right.
Examination of the oral cavity and oropharynx was within
normal limits. Video laryngoscopy showed no signicant
ndings. Systemic examination detected no abnormalities.
Routine blood investigation showed a raised total leuko-
cyte count of 10,360/dL and an ESR of 46 at rst hour. Patient
was negative for HIV. The Mantoux test was strongly positive
(20 mm). FNAC of the swelling showed caseous necrosis.
CECT of the neck and upper mediastinum was done which
showed a large pre and paravertebral collection from C3 to T5
but was continuing further down (Fig. 1A). As per orthopedi-
cians advice MRI of the spine was done, which showed a loc-
ulated collection from C3 to T10 vertebral levels with erosion
of few of the corresponding anterior vertebral bodies (Fig. 1B).
On the basis of these ndings, a diagnosis of paravertebral ab-
scess with Potts spine was made. Opinion was sought from the
pulmonologist and the cardiothoracic surgeon, and the patient
was discharged on Category (CAT) 1 antitubercular therapy
(ATT) along with injection of Streptomycin 1 g IV once daily.
Patient came back to us after 1 month with an increase in
size of the swelling and associated pain. On examination, the
neck swelling had increased in size (Fig. 2). The swelling was
tender and hot. Aspiration of the abscess was done and pus
was sent for culture and sensitivity, which showed no growth.
The case was reviewed by the cardiothoracic surgeon, and
thoracotomy with drainage of the pus was done (Fig. 3).
About 500 ml of pus was drained which decompressed the
neck swelling. Intercostal drainage tube was inserted, which
was removed on post-operative day 3. Patient was discharged
on CAT 1 ATT on post-operative day 6. Patient came with
recurrent neck swellings subsequently. So on 3 occasions, each
about 2 weeks apart, patient underwent needle aspiration.
After completion of the 1 year treatment, patient is on regular
follow up for another year and is asymptomatic.
3. Discussion
Vertebral tuberculosis is the commonest form of skeletal tuber-
culosis and it accounts for about 50% of the tuberculosis of the
bone and joints.
4
Of these, tuberculosis affecting the thoracic
spine is about 42%. Even though, it can occur in any age from
1 to 80 years, it is much more common in the rst three dec-
ades of life.
2
Patients usually present with clinical symptoms
of malaise, weight loss, and night sweats. Some patients may
also present in the later stages with spasm of muscles, parasp-
inal swellings or neurological decits.
Our case is unusual in that the patient presented to us with
extensive paravertebral abscess, around over 13 vertebrae and
the only presenting feature was neck swelling. The patient did
not have any spinal deformities or neurological decits. A deep
neck abscess may be life threatening because of the possibilities
of airway obstruction, involvement of the carotid sheath,
spread into the mediastinum, or septic shock.
The usual rst line of treatment in TB spine with paraver-
tebral abscess is antitubercular chemotherapy with rest and
immobilization.
5
In our institution, we follow the Directly Ob-
served Treatment, Short course (DOTS) regime as advised by
the Revised National TB Control Programme (RNTCP). Our
patient was put on CAT 1 DOTS, which consists of 4 drugs,
INH, rifampicin, pyrazinamide, and ethambutol. In addition,
we had put him on streptomycin injection. The common
Figure 1 (A) CECT of the neck and upper mediastinum showing
a large pre and paravertebral collection (white arrow) from C3 to
T5 vertebrae. (B) MRI of the spine showing a loculated collection
from C3 to T10 vertebral levels with erosion of few of the
corresponding anterior vertebral bodies (white arrow).
Figure 2 Diffuse neck swelling on the left side (black arrow).
Figure 3 Thoracotomy and drainage of the pus.
136 D. Deviprasad et al.
indications for surgical intervention are spinal deformities,
neurological decits, radiological increase in size of the abscess
despite treatment, progressive bone destruction despite chemo-
therapy, severe pain or when complicated with dysphagia or
dyspnoea.
6
This patient was put on ATT for a period of
1 month, despite of which his symptoms worsened. Due to
the possible threat to the deep structures of the neck, we
decided to go for surgical intervention.
To conclude, TB can present in a myriad of ways. Early
diagnosis of this progressive disease can save young patients
from death or permanent disability. TB should be part of the
differential diagnosis in any case of paravertebral abscess in
developing countries.
Conict of interest
None.
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Neck swelling: Unusual manifestation of Potts spine 137