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298 SECTION IV — Diseases of Pharynx
AETIOLOGY
Peritonsillar abscess usually follows acute tonsillitis
though it may arise de novo without previous history
of sore throats. First, one of the tonsillar crypts, usually
the crypta magna, gets infected and sealed off. It forms
an intratonsillar abscess which then bursts through
the tonsillar capsule to set up peritonsillitis and then an
Figure 52.2. Roots of molar teeth project below and those of premo- abscess.
lars above the attachment of mylohyoid muscle. Culture of pus from the abscess may reveal pure growth
of Streptococcus pyogenes, S. aureus or anaerobic organisms.
More often the growth is mixed, with both aerobic and
tender, and impart woody-hard feel. Usually, there is cel- anaerobic organisms.
lulitis of the tissues rather than frank abscess. Tongue is
progressively pushed upwards and backwards threatening
the airway. Laryngeal oedema may appear (Figure 52.3). CLINICAL FEATURES
Peritonsillar abscess mostly affects adults and rarely the
TREATMENT children though acute tonsillitis is more common in chil-
dren. Usually, it is unilateral though occasionally bilateral
1. Systemic antibiotics.
abscesses are recorded. Clinical features are divided into:
2. Incision and drainage of abscess.
(a) Intraoral—if infection is still localized to sublin- 1. General. They are due to septicaemia and resemble
gual space. any acute infection. They include fever (upto 104 °F),
(b) External—if infection involves submaxillary space. chills and rigors, general malaise, body aches, head-
A transverse incision extending from one angle of ache, nausea and constipation.
mandible to the other is made with vertical open- 2. Local
ing of midline musculature of tongue with a blunt (a) Severe pain in throat. Usually unilateral.
haemostat. Very often it is serous fluid rather than (b) Odynophagia. It is so marked that the patient can-
frank pus that is encountered. not even swallow his own saliva which dribbles
3. Tracheostomy, if airway is endangered. from the angle of his mouth. Patient is usually de-
hydrated.
COMPLICATIONS (c) Muffled and thick speech, often called “hot potato
voice.”
1. Spread of infection to parapharyngeal and retropharyn- (d) Foul breath due to sepsis in the oral cavity and
geal spaces and thence to the mediastinum. poor hygiene.
2. Airway obstruction due to laryngeal oedema, or swell- (e) Ipsilateral earache. This is referred pain via CN IX
ing and pushing back of the tongue. which supplies both the tonsil and the ear.
3. Septicaemia. (f) Trismus due to spasm of pterygoid muscles which
4. Aspiration pneumonia. are in close proximity to the superior constrictor.
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Chapter 52 — Head and Neck Space Infections 299
EXAMINATION the sinus forceps the following day may also be neces-
sary to drain any reaccumulation.
1. The tonsil, pillars and soft palate on the involved side • Interval tonsillectomy. Tonsils are removed 4–6 weeks
are congested and swollen. Tonsil itself may not appear following an attack of quinsy.
enlarged as it gets buried in the oedematous pillars • Abscess or hot tonsillectomy. Some people prefer to
(Figure 52.4). do “hot” tonsillectomy instead of incision and drain-
2. Uvula is swollen and oedematous and pushed to the age. Abscess tonsillectomy has the risk of rupture of
opposite side. the abscess during anaesthesia and excessive bleeding
3. Bulging of the soft palate and anterior pillar above the at the time of operation.
tonsil.
4. Mucopus may be seen covering the tonsillar region.
5. Cervical lymphadenopathy is commonly seen. This
COMPLICATIONS
involves jugulodigastric lymph nodes. Rare with modern therapy.
6. Torticollis. Patient keeps the neck tilted to the side
1. Parapharyngeal abscess (a peritonsillar abscess is a po-
of abscess.
tential parapharyngeal abscess).
2. Oedema of larynx. Tracheostomy may be required.
INVESTIGATION 3. Septicaemia. Other complications like endocarditis,
Contrast-enhanced CT or MRI shows the abscess and its nephritis, brain abscess may occur.
extent. Needle aspiration of an abscess provides material 4. Pneumonitis or lung abscess. Due to aspiration of pus,
for culture and sensitivity of bacteria. if spontaneous rupture of abscess has taken place.
5. Jugular vein thrombosis.
TREATMENT 6. Spontaneous haemorrhage from carotid artery or
jugular vein.
1. Hospitalization.
2. Intravenous fluids to combat dehydration.
3. Antibiotics. Suitable antibiotics in large i.v. doses to RETROPHARYNGEAL ABSCESS
cover both aerobic and anaerobic organisms.
4. Analgesics like paracetamol are given for relief of pain APPLIED ANATOMY
and to lower the temperature. Sometimes, stronger
analgesics like pethidine may be required. Aspirin is • Retropharyngeal space. It lies behind the pharynx
avoided because of the danger of bleeding. between the buccopharyngeal fascia covering phar-
5. Oral hygiene should be maintained by hydrogen perox- yngeal constrictor muscles and the prevertebral fas-
ide or saline mouth washes. cia. It extends from the base of skull to the bifurca-
tion of trachea. The space is divided into two lateral
The above conservative measures may cure peritonsil-
compartments (spaces of Gillette) by a fibrous raphe
litis. If a frank abscess has formed, incision and drainage
(Figure 52.6). Each lateral space contains retropharyn-
will be required.
geal nodes which usually disappear at 3–4 years of
• Incision and drainage of abscess. A peritonsillar ab- age. Parapharyngeal space communicates with the
scess is opened at the point of maximum bulge above retropharyngeal space. Infection of retropharyngeal
the upper pole of tonsil or just lateral to the point of space can pass down behind the oesophagus into the
junction of anterior pillar with a line drawn through mediastinum.
the base of uvula (Figure 52.5). With the help of a • Prevertebral space. It lies between the vertebral bodies
guarded knife, a small stab incision is made and then posteriorly and the prevertebral fascia anteriorly. It ex-
a sinus forceps inserted to open the abscess. Putting tends from the base to skull of coccyx. Infection of this
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300 SECTION IV — Diseases of Pharynx
CLINICAL FEATURES
1. Dysphagia and difficulty in breathing are prominent
symptoms 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. Figure 52.7. Retropharyngeal abscess. Radiograph of soft tissue,
4. Bulge in posterior pharyngeal wall. Usually seen on one lateral view neck showing widening of prevertebral space with gas
side of the midline. formation (arrow).
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Chapter 52 — Head and Neck Space Infections 301
TREATMENT AETIOLOGY
1. Incision and drainage of abscess. It can be done through Infection of parapharyngeal space can occur from:
a vertical incision along the anterior border of sterno-
mastoid (for low abscess) or along its posterior border 1. Pharynx. Acute and chronic infections of tonsil and
(for high abscess). adenoid, bursting of peritonsillar abscess.
2. Full course of antitubercular therapy should be given in 2. Teeth. Dental infection usually comes from the lower
cases of tubercular abscess. last molar tooth.
3. Ear. Bezold abscess and petrositis.
4. Other spaces. Infections of parotid, retropharyngeal
PARAPHARYNGEAL ABSCESS and submaxillary spaces.
5. External trauma. Penetrating injuries of neck, injec-
(Syn. Abscess of pharyngomaxillary or lateral pharyngeal tion of local anaesthetic for tonsillectomy or mandibu-
space.) lar nerve block.
Figure 52.8. (A) A prevertebral abscess (tubercular) as seen in the oropharynx. (B) An X-ray of the same.
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302 SECTION IV — Diseases of Pharynx
Figure 52.9. Spaces of head and neck seen in coronal section. Mucosa (1), pharyngobasilar fascia (2), buccopharyngeal fascia (3), superior con-
strictor muscle (4), superficial layer of deep cervical fascia enclosing submandibular gland (5), parotid gland (6), masseter muscle (7), temporalis
muscle (8) and medial pterygoid muscle (9).
TABLE 52.1 IMPORTANT SPACES OF THE HEAD AND NECK AND THEIR SOURCE OF INFECTION
Space Extent Location Source of infection
Parotid space Within two layers of superficial Parotid area Infection of oral cavity via
layer of deep cervical fascia Stenson’s duct
Submandibular space • Sublingual space. Oral mucosa Below the tongue • Sublingual sialadenitis, tooth
(submaxillary plus sublingual) to mylohyoid muscle infection
• Submaxillary space. Mylohyoid Submental and submandibular • Submandibular gland
muscle to superficial layer of triangles sialadenitis
deep cervical fascia extending • Molar tooth infection
from mandible to hyoid bone
Peritonsillar space Between superior constrictor Lateral to tonsil Infection of tonsillar crypt
and fibrous capsule on the
lateral aspect of tonsil
Retropharyngeal space Base of skull to tracheal Between alar fascia and the • Extension of infection from
bifurcation (T4) buccopharyngeal fascia parapharyngeal space, parotid
covering constrictor muscles or masticator space
• Oesophageal perforation
• Suppuration of
retropharyngeal nodes
Danger space Base of skull to diaphragm Between prevertebral fascia and Infected by rupture of
alar fascia retropharyngeal abscess
Prevertebral space Base of skull to coccyx Between vertebrae on one side • Tuberculosis of spine
and prevertebral muscles and • Penetrating trauma
the prevertebral fascia on the
other
Parapharyngeal space (Lateral Base of skull to hyoid bone and Buccopharyngeal fascia covering • Peritonsillar abscess
pharyngeal space or pharyngo- submandibular gland lateral aspect of pharynx • Parotid abscess
maxillary space) medially, and fascia covering • Submandibular gland
pterygoid muscles, mandible infection
and parotid gland laterally • Masticator space abscess
Masticator space Base of skull to lower border of Between superficial layer of Infection of second and third
mandible deep cervical fascia and the molar
muscles of mastication—
masseter, medial and lateral
pterygoids insertion of
temporalis muscle and the
mandible and the deep layer
of deep cervical fascia
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Chapter 52 — Head and Neck Space Infections 303
TREATMENT
1. Systemic antibiotics. Intravenous antibiotics may
become necessary to combat infection. Antibiotics
should be able to affect both aerobic and anaero-
bic organisms. Antibiotics selected for treatment
are amoxicillin–clavulanic acid, imipenem or mero-
penem along with clindamycin or metronidazole.
Gentamicin is useful for Gram-negative bacteria. The
sensitivity of an antibiotic should determine the se-
lection of antibiotic.
2. Drainage of abscess. This is usually done under
general anaesthesia. If the trismus is marked, preop-
erative tracheostomy becomes mandatory. Abscess is
drained by a horizontal incision, made 2–3 cm below
the angle of mandible. Blunt dissection along the in-
ner 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 Figure 52.10. Masticator space. It consists of three spaces: masse-
this space. teric, pterygomandibular and temporal.
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