Dusk before the dawn

A 46-year-old, otherwise healthy woman presented to the Emergency Department with a 3 days history of sore throat, difficulty in swallowing and restricted neck movements. No other significant medical history.

On examination:

  • Vitals are normal and stable.
  • Patient not on any respiratory distress.
  • Oral cavity – Normal
  • Oropharynx – Hyperemic
  • Neck – tender and movements were restricted
  • Rest of the physical examination was unremarkable.


  • Flexible nasopharyngoscopy – A swelling in the nasopharynx extending towards the oropharynx.
  • White blood cell count  was normal
  • C-reactive protein was 39.
  • A contrast-enhanced computed tomography (CECT) scan and a magnetic resonance imaging (MRI) were performed (see above image).


  1. What is your provisional diagnosis?
Calcific tendinitis
Cervical osteophytes
Retropharyngeal abscess
Tuberculosis of spine


The diagnosis is acute calcific tendinitis of the longus colli muscle.

In the sagittal CECT scan of the neck shows a retropharyngeal effusion (red arrow) with amorphous calcification of the longus colli muscle. The sagittal T2-weighted MRI scan shows expansion of the retropharyngeal space with effusion (red arrow).

Acute calcific prevertebral tendinitis also is known as calcific retropharyngeal tendinitis or prevertebral calcific tendinitis is a self-limiting clinical condition due to calcification and inflammation of longus colli muscle and tendon. The treatment of choice is non-steroidal anti-inflammatory drugs.

The clinical significance of the condition is that it mimics other life-threatening medical emergencies like retropharyngeal abscess, meningitis, and cervical disc herniation. Awareness of this condition can avoid unnecessary invasive interventions, increased costs, and delays that result from incorrect diagnosis and treatment.


  1. Al Balushi M, Varghese AM, Al Azri F, Al Abri R. It is always darkest before dawn. Oman medical journal. 2017 Sep;32(5):440.

Meet the author

Dr Sanu P Moideen is an Indian-born oto-rhino-laryngologist (ENT) based in Cochin, Kerala, India. He is currently working as Post-Doctoral Fellow in Head and Neck Oncology at Regional Cancer Center, Trivandrum, Kerala.

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