Pharyngeal Abscess

8/12/2019 Pharyngeal Abscess

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Infection of pharyngeal spaces


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The retropharyngeal space lies behind the pharynx andesophagus, just anterior to the prevertebral fascia. Itextends superiorly to the base of the skull and inferiorlyto the bifurcation of the trachea.

Patients generally present with trismus, drooling,dyspnea, dysphagia, and a mass, often fluctuant, on oneside of the posterior pharyngeal wall.

Lateral radiographs of the neck are also helpful in

diagnosis. It is important, however, to have properpositioning of the patient at the time of X-ray; otherwisethe results may be misleading. The patient should havethe neck extended in a true lateral position for the X-ray.


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The parapharyngeal space is cone shaped. Superiorly it startsat the base of the skull and inferiorly its margin ends at the

hyoid bone. The superior constrictor muscle is the medial

boundary, and the parotid gland, the mandible, and the

pterygoid muscle are its lateral margins , the prevertebral

fascia is present posteriorly.

A parapharyngeal space abscess can develop when infection

or pus from the tonsillar region goes through the superior

constrictor muscle. The abscess then forms between the

superior constrictor muscle and deep cervical fascia.

Patients can present with toxemia and pain in the throat and

neck, with tender swelling of the neck in the region of the

angle of the mandible. Examination may reveal tonsillitis

and/or medial displacement of the tonsil.


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Parapharyngeal AbscessRetro-pharyngeal

Abscess

(Acute & Chronic)


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Parapharyngeal Abscess

Def

What is parapharyngeal space?

Collection of pus in thePARA-PHARYNGEAL Space

A connective tissue space which:

-Lies on the lateral side of the nasopharnx and oropharynx-Extends from skull base to hyoid bone

-Contains:-Internal carotid artery

-Internal jagular vein

-Last 4 cranial nerves

-Cervical sympathetic trunk

-Deep cervical lynph nodes


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Etiology:- Acute Tonsillitis or after

tonsillectomy

- Infection of last lower molar

tooth

- Infection of the parotid

salivary gland

The infection passes through the

Superior constrictor muscle

Symptoms

Same as in Quinsy


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Complications

Spread to

- Skull base meningitis- carotid sheaththrombosis of IJV

and rupture of carotid artery

- Mediastinum Mediastinitis

- Larynx

laryngeal edema

Ruptureinto the pharynxaspiration

Bronchopneumonia


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Treatment

Medical: massive antibiotic therapyand,

Surgical drainage

A vertical incision

at the anterior border of

the sternomastoid muscle


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Acute Retropharyngeal Abscess

Collection of pus in the retropharyngeal space

BuccoPharyngeal

Fascia

Prevertebral fascia

The Retropharyngeal space

It is a connective tissue space between :

the buccopharyngeal fascia & pre-vertebral fascia The two fasciae are attached to each side by median raphe.

It extends from the skull base to the posterior mediastinum

It contains retropharyngeal lymph node one on each side

The Retropharyngeal LN atrophy at the age of 5


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Age: below the age of 5(The Retropharyngeal LN atrophy at the

age of 5)

Site: at one side of the midline (The two fasciae are attachedto each other at the midline by median raphe.)

Etiology

Upper Rrspiratory Tract Infectionwith suppuration of

Retropharyngeal LN

AfterAdenoidectomyoperation

Impacted FB


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Symptoms

In A child below 5 years

General: FHAM

Pharyngeal:

Severe sore throat

Dysphagia

Difficult breathing

Abscess


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Signs

General: fever

Pharyngeal

Swelling of the posterior

Pharyngeal wall to one

side of the midline

Cervical:Neck inclination

due to muscle spasm


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Normal Patient

Lateral view of the Neck

Look for

- The vertebral column( for any destruction e.g in

Potts disease)

- The pre-vertebral space

(3/4 the width of the body ofthe vertebra)

- The airway


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Investigations:

plain X ray & CT scan

Widening of

prevertebral space

Normal vertebralbodies

Complications:-Spread to mediastinummediastinitis-Rupture.


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Treatment

Medical: massive antibiotic therapyand,

Surgical drainage

Tracheostomyif indicated

Incision in the posteriorpharyngeal wall with thepatient in the Trendlenbergposition Why?

In this position the head is lower than the chest

to avoid aspiration of pus


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Etiology:

- Pott

s Disease

i.e tuberculosis of cervical

vertebrae the abscessrupture through the

prevertebral fascia the

abscess reaches the

Retropharyngeal space

prevertebral

fascia


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Symptoms

In an adult

General: Tuberculous ToxaemiaPharyngeal: Mild sore throat

Cervical: limited painful neck

movement

-Night sweets-Night fever

-Loss of weight

-Loss of appetite


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Signs:

General: Tuberculous toxaemiaPharyngeal:

Cervical: Tenderness overcervical spines

- Pallor

- Low grade fever

- Loss of weight

The swelling lies in the midline of

the posterior pharyngeal wall


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Investigations

Plain X ray & CTscan

Widening of the

Prevertebral space

Destruction of the

cervical vertebrae
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Treatment:

Medical:Antituberculoustherapy

SurgicalDrainage

Orthopedic Management

Through a vertical incision alongthe posterior border of the

sternomastoid muscle


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Hypopharyngeal

Pouch


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Hypopharyngeal pouch


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Synonyms

Hypopharyngeal diverticulum

Zenker

s diverticulum

Pharyngo-oesophageal pouch

Retropharyngeal pouch

Killians diverticulum


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Introduction

Hypopharyngeal pouch is an acquired

pulsion diverticulumcaused by posterior

protrusion of mucosa through pre-existing

weakness in muscle layers of pharynx or

esophagus.

In contrast, congenital diverticulum like

Meckel's diverticulum is covered b all


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Weak spots b/w muscles

Posterior:1. Between Thyropharyngeus &

Crico-

pharyngeus: Killian's dehiscence

(commonest)


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Origin of Zenkers diverticulum


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History

First described in

1769 by Ludlow

Friedrich Zenker&

von Ziemssen first

described its picture


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Etiology


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1. Tonic spasm of cricopharyngeal sphincter:

C.N.S. injury Gastro-esophageal reflux

2. Lack of inhibition of cricopharyngeal

sphincter

3. Neuromuscular in-coordination between

Thyro-pharyngeus & Cricopharyngeus

4. Second swallow against closed cricopharynx

These lead to increased intra-luminal pressure


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Clinical Features


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1. Entrapment of food in pouch:sensation of

food sticking in throat & later dysphagia2. Regurgitation of entrapped food:leads to

foul taste bad odor nocturnal coughing

choking

3. Hoarseness:due to spillage laryngitis or sac

pressure on recurrent laryngeal nerve

4. Weight loss:due to malnutrition

5. Com ressible neck swellin on left side:


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Complications

1. Lung aspiration of sac contents

2. Bleeding from sac mucosa

3. Absolute oesophageal obstruction

4. Fistula formation into:

trachea major blood vessel

5. Squamous cell carcinoma within Zenker

diverticulum (0.3% cases)


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Investigations

Chest X-ray:may show sac + air - fluid level

Barium swallow

Barium swallow with video-fluoroscopy

Rigid Oesophagoscopy

Flexible Endoscopic Evaluation of


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Barium swallow

B i ll i h Vid


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Barium swallow with Video-

fluoroscopy


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Rigid Oesophagoscopy


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Cricopharyngeal myotomy


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Styalgia

(Eagle Syndrome)


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Introduction

Normal length of styloid process is 2.02.5

cm

Length >30 mmin radiography is

considered an elongated styloid process

5-10% pt with elongated styloid have pain

Increased angulation of styloid process

both anteriorly & medially, can also cause


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Classical Variety

Occurs several years after tonsillectomy

Pharyngeal foreign body sensation

Dysphagia

Dull pharyngeal pain on swallowing,

rotation of neck or protrusion of tongue

Referred otalgia

Due to scar tissue in tonsillar fossa

en ulfin branches of losso har n eal


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Normal Styloid Process


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Elongated Styloid Process


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Theories for pain

Irritation of glossopharyngeal nerve

Irritation of sympathetic nerve plexus

around internal carotid artery

Inflammation of stylo-hyoid ligament

Stretching of overlying pharyngeal mucosa


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Diagnosis

1. Digital palpation of styloid process in

tonsillar fossa elicits similar pain

2. Relief of pain with injection of 2%Xylocaine solution into tonsillar fossa

3. X-ray neck lateral view

4. Ortho-pan-tomogram (O.P.G.)

5. Coronal C.T. scan skull

6. 3-D reconstruction of C.T. scan skull


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X-ray neck lateral view


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Coronal C.T. scan


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Coronal 3-D C.T. scan


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Medical Treatment

1. Oral analgesics

2. Injection of steroid + 2% Lignocaine into

tonsillar fossa

3. Carbamazepine:100 200 mg T.I.D.

4. Operative intervention reserved for:

failed medical management for 3 months

severe & rapidly progressive complaints


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Styloid Process

Excision


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Intra-oral route

via tonsil fossa

no external scarring

poor visibility due to difficult access

high risk of damage to internal carotid

artery

iatrogenic glossopharyngeal nerve injury


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Styloidectomy


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Styloidectomy

Tonsillectomy done. Styloid process

palpated.

Incision made in tonsillar fossa just over the

tip.

Styloid attachments elevated till its base with

periosteal elevator.

Styloid process broken near its base with


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Pharyngeal Abscess

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