Retropharyngeal TendinitisRetropharyngeal tendinitis is either very rare or goes unrecognised. It is self-limiting, so specialists may not see the condition very often unless their practice has emergency access. Classically the patient experiences increasingly severe pain in the neck (can be one side or both), and this pain is excruciating on attempting to look up i.e. neck extension. In fact, there is complete resistance to any neck movement whatsoever, and the head is often held still by one or both hands. Gentle forward flexion of the neck is in fact possible with encouragement. A fever is recorded in about 50% of cases. Patients are usually in their late 30's or older. As the affected muscle and tendon lie just behind the throat and upper oesophagus, there is also pain on swallowing (odynophagia), which is a clue to the condition. The pain, which is non-pulsatile, can spread all the way up the back of the neck to the back of the head. Palpation of the neck muscles over the transverse processes of the higher cervical vertebrae is usually tender. Differential DiagnosisSometimes the case is confused for meningitis, and a lumbar puncture is performed, but in the 5 cases where lumbar puncture was documented, all had normal cerebrospinal fluid.The condition can be confused with acute thyroid inflammation - thyroiditis, and carotid dissection or vertebral dissection may need to be excluded. I do not know of any recorded cases where dissection was confused for retropharyngeal tendinitis or vice-versa. Retropharyngeal abscess may be sought, and excluded, by ENT surgeons. Some patients report preceding trauma, and cervical discitis is suspected in others. Other causes of severe, new onset pain in the back of the head includes occipital neuralgia and Chiari Malformation. There is a differential diagnosis that does need considered carefully. Investigations
Blood tests are usually normal, although one series noted a raised ESR in 19/28 cases. X-rays of the soft tissue in front of the spinal column can show thickening, and on MRI affected cases have an average pre-vertebral soft tissue thickness of 6-8mm, compared to 2.5mm in controls. The longus colli muscle has high signal change on T2-weighted imaging. Calcification can be seen on CT scans just in front of the upper cervical spine, as seen in the image here (Courtesy of baillement.com, Creative Commons Attribution) or plain x-rays.The condition is thought to be an inflammation of the longus colli muscle and tendon, with secondary hydroxyapatite deposition (calcification) which may be a reaction to trauma or systemic infection. TreatmentTendinitis usually responds within a week to NSAIDs e.g. Indomethacin or Naproxen.ReferencesEkbom K et al. Retropharyngeal effusion in acute calcific prevertebral tendonitis: diagnosis with CT and MR imaging. Am J Neuroradiol 1998;19:1789-92. (Free Abstract only)J M Pearce Longus cervicis colli "myositis" (syn: retropharyngeal tendinitis). J Neurology Neurosurgery and Psychiatry 1996;61:324. (Free Full Text)
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