A 55-year-old woman presented with 7 days of progressively worsening posterior neck pain, a low grade fever, odynophagia and hoarseness of her voice. Her past medical history includes diabetes mellitus, hypertension and osteoarthritis. A day after onset of the pain, she went to her primary care physician’s office for evaluation. A throat culture was negative but she was prescribed a 7-day course of amoxicillin-clavulanic acid without relief. She later presented to an Urgent care clinic where a rapid group A streptococcus test was negative and she received intravenous ketorolac for pain. Examination in our Emergency Department was notable for a low grade fever of 37.9 degrees Celsius with otherwise normal vital signs. She had limited extension and lateral movement of the neck as well as tenderness to palpation on the posterolateral aspect of the left side of her neck. There was no overlying erythema, pharyngeal erythema or exudates, cervical lymphadenopathy, or signs of airway compromise. Physical examination was otherwise normal. Flexible fiberoptic laryngoscopy was normal. Laboratory evaluation was notable for leukocytosis of 14.5 and elevated creatinine level of 1.5 from a baseline of 1.1. Computed tomography(CT) of the neck with intravenous contrast was performed and revealed “amorphous fragmented calcifications just below the arch of C1” associated with an “edematous process of the retropharyngeal region extending inferiorly to approximately the bottom of C3.” These findings are consistent with acute calcific tendinitis of the longus colli muscle.
Given her elevated creatinine, non-steroidal anti-inflammatory drugs were not used. Acetaminophen, lidocaine patches and warm compresses were used for pain control. Patient was discharged and her symptoms resolved within a week.
Discussion:
Acute calcific tendinitis of the longus colli muscle presents with acute severe neck pain, at times associated with odynophagia, mild fever, leukocytosis and elevated inflammatory markers. It is caused by deposition of calcium hydroxyapatite crystals and subsequent granuloma formation, which most commonly occurs on the superior fibers of the longus colli muscle. The definitive diagnosis is established with imaging, specifically computed tomography(CT) of the neck with contrast which reveals amorphous calcifications of the muscle fibers. Treatment of this condition is supportive with analgesics.
Given its presentation, it can be confused with an infectious process such as retropharyngeal abscess and may lead to unwarranted and unnecessary interventions. In this case, the patient was treated with antibiotics despite the absence of active infection.
Conclusions:
Acute calcific tendinitis of the longus colli muscle is a rare cause of neck pain and odynophagia. Diagnosis is based on imaging findings and treatment is supportive. Prompt recognition of this entity is essential in order to avoid unnecessary and possibly invasive interventions.