Headache Medicine, v.10, n.3, p.76-79, 2019
76
ABSTRACT
RESUMO
Descritores: Cefaleia; Distúrbio da deglutição; Tendinopatia
CASE REPORT
Acute calcic retropharyngeal tendinitis: a three-case
series and a literature review
Tendinite retrofaríngea calcicada aguda: série de três casos e
revisão de literatura
Paulo Sérgio Faro Santos
1
Ana Carolina Andrade
2
1
Neurologist, Head of the Headache and
Orofacial Pain Sector, Department of
Neurology, Institute of Neurology of Curitiba,
PR, Brazil
2
Resident doctor, Department of Neurology,
Institute of Neurology of Curitiba, PR, Brazil
*Correspondence
Paulo Faro
E-mail: dr.paulo.faro@gmail.com
Received: September 1, 2019.
Accepted: September 8, 2019.
Acute retropharyngeal tendinitis is a rare, self-limiting, benign condition that is
poorly described in the literature. It is clinically characterized by neck pain and
stiffness and either dysphagia or odynophagia. Diagnosis depends on clinical
suspicion and imaging examination (computed tomography of the cervical
spine is the gold standard), with calcication found in the anterior region of the
rst and second vertebrae. The disease usually presents good clinical course,
with satisfactory response to the use of either non-steroidal anti-inammatory
drugs or corticosteroids, with remission of symptoms in days to weeks and of
the calcication process in weeks to months.
Keywords: Headache; Deglutition disorder; Tendon injury.
Tendinite retrofaríngea aguda é uma condição rara, autolimitada, benigna e
pouco descrita na literatura. Caracteriza-se clinicamente por cervicalgia, rigidez
de pescoço e disfagia ou odinofagia. O diagnóstico depende da suspeição
clínica e de exame de imagem, sendo a tomograa computadorizada de coluna
cervical o padrão-ouro, com o achado de calcicação em região anterior da
primeira e segunda vértebras. A doença costuma apresentar uma boa evolução
clínica, com resposta satisfatória ao uso de anti-inamatórios não esteroidais ou
corticosteroides, com remissão dos sintomas em dias a semanas e do processo
de calcicação em semanas a meses.
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INTRODUCTION
Acute retropharyngeal calcic tendinitis is a
rare, self-limiting, benign condition that is poorly
described in the literature. It was rst reported in 1964
by Hartley
1
. The incidence of the disease is uncertain
and the age it usually manifests is between 30 and
60 years, though there are reports that vary from 21
to 81 years of age
2
. The condition is characterized by
an inammatory process in the longus colli muscle,
with the deposition of calcium hydroxyapatite crystals
more commonly on the superior oblique tendon of
the muscle
1
. It is classically characterized by the triad
of neck pain, neck stiffness and either dysphagia or
odynophagia
1
. A computed tomography of the cervical
spine is the gold standard for investigations
3
. Though
the disease presents a self-limited course, it can be
very impairing and require the prescription of non-
steroidal anti-inammatory drugs or corticosteroids
so to accelerate the process of clinical improvement
4
.
The objective of the present study was to describe
three cases of individuals that sought urgent medical
care at a neurological hospital due to intense neck
pain and were suspected of having retropharyngeal
tendinitis after they reported a worsening in the pain
with deglutition.
Case 1
Male, 45 years old, presented intense pulsating left
occipital headache with ipsilateral parietal radiation, that
worsened with speech, deglutition and head movement.
The pain began while sleeping three days prior. During
examination, the patient showed antalgic limitations
regarding neck rotation and extension, with no further
ndings. Magnetic resonance and cervical spine
tomography images showed prevertebral calcication
between C1 and C2. After treatment with intravenous
analgesic, anti-inammatory and corticoid drugs, there
was complete remission of the condition.
Case 2
Female, 33 years old, with insidious yet intense
occipital headache and neck pain, associated with
odynophagia and functional limitation of the neck
over the past two weeks and without improvement
using common analgesics. When examined, the
patient reported pain when extending and rotating
the neck and pain during palpation of the cervical
spine apophyses. Computed tomography images of
the cervical spine revealed calcication and edema
of the prevertebral soft tissue at the C2 level (Figure
1). Treatment with an oral corticoid led to symptom
improvement during the rst week.
Case 3
Male, 31 years old, suffering from neck pain for ve
days and with worsening over the previous 24 hours,
limited range of neck movement, and associated with
paresthesia and hypoesthesia in the left ear and left
cervical region. Denied having a fever. When examined,
the patient showed limited neck movement in all directions
and hypoesthesia in the left cervical region. Initially
submitted to a computed tomography of the cervical
spine that showed hyperdensity at the back of C1 and C2
cervical processes. A magnetic resonance of the cervical
spine was then requested, which showed a hypersignal in
T2 at the back of vertebrae C1, C2 and C3, compatible with
edema of the longus colli muscle (Figure 2). The patient
was treated with corticosteroids (prednisone) for seven
days but did not return for follow-up.
Figure 1. Computed tomography of the cervical spine: presence
of calcication in the anterior region of C2 (sagittal and axial
sections, respectively).
Source: personal archive.
Figure 2. Magnetic resonance of the cervical spine: hypersignal
in T2 at the back of C1, C2 and C3.
Source: personal archive.
DISCUSSION
Since acute retropharyngeal tendinitis was rst
described in 1964, little more than 80 cases have been
reported in the literature
5
. The incidence of the disease
in unknown, though it is estimated as 0.5 case per
100,000 inhabitants
6
. Though there seems to be no
difference between sexes affected, some studies indicate
that women are slightly more prone to the condition,
accounting for close to 58% of cases
7,8.
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In a literature review conducted by Park et al.
1
, with
71 cases described, age varied from 21 to 65 years and
the time of establishing a diagnosis since the beginning
of the symptoms ranged from less than seven days to 21
days.
Regarding anatomy, the longus colli muscle is
one of the four muscles that form the anterior cervical
region. It originates from the vertebral bodies of C3-
C7 and T1-T3, becoming inserted along the bodies
of C2-C4 and anterior tubercles of vertebrae C1-C6.
This muscle is divided in vertical, superior oblique
and inferior oblique portions
9
. The superior oblique
portion, which originates from the anterior tubercles
of transverse processes in C3 to C5, is the part that is
involved in acute retropharyngeal tendinitis
10
.
The etiology of the disease is still unclear, but it
is believed that repetition trauma, ischemia, necrosis,
tendon degeneration, chronic kidney disease, collagen
vascular disease and osteoarthritis are involved in the
pathogenesis of retropharyngeal tendinitis
1
. Regarding
the physiopathology of the disease, a model has been
proposed dividing the process into ve phases: pre-
calcication, formative, rest, reabsorption and post-
calcic
11
. The process is believed to begin after exposure
to an unknown triggering factor, which leads to
brocartilaginous metaplasia of tendon cells associated
with an accumulation of calcium crystals in the matrix
vesicles. The formation of calcium centers separated by
brocartilage (formative phase) is followed by the rest
phase. The later appearance of vascular channels and
phagocytosis of fragments mediated by macrophages
(reabsorption phase) precedes the post-calcic
phase, which is characterized by deposition mediated
with type-III collagen broblasts and formation of
granulation tissue
4
.
The disease has variable clinical presentations
1
. Its
beginning is typically either acute or subacute with neck
pain that can spread to the occipital region, associated
with neck stiffness, odynophagia or dysphagia
1
. A relevant
aspect is that neck pain may worsen with deglutition
and head movement
1
. Moreover, headaches, longus colli
muscle spasms, limitation in neck movement, particularly
extension, pharyngeal edema, nasopharyngeal erythema,
fever, increase inammatory markers, and leukocytosis
can also be present
12
.
Physical examination of the patient reveals spasms in
cervical spinal musculature and palpation of the anterior
cervical region between the sternocleidomastoid muscle
and larynx can be painful due to direct manipulation
of the longus colli muscle
1
. The posterior aspect of the
nasopharynx is usually swollen and erythematous
13
.
Regarding diagnostic imaging, computed
tomography of the cervical spine is considered the gold
standard
14
. Pathognomonic ndings are represented by
amorphic calcication anterior to the vertebral body of
either the rst or second cervical vertebrae and edema
in prevertebral soft tissues, which can extend from the
rst to the fourth cervical vertebra associated with a
collection of uid in the retropharyngeal space
14
. In
turn, while a nuclear magnetic resonance is an excellent
method to identify edema of soft tissues and collection
of uids, it is not appropriate to observe calcication
15
.
T2-weighted sagittal section hyperintensity in the
prevertebral region at the level of C2 to C6, though
potentially extending to the base of the skull, is a
characteristic nding in retropharyngeal tendinitis
16
. It
indicates edema of the longus colli muscle
17
. Cervical
spine lateral view radiographs do not detect calcication
in a small percentage of patients
19
.
The possibility for differential diagnoses is broad
and with potentially severe conditions that should be
quickly excluded, such as: retropharyngeal abscess,
cervical osteomyelitis and vertebral artery dissection
14
.
Other conditions include meningitis, neoplasia, cervical
myelopathy, traumatism, foreign body aspiration
and spondylodiscitis
13
. In turn, differential diagnoses
by imaging include bulging cervical disc and bone
fragment from an avulsion fracture when there is a
history of recent trauma
14
.
The natural history of the disease is marked by
spontaneous resolution, approximately two weeks after
the symptoms begin
17
. However, the use of nonsteroidal
anti-inammatory drugs accelerates the healing process,
thus promoting an improvement in the condition within
24 to 48 hours
13
. In cases of severe pain, the use of
corticosteroids and opioids is necessary. Patients become
asymptomatic after seven to 15 days and the calcication
process disappears in one to two months
19.
CONCLUSION
Although retropharyngeal tendinitis is a rare clinical
condition, it should be part of clinical suspicion when in
face of a case of neck pain, particularly when it worsens
during deglutition, and should be a differential diagnosis
for occipital headaches.
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