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abses parafaring
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Introduction Parapharyngeal abcessis a dangerous disease,
that can be life-threatening causing mediastinitisand sepsis
Derived from infection of the surronding organs
Diagnosis anamnesis, physical examination, laboratory & radiologic examination (CT scan able to assess the extension of infection)
Introduction Rare case
Management of Parapharyngeal abcessincision-drainage, antibiotic administration according to culture and sensitivity test
One case of parapharyngeal abscess with extraoralincision approach was reported
Literature Deep neck space
Neck fascia consist of fibrous connective tissue that encloses the organs, muscles, nerves, blood vessels
divided into superficial and deep cervical fascia
The deep cervical fascia create space of neck related to other space infection one space can extend to other space
Parapharyngeal Space
Parapharyngeal space also known as pharyngomaxilaris or pherypharyngeal space
Divided into two partanterior (prestyloid) and posterior (retrostyloid)
Paparella mention that parapharyngeal space as pyramid or cone shaped with four walls
Parapharyngeal Space Anatomy
Medial m. superior pharyngeal constrictor Lateral m.pterygoid medial, ramus mandible,
medial surface of the parotid gland,m.sternocleidomastoid and posterior belly of digastric muscle
Anterior pterygo mandibular raphe Posterior fascia prevertebra
Etiology Infection of the pharynx, tonsils, adenoids, teeth,
parotid, or lymphatic glands
In many cases, parapharyngeal abscess was an extension of the adjacent neck abscess such asperitonsilar abscess, submandibular abscess, retropharyngeal abcess
Pathogenesis Parapharyngeal abscess occurs due to extension of
infection from the surrounding organs The inflammation process spread through 3 ways:1. Directly extention2. Suppuration process of the teeth, tonsils,
pharynx and mastoid3. Infection spread from peritonsillar space ,
retropharyx or submandibula
Microbiology Caused by aerob and anaerob bacteria
The most frequent pathogen in parapharyngealabscess are Streptococcus, Staphylococcus aureus, Haemophilus influenzae and sometimes caused Coliforms or Pseudomonas aeroginosa
Anaerobic bacteria Peptostreptokokus, Bakteriodes and Fusobakteria
Nicolai et al reported there were 62% of patients with polymicrobial cultures and 13% of patient with nobacterial growth on culture
Anamnesa
•Fever•Anorexia•Dysphagia•Trismus•Drooling•Headache
•Otalgia•Stifness of neck•Swelling and pain in infected area
•History of toothache andtooth extraction
•History of foreignbody puncture
Anterior parapharyngealabcess
Posterior parapharyngealabcess
• Trismus,
• Swelling and induration at the angle of mandible or at the lower end of the parotid gland
• Prolapsed of tonsil and tonsil fossa
• Swelling at the lateral pharyngeal wall of the posterior region
• Swelling at the parotid area
• There were no trismus dan prolapstonsil
Paparella
Physical examination
Laboratory
• Bacteria culture
• Antibiotic sensitivity test
Radiology examination
• Cervical AP/Lateral
• Thorax X ray
• CT scan
Management
Patient must be hospitalized
Antibiotic administration
Abcess incision and drainage
Elimination control of factors that can inhibit healing process like infection of teeth, comorbid disorders such as diabetes mellitus
Tonsilectomies for prevent a recurrence of parapharyngeal abcess
Nicolai et al
• Parapharyngeal abcess usually drained through either a submandibular incision or an incision along the anterior border of the sternocleidomastoideus muscle
Antibiotic Antibiotic administration based on
Culture and sensitivity test
Emperical antibiotic
Penicillin G is a first choice
If allergic to penicillin, patient can give eritromycin, clindamycin or cephalosporin
Case report Female , 35 years old, admitted emergency
department Sanglah Hospital Denpasar on the 8th
December 2013 with referal from private hospital with parapharyngeal abcess
Chief complain of the patient were painfull during swallowing since six day before admission to the emergency department
Others complains were fever , swelling on the right neck, pus on throat, headache
She have always suffering from sore throat
But she has no sign of cough, flu, shorthness of breath
History of toothache , diabetes mellitus, hypertension, allergy of drug, history of oral surgery were denied.
History of tooth extraction 8 years ago
Before admision to the emergency department Sanglah hospital, patients went to private hospital and was admitted for 4 days
Medication given to the patient were baquinor, tricodazol, sanexon, heksadol
But complaints getting worsepatient can not eat and drink
Physical examinationPresent status :
Vital sign : T 110/70mmHg, N 76x/mnt
R 20x/mnt, temp 38ºC
ENT status:
Ear and nose within normal limit
Throat : swelling in the right lateral pharyngeal wall
with pus, tonsi T1/T1 hyperemi, uvula normal,
pharyngeal mucosa hyperemi
LI: Pus (+)
Neck: swelling behind the right angle mandible, size
5x5x4 cm, hyperemia, fluctuative, tenderness
Paracervical muscle spasm
Hearth and lung within normal limit
WBC 11,9 x 103/uL, other within normal limit
Ro cervical Ap/lateral
Thorax AP
Laboratory
Management Patient was hospitalized
Observation vital sign and sign s of airway obstruction
IVFD Nacl 0,9% and dextrosa 5% 1:1 20 gtt/ minute
Ceftriaxon injection 1 gram @ 12 hour
Metronidazol 500 mg injection @ 8 hour
Ketorolac 30 mg injection @ 8 hour
Trendelenberg position
9/12/13
• CT Scan
• Throat swab with pus culture and sensitivity test
11/12/13
• CT Scan result cystic mass with aerocelle projection at the soft tissue region right strenocleidomastoideus to the right paratracheabenign lession dd/ Abcess
• Incision and drainage with general anestesi was planned
12/12/14
• Internist consultation
• Anastesiology consultation
ceftriaxon 2x1 iv, metronidazol 3x500 mg iv, ketorolak 3x30 mg iv, metilprednisolon 2x62,5 mg iv, ranitidin 2x50 mg iv, Trendelenberg position
13/12/13
Incision drainage abcess with trancervicalapproach anterior sternocleidomastoideus
14/12/13
• The result of the culture from throat swab no growth
• puss of the drain was reduced
17/12/13
• No pus aff drain
• Culture result from trancervical incision no growth
19/12/13
• WBC 10,3 x 103/uL , others within normal limit
Day 8 post incision-drainage aff hecting, incision wound has a good condition, no swelling in the neck and no pain in swallowing
Patient can eat properly discharge from hospital
Three days later the patient control to the ENT clinic within good condition and no complain
Discussion
Literature case
Diagnosis:•Anamnesis•Physical examination
•Laboratory •Radiology
Diagnosis:•Anamnesis•Phyisicalexamination•Laboratory •Cervical AP/Lateral•CT scan
Literature Case
Anamnesa:Fever, anorexia, dysphagia, trismus, drooling, headache, otalgia, stifness of neck, swelling and pain in infection, history of toothache, and tooth extraction, history of foreign body punctured
Anamnesa:Painfull swallowing since sixth day ago, swelling on the right neck, pus in throat, headache
Literature Case
Etiology:Infection of the pharynx, tonsils, adenoids, teeth, parotid, or lymphatic glands, peritonsilarabscess, submandibularabscess, retrofaringabcess
Etiology:Reccurent infection from pharyx and tonsils
Literature Case
Physical examinationPosterior parapharyngealabcess swelling at the posterior palatoglossusplica, swelling at the lateral pharyngeal wall of the posterior region, swelling at the parotid area, there was no trismusand prolaps tonsil
Physical examinationPosterior parapharyngealabcess swelling in the right lateral pharyngeal wall with pus, swelling behind the right angle mandible, no trismus and prolaps tonsil
Parapharyngeal abcess are usually drained through either a submandibular incision or an incision along the anterior border of the sternocleidomastoideus muscle
Incision drainage abcess with trancervicalapproach anterior sternocleidomastoideusmuscle
Literature
Case
Management
Nicolai et al there are 62% of patients with polymicrobialcultures and 13% no found
bacterial growth on culture results
Culture result no growthemperical antibiotic
Literature
Case
Management
Conclusion One case with parapharyngeal abcess in adult
women
Diagnosis based on anamnesis, physical examination, laboratory, radiology (CT scan)
Management adequate incision drainage, antibiotic according to culture and sensitivity tesor empirical antibiotic
Cause of the infection need further investigation to prevent recurrence