Abscesses of pharynx

Abscesses of PharynxDr.T.Dinesh SinghProfessorMRIMS

Peritonsillar Abscess [Quinsy] Definition – acute inflammation of the

peritonsillar space. Place – lies between superior constrictor

muscle & the tonsillar capsule. Etiology – Recurrent attacks of tonsillitis- Trauma or Foreign body- Dental infections & surrounding areas- Immunocompromised status

Peritonsillar abscess

Peritonsillar abscess Crypta magna gets

obstructed – intratonsillar abscess.

Supratonsillar space of soft palate, immediately above the superior pole of tonsil, internal pterygoids

Group A beta-haemolytic streptococcus

Clinical features Symptoms – General – fever, chills & rigor, malaise,

body aches & toxic features Local –odynophagia [ severe ] Otalgia Neck pain Trismus – pterygoid muscle spasm Muffled speech – hot potato voice

Clinical features

Clinical features Signs –anterior pillar cannot be

distinguised – oedema of surrounding tissues

Tonsil – pushed medially & downwards Tonsil congested – follicles may be filled

and membrane may be seen Uvula congested & pushed medially Mouth opening is poor

Clinical features Lymph nodes – tender

enlarged discrete Untreated – abscess

may rupture – foul smelling discharge

DD – peritonsillitis- Parapharyngeal

abscess- Parapharyngeal

malignancy

Investigations & Treatment Throat swab for culture

sensitivity CBP DM & CT Scan Treatment –

antibiotics & analgesics Hospitalization Incision & Drainage Hot tonsillectomy &

Interval tonsillectomy.

CT Scan – peritonsillar abscess

Parapharyngeal abscess Synonyms – pharyngomaxillary space- Lateral pharyngeal space Anatomy – potential space lateral to

pharynx Inverted Pyramid or V shaped – base of

skull to level of hyoid bone Content – carotid sheath and

surroundings

Boundaries Anterior – interpterygoid fascia &

pterygomandibular raphe Posterior – prevertebral division of deep layer &

posterior aspect of carotid sheath Medial – middle layer of deep cervical fascia

around the pharyngeal constrictor & the fascia of the tensor & levator muscles of the velum palatani & the styloglossus.

Lateral – superficial layer of deep cervical fascia – overlies the mandible, medial pterygoid & parotid.

Parapharyngeal space

Compartments & Contents Divided – styloid process Anterior – pre-styloid compartment –

fat, loose areolar tissue, lymph nodes, internal maxillary artery.

Posterior – post-styloid compartment – carotid artery, IJV, cervical sympathetic chain, cervical nerves IX, X, XI, XII.

Clinical features Etiology - Dental infections, tonsillitis,

sialadenitis, lymph node suppuration Firm induration [ swelling ], erythema –

seen lateral and anterior to sterocleidomastoid muscle

Difficulty in flexing & turning neck Trismus – pterygoid muscle Dysphagia & dyspnea Bulge – lateral wall of pharynx

Investigations & treatment CT Scan – neck – location and extent Needle aspiration Chest X-Ray & CT chest Dental evaluation Treatment – antibiotics & analgesics Airway protection Surgical drainage – incision at level of

hyoid across SCM muscle

DD Peritonsillar abscess Cervical adenitis Masticator space infection Submandibular space infection

Complications 1] IJV – thrombosis Shaking chills, spiking fever, prostration Tenderness at angle of mandible & along SCM

muscle Asso. Bacteremia, pulmonary emboli,

suppurative subclavian phlebitis, lateral sinus thrombosis, brain abscess, metastatic abscess

Treatment – prolonged antibiotics, surgical drainage, ligation of involved vein.

Complications 2] Carotid artery rupture - false aneurysm formation - herald bleeds – before major bleed - ICA – common involvement 3] Laryngeal edema 4] Mediastinitis

Submandibular space abscess [ LUDWIG’S ANGINA ] Inflammation of the submaxillary and

sublingual space Cellulitis without lymphatic involvement

– causing massive swelling of tongue & floor of mouth.

Fatal – respiratory obstruction

Ludwig’s angina

Etiology Age - 20 to 50 yrs Dental caries – 2nd & 3rd molar Trauma of tongue & floor of mouth Lingual tonsillitis Post dental extraction Post radiotherapy

Clinical features Toxic – high fever & malaise Painful swelling – region below the

mandible Dysphagia, difficulty in mouth opening,

dysarthria, & dyspnea Trismus Absence of lymphadenitis Drooling of saliva & rare stridor

Ludwig’s angina

Clinical features Baruny edema of the floor of mouth &

tongue pushing tongue posteriorly Laryngeal edema – forces the patient to

sit up & lean forwards. DD – submental space infection- Submandibular sialadenitis- Plunging ranula- Tumors.

Investigations & Treatment Dental X-Rays CT-Scan – extent of disease, extension

to other neck spaces, airway. Treatment – antibiotics & analgesics Surgical drainage – mylohyoid opened Tracheostomy Treat – underlying cause

Ludwig’s angina

Complications Airway obstruction Aspiration pneumonia Lung abscess Tongue necrosis Spread to other spaces.