Clival Osteomyelitis with Retropharyngeal and Epidural Abscesses in a Child

Purpose: Osteomyelitis of the clivus is a rare, life threatening infection in children and can develop from adjacent sinonasal and temporal bone infection. It has been postulated that patients with congenital anomalies of the clivus including fossa navicularis may be at increased risk for extension of nasopharyngeal infections into the clivus. This is the first report describing association with both intracranial and retropharyngeal collections.

Methods: Case report and literature review.

Results: Very few case reports of clival osteomyelitis have been described in children. We present the case of a 3 year old immunocompetent female who underwent MRI of the brain after developing esotropia 11 days into a workup for fever and abdominal pain. MRI showed hyperintensity of the clivus with both retropharyngeal and epidural collections. Treatment included of trans-oral incision and drainage of the retropharyngeal abscess, culture and IV antibiotics. No drainage of the intracranial portion of the infection was performed. Review of the CT scan showed the presence of a fossa navicularis. The patient improved clinically following drainage, and a repeat MRI one week later showed resolution of the epidural and retropharyngeal collections. There has been no recurrence of symptoms.

Conclusions: Fever of unknown origin with development of cranial neuropathy warrants urgent imaging to examine for intracranial pathology. In this patient with both retropharyngeal and retroclival epidural collections, retropharyngeal incision and drainage was sufficient for treatment. There is a high prevalence of fossa navicularis in the reported cases of pediatric clival osteomyelitis, warranting additional research into its significance.