Pharyngeal Abscess

BY-XYZ
GROUP- 479
Basics

 Retropharyngeal space. It lies behind the pharynx between the buccopharyngeal

fascia covering pharyngeal constrictor muscles and the prevertebral fascia. It
extends from the base of skull to the bifurcation of trachea. The space is divided
into two lateral compartments (spaces of Gillette) by a fibrous raphe (Figure
52.6). Each lateral space contains retropharyngeal nodes which usually disappear
at 3–4 years of age. Parapharyngeal space communicates with the
retropharyngeal space. Infection of retropharyn- geal space can pass down
behind the oesophagus into the mediastinum.
 Prevertebral space. It lies between the vertebral bodies posteriorly and the
prevertebral fascia anteriorly. It extends from the base to skull of coccyx.
Infection of this spaceusually comes from the caries of spine.
 Abscess of this space produces a midline bulge in contrast to abscess of
retropha- ryngeal space which causes unilateral bulge.
ACUTE RETROPHARYNGEAL ABSCESS

 Ethology-
 It is commonly seen in children below 3 years. It is the result of suppuration of
retropharyngeal lymph nodes secondary to infection in the adenoids,
nasopharynx, posterior nasal sinuses or nasal cavity. In adults, it may result from
penetrat- ing injury of posterior pharyngeal wall or cervical oesoph- agus.
Rarely, pus from acute mastoiditis tracks along the undersurface of petrous bone
to present as retropharyngeal abscess.
 CLINICAL FEATURES
 1. Dysphagia and difficulty in breathing are prominent symp- toms as the
abscess obstructs the air and food passages.
 2. Stridor and croupy cough may be present.
 3. Torticollis. The neck becomes stiff and the head is kept extended.
 4. Bulge in posterior pharyngeal wall. Usually seen on one sideof the
midline.Radiograph of soft tissue, lateral view of the neck showswidening of
prevertebral shadow and possibly even the pres- ence of gas
 Treatment-
 1. Incision and drainage of abscess. This is usually done without anaesthesia as
there is risk of rupture of abscess dur- ing intubation. Child is kept supine with
head low. Mouth is opened with a gag. A vertical incision is given in the most
fluctuant area of the abscess. Suction should always be avail- able to prevent
aspiration of pus.
 2. Systemic antibiotics. Suitable antibiotics are given.
 3. Tracheostomy. A large abscess may cause mechanical obstruction to the airway
or lead to laryngeal oedema. Tra- cheostomy becomes mandatory in these cases.
CHRONIC RETROPHARYNGEAL
ABSCESS

 Etiology-
 It is tubercular in nature and is the result of (i) caries of cer- vical spine or (ii)
tuberculous infection of retropharyngeallymph nodes secondary to tuberculosis
of deep cervical nodes. The former presents centrally behind the preverte- bral
fascia while the latter is limited to one side of midline as in true retropharyngeal
abscess behind the buccopharyn- geal fascia.
 CLINICAL FEATURES
 Patient may complain of discomfort in throat. Dysphagia, though present, is not
marked. Posterior pharyngeal wall shows a fluctuant swelling centrally or on one
side of mid- line. Neck may show tuberculous lymph nodes. In cases with caries
of cervical spine, X-rays are diagnostic.
 TREATMENT- 1. Incision and drainage of abscess. It can be done through a
vertical incision along the anterior border of sternomas- toid (for low abscess) or
along its posterior border (for high abscess). 2. Full course of antitubercular
therapy should be given.
PARAPHARYNGEAL ABSCESS

 Parapharyngeal space is pyramidal in shape with its base at the base of skull and
its apex at the hyoid bone.
 Medial. Buccopharyngeal fascia covering the constrictor muscles.
 Posterior. Prevertebral fascia covering prevertebral mus- cles and transverse
processes of cervical vertebrae.
 Lateral. Medial pterygoid muscle, mandible and deep sur- face of parotid gland.
 Styloid process and the muscles attached to it divide the parapharyngeal space
into anterior and posterior com- partments. Anterior compartment is related to
tonsillar fossa medially and medial pterygoid muscle laterally. Posterior
compartment is related to posterior part of lateral pharyngeal wall medially and
parotid gland laterally. Through the poste- rior compartment pass the carotid
artery, jugular vein, IXth, Xth, XIth, XIIth cranial nerves and sympathetic
trunk.It also contains upper deep cervical nodes.Parapharyngeal space
communicates with other spaces, viz. retropharyngeal, submandibular, parotid,
carotid and visceral
 Etiology-
 Infection of parapharyngeal space can occur from:1. Pharynx. Acute and chronic
infections of tonsil and ade- noid, bursting of peritonsillar abscess.2. Teeth. Dental
infection usually comes from the lower last molar tooth.3. Ear. Bezold abscess and
petrositis.4. Other spaces. Infections of parotid, retropharyngeal andsubmaxillary
spaces.5. External trauma. Penetrating injuries of neck, injectionof local anaesthetic for
tonsillectomy or mandibular nerve block.
 CLINICAL FEATURES- Clinical features depend on the compartment involved.
Anterior compartment infections produce a triad of symptoms: (i) prolapse of
tonsil and tonsillar fossa, (ii) trismus (due to spasm of medial pterygoid muscle)
and (iii) exter- nal swelling behind the angle of jaw. There is marked odyno-
phagia associated with it.Posterior compartment involvement produces (i) bulge
of pharynx behind the posterior pillar, (ii) paralysis of CN IX, X, XI, and XII
and sympathetic chain, and (iii) swell- ing of parotid region. There is minimal
trismus or tonsillar prolapse.Fever, odynophagia, sore throat, torticollis (due to
spasm of prevertebral muscles) and signs of toxaemia are common to both
compartments.
 COMPLICATIONS-
 1. Acute oedema of larynx with respiratory obstruction.
 2. Thrombophlebitis of jugular vein with septicaemia.
 3. Spread of infection to retropharyngeal space.
 4. Spread of infection to mediastinum along the carotidspace.
 5. Mycotic aneurysm of carotid artery from weakening of its wall by purulent material. It
may involve common carotid or internal carotid artery
 6. Carotid blow out with massive haemorrhage.
 TREATMENT-
 1.Systemic antibiotics. Intravenous antibiotics may become necessary to combat
infection.
 2.Drainage of abscess. This is usually done under gen- eral anaesthesia. If the trismus is
marked, preoperative tracheostomy becomes mandatory. Abscess is drained by a
horizontal incision, made 2–3 cm below the angle of mandible. Blunt dissection along the
inner surface of medial pterygoid muscle towards styloid process is carried out and
abscess evacuated. A drain is inserted. Transoral drainage should never be done due to
danger of injury to great vessels which pass through this space.