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Parapharyngeal abscess: Diagnosis, complications and management in adults
Abstract
Parapharyngeal abscess may cause life-threatening complications. Peritonsillar abscess and tonsillitis may result in parapharyngeal abscess. Since the introduction of antibiotics, the incidence of parapharyngeal abscess secondary to tonsillitis and peritonsillar abscess has decreased dramatically. We present five cases of parapharyngeal abscess resulting from tonsillitis and peritonsillar infection extending to the parapharyngeal space in adult patients. Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. We emphasize the diagnostic role of computerized tomography (CT) scan and the importance of early and proper drainage of these abscesses.
... However, it is still a condition that should be kept in mind and not be disregarded (1,2). The most common etiological causes of parapharyngeal abscesses are dental infections and tonsillitis (1,3,4). Mediastinitis can cause serious complications such as internal jugular vein thrombosis, carotid artery rupture, cavernous sinus thrombosis, pericarditis, sepsis, epidural abscess and even mortality (1)(2)(3)5). ...
... The most common etiological causes of parapharyngeal abscesses are dental infections and tonsillitis (1,3,4). Mediastinitis can cause serious complications such as internal jugular vein thrombosis, carotid artery rupture, cavernous sinus thrombosis, pericarditis, sepsis, epidural abscess and even mortality (1)(2)(3)5). ...
... Here, contrast-enhanced tomography comes to the fore. Contrast-enhanced neck tomography is very useful in detecting the infection focus in symptoms such as dysphagia, odynophagia, fever, neck pain, swelling and pain in the neck, and elevated laboratory parameters indicating infection (2,3,5). ...
... Parapharyngeal abscess (PPA) refers to a collection of pus located peripherally to the pharyngeal constrictor muscle. PPAs are relatively rare (annual incidence ~ 1/1,00,000 population), but may lead to fatal complications, such as airway obstruction, descending mediastinitis, necrotizing fasciitis, and carotid pseudoaneurism [1][2][3][4][5]. Though some studies suggest that conservative treatment with intravenous antibiotics alone may be safe and efficient in selected cases, aggressive management including combined surgical drainage and antibiotic therapy is generally recommended for rapid recovery and decreased risk of complications [2,[5][6][7][8][9]. ...
... While pediatric cases have been studied more intensively, very few previous studies have been conducted describing the microbiology of PPA in adults [3,4,[10][11][12]. Hence, the significant pathogens associated with adult PPA are largely unidentified. ...
... Furthermore, to the best of our knowledge, no studies evaluating different antibiotic regimens for the treatment of PPA have been published. Some researchers recommend broad-spectrum intravenous antibiotics for the treatment of adult PPA, but based on the existing literature, no specific antibiotic guidelines have been substantiated [4,11]. ...
Purpose
We aimed to evaluate the effectiveness of different antibiotic regimens for the treatment of parapharyngeal abscess (PPA) and characterize patients, who suffered potentially preventable complications (defined as death, abscess recurrence, spread of infection, or altered antibiotic treatment because of insufficient progress).
Methods
Sixty adult patients with surgically verified PPA were prospectively enrolled at five Danish Ear–nose–throat departments.
Results
Surgical treatment included internal incision (100%), external incision (13%), and tonsillectomy (88%). Patients were treated with penicillin G ± metronidazole (n = 39), cefuroxime ± metronidazole (n = 16), or other antibiotics (n = 5). Compared to penicillin-treated patients, cefuroxime-treated patients were hospitalized for longer (4.5 vs 3.0 days, p = 0.007), were more frequently admitted to intensive care (56 vs 15%, p = 0.006), underwent external incision more frequently (31 vs 5%, p = 0.018), and suffered more complications (50 vs 18%, p = 0.022), including re-operation because of abscess recurrence (44 vs 3%, p < 0.001). Nine patients suffered potentially preventable complications. These patients displayed significantly higher C-reactive protein levels, received antibiotics prior to admission more frequently, underwent external incision more commonly, and were admitted to intensive care more frequently compared to other patients.
Conclusion
The majority of patients with PPA were effectively managed by abscess incision, tonsillectomy, and penicillin G ± metronidazole. Cefuroxime-treated patients were more severely ill at time of admission and had worse outcome compared to penicillin-treated patients. We recommend penicillin G + metronidazole as standard treatment for patients with PPA, but in cases with more risk factors for potentially preventable complications, we recommend aggressive surgical and broadened antibiotic therapy, e.g. piperacillin–tazobactam.
... The knowledge regarding significant pathogens associated with PPA is very limited. The few previous studies focusing on the microbiology of PPA in adults were all retrospective, and thus reported findings in routine cultures, and no attempts were made to analyze the significance of the recovered bacteria [2,5,8,9]. ...
... ( n = 1), and Lachnoanaerobaculum orale (n = 1)) ( Table 3). (106) 177 (111) 176 (104) 192 (55) 299 (141) Leukocyte count (× 10 9 /L) 8 15.4 (3.6) 14.6 (2.8) 15.1 (4.2) 17.2 (3.9) 18.3 (1.8) Neutrophil count (× 10 9 /L) 9 12.4 (3.2) 11.9 (2.5) 11.8 ...
... Only a few studies of adult PPA patients include information on the microbiology, and no previous attempts to exhaustively define the bacteriology have been done [2,5,8,9,17]. Hence, previous studies were retrospective and described routine culture findings. ...
We aimed to describe the microbiology of parapharyngeal abscess (PPA) and point out the likely pathogens using the following principles to suggest pathogenic significance: (1) frequent recovery, (2) abundant growth, (3) growth in relative abundance to other microorganisms, (4) percentage of the isolates recovered in both absolute and relative abundance, (5) more frequent recovery in PPA pus compared with tonsillar surface and tissue. Comprehensive bacterial cultures were performed on specimens obtained from adult patients ( n = 60) with surgically verified PPA, who were prospectively enrolled at five Danish ear-nose-throat departments. The prevalent isolates (in PPA pus) were unspecified anaerobes (73%), non-hemolytic streptococci (67%), Streptococcus anginosus group (SAG) (40%), Corynebacterium spp. (25%), Neisseria spp. (23%), Fusobacterium spp. (22%), Fusobacterium necrophorum (17%), Prevotella spp. (12%), and Streptococcus pyogenes (10%). The bacteria most frequently isolated in heavy (maximum) growth were unspecified anaerobes (60%), SAG (40%), F. necrophorum (23%), and Prevotella spp. (17%). The predominant microorganisms (those found in highest relative abundance) were unspecified anaerobes (53%), SAG (28%), non-hemolytic streptococci (25%), F. necrophorum (15%), S. pyogenes (10%), and Prevotella spp. (10%). Four potential pathogens were found in both heavy growth and highest relative abundance in at least 50% of cases: F. necrophorum , Prevotella spp., SAG, and S. pyogenes . SAG, Prevotella spp., F. necrophorum , S. pyogenes , and Bacteroides spp. were recovered with the same or higher frequency from PPA pus compared with tonsillar tissue and surface. Our findings suggest that SAG, F. necrophorum , Prevotella, and S. pyogenes are significant pathogens in PPA development.
... [16,17] Interestingly, methicillin-resistant S. aureus has been the less common reason for bacterial tonsillitis. [18] The complications of tonsillitis were found to be the main reason behind the deterioration of the patient's condition, especially in those who had recurrent or chronic tonsillitis which may result in life-threatening, [19] such as rheumatic fever, scarlet fever, nephritis, and other complications which may develop auto-immune diseases. [20,21] Otitis media is considered one of the other tonsillitis complications. ...
... [47] Furthermore, data suggests that treating recurrent tonsillitis with tonsillectomy to avoid the consequences of Staphylococcus aureus infection and to avoid any problems caused by difficult-to-treat or persistent bacterial infections. [48] Tonsillectomy was done on (n=68, 19.5%) of the study participants in the present study. This was much lower than recent studies that showed tonsillectomy was done in (n=137, 43.58%; and n=30, 60%). ...
Abstract
Background:
Tonsillitis is considered one of the most otolaryngological diseases affecting children and adults. Tonsillectomy is one of the common surgical procedures mostly with children and in cases of chronic tonsillitis or recurrent tonsillitis.
Aims:
The objective of this study was to examine the incidence of tonsillitis, along with its methods of diagnosis and treatment, among patients residing in the Al-Baha region of Saudi Arabia.
Settings and Design:
A retrospective observational cross-sectional analysis of tonsillitis patients who attended the pediatric, emergency room, adult surgery, and ear, nose, and throat clinics at a hospital in Al-Baha, Saudi Arabia, from January 2019 to January 2023.
Subjects and Methods:
This research used purposive sampling. Covered examining data acquired and analyzed 348 tonsillitis-related throat swabs and blood samples.
Statistical Analysis Used:
Data were statistically analyzed using the Statistical Package for the Social Sciences software version 20.0 IBM (Armonk, New York, USA).
Results:
A total of 348 patients diagnosed with tonsillitis were examined. Males had tonsillitis more than females (n = 208, 60% and n = 140, 40%, respectively). The most frequent bacteria isolated were Streptococcus pyogenes group A beta-hemolytic, Staphylococcus aureus, methicillin-resistant S. aureus, and Klebsiella pneumoniae (n = 68, 19.5%; n = 24, 6.9%; n = 12, 3.4%; and n = 12, 3.4%, respectively).
Conclusions:
Tonsillitis is an oral and public disease affecting both children and adults in Al-Baha region. The emphasis should be on enhancing the public health system to reduce tonsillitis and its consequences via effective awareness efforts. Hospitals may also be urged to develop unique criteria for tonsillitis swabs in order to reduce contamination and improve diagnosing the etiology of bacterial tonsillitis.
... The first-line diagnostic tool for parotid gland diseases is ultrasonography as it is easily available and gives good radiological insight into differential diagnosis (8). However, if severe complications of acute bacterial parotitis are suspected, particularly parapharyngeal space and extended neck phlegmon, or mediastinitis, CT scan of neck and/or thorax with contrast should be immediately performed (2,8,9,10,11,12). The management of parotid gland abscess includes broad-spectrum antibiotic therapy, and surgical drainage, which is mandatory in patients who also develop neck phlegmon (2,4,10,12,13). ...
... However, if severe complications of acute bacterial parotitis are suspected, particularly parapharyngeal space and extended neck phlegmon, or mediastinitis, CT scan of neck and/or thorax with contrast should be immediately performed (2,8,9,10,11,12). The management of parotid gland abscess includes broad-spectrum antibiotic therapy, and surgical drainage, which is mandatory in patients who also develop neck phlegmon (2,4,10,12,13). Due to various medical problems with which the patients with neck phlegmon are struggling which can also include mediastinitis and sepsis, it is crucial to underline the necessity of complex medical assessment of the patient's general condition and medical therapy, especially incuding the hydro-electrolyte imbalance management. Parotid gland abscess and complicated neck phlegmon could be successfully treated, if immediate medical and surgical management is undertaken following careful and constant medical care (8). ...
The diagnosis of acute bacterial parotitis usually does not cause much clinical concern due to the characteristic clinical signs and symptoms, such as pain and swelling of parotid gland associated with fever and elevated inflammatory markers in laboratory tests. Early diagnosis and accurate treatment result in fast recovery without complications. In rare cases, acute bacterial parotitis may cause severe complications, such as parotid gland abscess or parapharyngeal space phlegmon. Parapharyngeal space phlegmon is a severe, life-threatening condition. It can spread to craniofacial and neck fascial spaces, mediastinum, and lead to sepsis and septic shock. Craniofacial and neck phlegmon requires prompt surgical treatment and intensive antibiotic therapy. In this case study, we present an 82-year-old woman with bacterial parotitis that resulted in multiple complications. The first complication was parotid gland abscess, which caused extended craniofacial and neck phlegmon that led to sepsis. As a result of immediate intensive treatment, which consisted of broad-spectrum antibiotic therapy, surgical drainage, and hydro-electrolyte imbalance management, the treatment ended in a success. The patient fully recovered and was discharged home in a good general condition.
... Peritonsillar abscess was more commonly described in children older than 10 years [3]. Anecdotal reports of older individuals having PTA described worse morbidity rates [4,5]. ...
... Although PTA in the pediatric age group is associated with low morbidity rate, short hospitalization period, and a low complication rate [20], PTA in the older age group was reported to be associated with substantial morbidity and mortality rates [4,5]. Focused on patients aged 40 years or older in this study, some characterizations of PTA in this age group were well distinguished. ...
Objective To assess changes in the characteristics of peritonsillar abscess (PTA). Methods A retrospective cohort study. Data obtained from medical records of patients diagnosed as having a peritonsillar abscess that were treated in a secondary urban medical center over a ten-year period (1998-2007). Results 427 patients, within ages of 3 to 91 years (average 31.6, SD 15.2, median 30) were enrolled. 47 patients (11%) were admitted more than once for PTA. There was no gender, seasonal, or localization predominance. 13 patients (3%) developed PTA complications. 104 patients (24.4%) were 40 years old or older, having a longer hospitalization period, and were more prone to complications. 102 patients (23.9%) did not have acute tonsillitis before PTA evolvement. Smoking was more common among patients than in the general population rate (33% vs 25%), associated with a higher complication. Culture results and antibiotic therapy influence were analyzed for all PTA cases (n=486). In 283 patients (58.2%) developed PTA in spite of a prior antibiotic therapy. Smoking was associated with a higher infection rate by Streptococcus viridans. Conclusions Comparison of current data to earlier reports suggests that PTA has gradually changed its characteristics: affecting older patients, having a more vigorous presentation and a longer course, abscess evolvement without an anteceding tonsillitis, and patients developing PTA in spite of a prior adequate antibiotic therapy. In addition, smoking may be a predisposing factor.
... Parapharyngeal abscess is the second most common deep neck abscess after peritonsillar abscess (1). It is much more common in children although adults who are immunocompromised due to conditions such as diabetes too may suffer (2). They present with swinging fever, sore throat, dysphagia, odynophagia, change in voice and patients are generally very unwell. ...
... Smaller abscesses can be managed by intravenous antibiotics alone (2) or with added steroids and fine needle aspiration (3,1). Due to the prevalence of streptococci and staphylococci in pathogenesis preferred firstline antibiotics are amoxicillin and clavulonic acid combinations (3). ...
... Среди наиболее часто встречаю щихся микроорганизмов упоминаются неуточненные анаэробы, негемолитические стрептококки, коринебактерии, нейссерии, пиогенный стрептококк и др. При этом сообщается, что чаще всего выделяются полимикробные ассоциации [17][18][19]. ...
Introduction. The most dangerous local complication of acute and exacerbations of chronic inflammatory diseases of the pharynx is the formation of abscesses in the structure of the cellular spaces of the neck. Paratonsillar abscess (PTA) is the most common abscessing lesion. In turn, parapharyngeal abscess (PFA) is often found in patients with PTA as its complication.
Aim. To study the clinical, microbiological and pathomorphological features of parapharyngeal complications in patients with PTA.
Materials and methods . The analysis of medical records of 50 patients with diagnoses of parathonsillar and parapharyngeal abscesses who underwent inpatient treatment at the otorhinolaryngological department of the N.I. Pirogov State Clinical Hospital No. 1 in the period from September 2021 to April 2023 was carried out. The studied patients were divided into 2 groups. In group 2 of patients (n = 25; F 10, M 15; average age -37.2 years ± 10.8 years) an isolated PTA was diagnosed. In the 2 group of patients (n = 25; F 10, M 15, the average age was 44.6 years ± 14.8 years) PTA was complicated by the development of PFA.
Results and discussion . Associations of facultative anaerobic and obligate anaerobic microorganisms were found in all pus aspirates obtained from PTA and PFA. Monocultures of microorganisms were not isolated in any case. The detection of Fusobacterium necrophorum was associated with pronounced necrotic changes in the tissues of the tonsils and surrounding structures; Peptostreptococcus anaerobius with purulent melting of fiber tissue; Veillonella dispar with pronounced infiltrative processes in tissues combined with oral pathology in patients.
Conclusions. The most common microorganisms in patients with PTA and PFA were Streptococcus pyogenes and Fusobacterium necrophorum. The activity of Fusobacterium necrophorum is associated with a more severe course of the inflammatory process in the near-pharyngeal space.
... Moreover, 52 % of PPA patients had concomitant PTA, which stresses the common tonsillar origin of these infections. This association seems much higher in this study than previously documented [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. The frequent co-existence of PPA and PTA is not only interesting in terms of the pathogenesis of PPA, but may also give rise to therapeutic considerations as both abscesses ought to be drained for optimal recovery. ...
The aims of the present case report were to review, computed tomography (CT) scans, clinical signs, treatment, and outcome of parapharyngeal space infections. These infections remain an important health problem with significant risks of morbidity and mortality. The term parapharyngeal abscess or infection is composed of two different disorders: infection located in the posterior part of the PPS with no invasion into the parapharyngeal fat and the second disorder is when the infection involving the parapharyngeal fat may be termed parapharyngeal abscess or deep neck abscess. Diffusion into the mediastinum and other severe complications are frequent. A 59 year old male, presented with three days history of intermittent high grade fever and left neck swelling which was rapidly increasing in size and associated with stridor, odynophagia and neck pain. The infection and accumulation of purulent discharge extend into the pharyngomaxillary space and inferiorly is located at the greater cornu of the hyoid bone. Temporary tracheostomy for respiratory assistance was performed. The frequent co-existence of parapharyngeal abscess and peritonsillar abscess favours careful consideration of addition of tracheotomy to lateral cervicotomy. Parapharyngeal abscess are deep neck abscesses that are common and thorough knowledge of their complex anatomy and aetiologies is essential in their treatment. Urgent surgical drainage is therefore mandatory.
... Prompt treatment is necessary, as PTA may give rise, albeit rarely, to life-threatening complications secondary to spread along fascial planes to the deep neck and chest. [6][7][8] The COVID-19 pandemic has been shown to impact the microbiology 9 and clinical course of several paediatric ENT infectious diseases, including otitis media, sinusitis, laryngitis and mastoiditis. [10][11][12] Acute mastoiditis demonstrated reductions in common pathogens such as Streptococcus pneumoniae and Haemophilus influenzae, with a concomitant increase in Pseudomonas cultivation during the COVID era. ...
Objectives
Peritonsillar abscess (PTA) is the most common soft‐tissue infection of the head and neck. This potential complication of tonsillitis has demonstrated unique microbial trends during the COVID‐19 pandemic. This era has resulted in a major shift in the hygiene and social habits of the general population, which has resulted in changes in the presentation, management and microbiology of several infectious diseases. To date, the impact of COVID 19 on PTA microbiology and clinical presentation in the paediatric population has yet to be investigated.
Design
Retrospective chart review comparing all cases of paediatric (age 0–18) PTA in an academic tertiary centre during the COVID‐19 pandemic (03/2020–02/2022) and compared them to two control groups: pre‐COVID (03/2018–02/2020) and post‐COVID (03/2022–03/2023). All patients were treated with either needle aspiration, incision and drainage or both means in addition to intravenous antibiotics.
Setting
A large Ear Nose and Throat department in a tertiary referral center.
Participants
Consecutive children aged 18 years or under, admitted with a diagnosis of Peritonsillar abscess.
Main Outcome Measures
We analyzed the clinical and microbiologcal features of all cases of pediatric peritonsillar abscess during the COVID‐19 era (03/2020‐02/2022) and compared them to a pre and post control cases.
Results
A total of 96 PTA cases were included (35 pre‐COVID, 35 COVID and 26 post‐COVID). The means of procedural treatment shifted in favour of incision and drainage versus needle aspiration during the COVID era. The length of hospitalisation increased during the COVID era (3.6 days vs. 2.1 and 3.1 pre and post‐COVID respectively, p < .001). No other notable differences in the clinical and demographic features were found between the three eras. The COVID‐19 era saw an increase in Fusobacterium (37.1% vs. 8.6% and 24% pre and post‐COVID, respectively; p = .008) and Streptococcus Anginosus (31.4% vs. 5.7% and 7.7% pre and post‐COVID, respectively; p = .007) species isolation.
Conclusions
The COVID‐19 pandemic did not seem to impact the clinical presentation of paediatric PTA yet resulted in a change in microbiological pathogens. The choice of I&D as a means to shorten hospital stay during the pandemic may have led to an actual increase in hospital stay, suggesting that NA may be the preferred management approach.
... Eine schnelle Diagnostik sowie Therapieeinleitung sind essenziell. Eine unbehandelte Infektion kann zu einer Ruptur des Abszesses mit Eiteraspiration oder einem Absinken des Abszesses mit Obstruktion der Atemwege, Infektion der tiefen Halsweichteile bis hin zu einer nekrotisierenden Fasziitis und Mediastinitis führen [1,4,16]. ...
Zusammenfassung
Hintergrund
Der Peritonsillarabszess (PTA) wird häufig als Komplikation der akuten Tonsillitis gesehen und ist definiert als Eiterverhalt zwischen der Tonsillenkapsel und dem peritonsillären Gewebe. Die Ätiologie und Pathogenese sind bisher noch nicht vollständig geklärt. Ein Zusammenhang zwischen bestimmten Wetterbedingungen und Temperaturschwankungen und dem Auftreten von Abszessen im Kopf-Hals-Bereich wird seit Jahren diskutiert. Hierbei ist die Frage, ob höhergradige Temperaturschwankungen prädisponierend sind für die Ausbildung von Abszessen.
Material und Methodik
Es erfolgte eine retrospektive Auswertung aller Patienten, die in einem Zeitraum von 10 Jahren (2012–2021) in der Klinik und Poliklinik für Hals, Nasen‑, Ohrenheilkunde des Klinikums rechts der Isar der Technischen Universität München mit einer Peritonsillitis oder einem PTA stationär behandelt wurden. Jeder Patient wurde einzeln mit den täglichen Temperaturdaten des statistischen Wetteramts für die Stadt München korreliert.
Ergebnisse
Insgesamt konnten 1450 Patienten in die Studie eingeschlossen werden. Von den 1450 Patienten hatten 270 Patienten (18,62 %) eine Peritonsillitis, 1180 Patienten (81,38 %) einen PTA. Eine Korrelation zwischen dem Auftreten von Peritonsillitiden oder PTA und größeren Temperaturschwankungen konnte in diesem großen Patientenkollektiv ausgeschlossen werden. Auch zeigte sich über das ganze Jahr eine ähnliche Häufigkeit von Peritonsillitiden und PTA.
Schlussfolgerung
Peritonsillitiden oder Peritonsillarabszesse entwickeln sich nach Datenlage der vorliegenden Studie wetterunabhängig.
... Incidence of peritonsillar abscess is associated with increasing acute tonsillitis in winter seasons. The occurrence of retropharyngeal and parapharyngeal abscesses in older ages is highly associated with dental manipulation as well as tonsillitis [15]. The common etiologic factors in children for retropharyngeal abscess are upper respiratory tract infections [16]. ...
Background
Deep neck space abscesses are an important medical problem but the extent of their seasonality is not yet fully understood. Thus, we aimed to examine the seasonality of deep neck space abscesses and define the associated climate factors using a nationwide, population-based, cross‐sectional data.
Methods
Korean National Health Insurance-derived database with records from January 2010 to December 2019 was utilized in this study. We identified patients with peritonsillar, retropharyngeal, and parapharyngeal abscesses who were assigned the following diagnostic codes as a principal or first additional diagnosis: The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes J36 (peritonsillar abscess), J39.0, and J39.1 (retropharyngeal and parapharyngeal abscess and other abscess of the pharynx). We calculated the seasonal ratio as the ratio of the highest to the lowest number of patients per each month to assess the degree of seasonality for each studied condition. In addition, climate data points corresponding to each month were obtained. Thus, we analyzed correlations between the monthly patient numbers for each disease and various climate-related factors.
Results
We detected seasonal variations in the number of peritonsillar, retropharyngeal, and parapharyngeal abscesses, which were highest in winter-to-spring and lowest in summer. Peritonsillar abscesses were strongly correlated with average temperature, ground temperature, relative humidity, precipitation, daily temperature range, and particulate matter < 10µm (PM10). Retropharyngeal and parapharyngeal abscesses were linked to similar climate factors but with sunlight rate instead of PM10.
Conclusion
This large population-based study highlights a clear seasonality and climate relevance in patients with deep neck space abscesses. Further studies exploring detailed demographic factors associated with the incidence of deep neck space abscesses are required to better characterize these conditions.
... Deep neck infections are most commonly caused by dental abscesses and tonsillitis and lead to parapharyngeal, peritonsillar, and retropharyngeal abscesses [5]. Although rare, foreign bodies in the parapharyngeal space can sometimes be a causative factor [4]. Deep neck infections are commonly polymicrobial-with prevalent causative organisms inclusive of Klebsiella pneumoniae, Streptococcus Group, anaerobic bacteria and Staphylococcus aureus [6]. ...
Purpose:
Education in airway management is a fundamental component of anesthesiology training programs. There has been a shift towards the use of simulation models of higher fidelity for education in airway management. The goal of this study was to create a novel cadaveric model of a simulated parapharyngeal abscess with features of a difficult airway such as distorted anatomy and narrow airway passages presenting as stridor. The model was further assessed for its suitability for enhanced experiential learning in the management of difficult airways.
Methods:
Cadaver heads were modified surgically to simulate parapharyngeal abscess. Airtight torso of the cadaver was connected to an Oxylog ventilator to simulate respiratory movements-the opening and closing of air channels with breaths in a patient with parapharyngeal abscess. Advanced airway workshop facilitators conducted directed one-to-one learning, and provided feedback to participants. A paper-based feedback was obtained from 72 participants on their confidence level, and the realism, attractiveness, beneficial, and difficulty levels of the simulated cadaveric models.
Results:
The modified cadavers were reliable in simulating difficult airways. The majority of participants (91%) reported an increase in confidence level for management of the difficult airway after the experience with the modified cadavers and found the models realistic (93%), attractive (92%), beneficial (93%), and difficult (85%).
Conclusions:
Surgical modifications of cadavers to simulate difficult airways such as parapharyngeal abscess with edema and stridor can be incorporated into advanced airway management courses to enhance experiential learning in airway management by awake fibreoptic intubation, and promote patient safety.
... In our study, the durations of hospitalization determined for the non-RA and the RA cohorts with PTA were noted to be similar to previous reports; we determined the RA cohort with PTA to have a significantly longer length of hospital stay (RA-PTA vs non-RA-PTA 6.5 ± 4.5 vs 4.6 ± 2.8 d, P = 0.045). Severe PTA can cause DNI and even mediastinitis [31][32][33]. The probability of PTA complicated with DNI, such as abscess extending to the parapharyngeal space or retropharyngeal space, was previously reported to be 13.3% [34]. ...
PurposeThe peritonsillar abscess (PTA)–rheumatoid arthritis (RA) association remains unclear. Here, the effects of RA on PTA incidence and prognosis are elucidated.Methods
We compared PTA incidence and prognosis of 30,706 RFCIP-registered patients with RA (RA cohort) with matched individuals without RA from another database of 1 million randomly selected people representing Taiwan’s population (non-RA cohort).ResultsThe RA cohort had significantly higher PTA incidence [incidence rate ratio (IRR) (95% CI) 1.73 (1.10–2.71), P = 0.017) and cumulative incidence (P = 0.016, Kaplan–Meier curves). Cox regression analyses demonstrated RA cohort to have an estimated 1.72-fold increased PTA risk (95% CI 1.09–2.69, P = 0.019). PTA was more likely within the first 5 years of RA diagnosis (for < 1, 1–5, and ≥ 5 postdiagnosis years, IRRs: 2.67, 2.31, and 1.10, respectively, and P = 0.063, 0.021, and 0.794, respectively; average onset duration: 4.3 ± 3.3 years after RA diagnosis). PTA increased length of hospital stay significantly and risk of complication with deep neck infection nonsignificantly [6.5 ± 4.5 vs 4.6 ± 2.8 days (P = 0.045) and 18.52% vs 7.81% (P = 0.155), respectively]. Moreover, RA-cohort patients not receiving RA therapy exhibited 5.06-fold higher PTA risk than those receiving RA-related therapy (95% CI 1.75–14.62, P = 0.003).Conclusions
In patients with RA, PTA incidence is the highest within 5 years of RA diagnosis, and RA therapy is essential for reducing PTA risk.Level of evidence4.
... Infections laterally or posteriorly to the pharyngeal constrictor muscle are referred to as para-and retropharyngeal abscess or phlegmon. These infections may arise after spread of bacteria from the teeth or upper airway mucosa through neck tissues or lymph ducts [27,28]. Less frequently, para-and retropharyngeal infections are described as extensions of PTA [20,26,[29][30][31][32][33][34][35][36][37]. ...
Background:
The vast majority of patients with peritonsillar abscess (PTA) recover uneventfully on abscess drainage and antibiotic therapy. However, occasionally patient´s condition deteriorates as the infection spread in the upper airway mucosa, through cervical tissues, or hematogenously. The bacterial etiology of PTA is unclarified and the preferred antimicrobial regimen remains controversial. The current narrative review was carried out with an aim to (1) describe the spectrum of complications previously recognized in patients with peritonsillar abscess (PTA), (2) describe the bacterial findings in PTA-associated complications, and (3) describe the time relation between PTA and complications.
Methods:
Systematic searches in the Medline and EMBASE databases were conducted and data on cases with PTA and one or more complications were elicited.
Results:
Seventeen different complications of PTA were reported. The most frequently described complications were descending mediastinitis (n = 113), para- and retropharyngeal abscess (n = 96), necrotizing fasciitis (n = 38), and Lemierre´s syndrome (n = 35). Males constituted 70% of cases and 49% of patients were > 40 years of age. The overall mortality rate was 10%. The most prevalent bacteria were viridans group streptococci (n = 41, 25%), beta-hemolytic streptococci (n = 32, 20%), F. necrophorum (n = 21, 13%), S. aureus (n = 18, 11%), Prevotella species (n = 17, 10%), and Bacteroides species (n = 14, 9%). Simultaneous diagnosis of PTA and complication was more common (59%) than development of complication after PTA treatment (36%) or recognition of complication prior to PTA (6%).
Conclusion:
Clinicians involved in the management of PTA patients should be aware of the wide range of complications, which may arise in association with PTA development. Especially males and patients > 40 years of age seem to be at an increased risk of complicated disease. In addition to Group A streptococci and F. necrophorum, the current findings suggest that viridans group streptococci, S. aureus, Prevotella, and Bacteroides may also play occasional roles in the development of PTA as well as spread of infection. Complications occasionally develop in PTA patients, who are treated with antibiotics and surgical drainage.
... Although relatively rare, abscesses of the multiple maxillofacial spaces, especially the parapharyngeal space (PPS; also known as the lateral pharyngeal space or pharyngomaxillary space), can progress rapidly, potentially causing life-threatening conditions such as a compromised airway, descending necrotizing mediastinitis, deep vein thrombosis and sepsis [1]. Recent research showed that, in select cases, an uncomplicated deep neck abscess can be effectively treated with antibiotics and careful monitoring, without surgical drainage [2]. ...
The parapharyngeal space (PPS) connects multiple maxillofacial spaces (including the submandibular, retropharyngeal, and submasseteric spaces), and it is one of the most complex anatomic locations in the head and neck. Infection in the PPS may cause a series of life-threatening conditions such as mediastinal abscesses. Herein, we present the case of a PPS abscess involving multiple maxillofacial spaces, which was successfully incised and drained using a minimally invasive transoral approach under local anaesthesia. This minimally invasive approach requires full anatomic knowledge of the neck spaces. Additionally, the approach requires that the patient should be able to tolerate local anaesthesia and not have a compromised airway or severe trismus, and the infection should only affect the prestyloid compartment.
... 7 The complications associated to cervical suppurations may be: acute obstruction of upper respiratory tract, mediastinitis, internal jugular vein thrombosis, carotid artery rupture, necrotizing fasciitis, pneumonia, sepsis. 8,9 Case Report 1 ...
... Infection of the parapharyngeal space is very likely to cause fatal complications such as airway obstruction and mediastinitis. 11 The retropharyngeal space is located between the posterior pharyngeal wall and the anterior intervertebral space. This space is connected upward to the print & web 4C=FPO 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 base of the skull and downward to the retroesophageal space. ...
Purpose:
Descending necrotizing mediastinitis (DNM) has been the most common life-threatening complication of multispace infection (MSI) in the maxillofacial region owing to the lack of a timely diagnosis and treatment. We assessed the clinical characteristics and diagnosis of odontogenic MSI and evaluated the risk factors for DNM caused by MSI.
Patients and methods:
We performed a retrospective cohort study of inpatients with MSI in the maxillofacial region from January 2012 to October 2016. The patients were classified into a non-DNM group and a secondary DNM group. The information collected included gender, age, systemic comorbidities, source of maxillofacial infection, computed tomography imaging data, and laboratory test results. Univariate analysis (test, t test and χ2 test, or the Fisher exact test) and logistic regression analysis were applied.
Results:
A total of 296 patients were included. The mortality was 6.3%. On univariate analysis, the following factors were statistically significant: gender (P = .001); age (P = .003); source of infection (P = .004); number of affected spaces (P < .001); involvement of the parotid space (P < .001), submandibular space (P < .001), subgingival space (P < .001), pterygomandibular space (P < .001), parapharyngeal space (P < .001), and retropharyngeal space (P < .001); and percentage of neutrophils (P < .001). On multivariate analysis, the parapharyngeal space (P = .008), source of infection (P = .037), and number of affected spaces (P < .001) were statistically significant.
Conclusions:
Glandular infection, parapharyngeal space involvement, and the presence of multiple affected spaces were risk factors for DNM. Clinicians should vigilantly watch for these factors during clinical treatment and effective measures taken to prevent the occurrence of DNM as soon as possible.
... It also helps in delineating the exact extent and size of infectious process/collection and to decide whether surgical drainage is required or not. The presence of gas in the neck and/or mediastinum as visualised on CT is usually associated with a more potentially serious course requiring ICU care [26]. CT thorax must be advised in those DNSIs cases where there is inadequate response to surgical drainage of neck, where re-exploration of neck has been done but no improvement, x ray chest suggestive of disseminated foci, or inadequate response to antibiotics in spite of good appearance of neck wound, and deranged respiratory parameters in spite of patent airway, elevated blood counts even in presence of normal looking neck wound. ...
The diagnosis and management of deep neck space infections remain a challenging task for otolaryngologists. A retrospective observational analysis of 137 cases of deep neck infections at a tertiary care centre was reviewed. We present 137 treated cases of DNSIs in a retrospective 5 years clinical study conducted in the department of otolaryngology at a tertiary care center from January 2012 to December 2016. Demographic information, Socio-economic data, etiopathogenesis, clinical presentation, spaces involved, diagnosis, and treatment strategies, associated morbidities, course and complications were analysed and compared with past experiences. Odontogenic and salivary gland infections causes were the most common source of DNIs. Major complication observed was skin defect. In this study, submandibular space infection was found to be the most common space involved in DNSI. Pain (100%) was the most common clinical complaint followed by neck swelling (65.69%). Staphylococcus aureus (38 cases) was the most common micro-organism isolated. Surgical intervention was the main modality of treatment and there was one mortality. DNSIs are fairly common challenging and potentially lethal entities which can lead to severe complications in a very short time, should there be delay in its prompt diagnosis and management. Computerized Tomography Scan (CT scan) with contrast is the investigation of choice in diagnosing DNSIs. Assessment of airway control must take precedence.
... Deep neck infections were seen in 24 patients (38.1%) and were most commonly located in the parapharyngeal space. This result is consistent with other studies (7) and is anatomically reasonable, as the parapharyngeal space communicates with other spaces (8). ...
Background and purpose:
With the use of antibiotic therapy, the incidence of deep neck infections has decreased in recent decades. The aim of this investigation was to review the clinical course and the management of deep neck infections in our department, compare them to the experiences of the common literature and identify predisposing factors for lethal complications.
Material and methods:
In this single-center analysis, 63 patients with deep neck infections were treated surgically. The following clinical data were analyzed and compared: age, gender, laboratory data, spatial manifestation, therapeutic modalities, comorbidities, length of hospitalization and complications.
Results:
There was a predominance of male patients (58.7%) and a mean age of 57.9 years. The most common symptoms at diagnosis were sore throat (96.8%) and neck swelling (92.0%). Cardio/pulmonary diseases and diabetes mellitus were the most common comorbidities. There was a significantly longer hospital stay for patients with diabetes mellitus. The most common manifestation was a parapharyngeal abscess in 24 patients (38.1%), followed by peri-/retrotonsillar infections in 19 patients (30.2%). In 29 patients, a multiple space infection was observed, with a significantly longer duration of hospitalization and a higher rate of complications. The main life-threatening complication was the development of airway obstruction in 20 patients (31.7%), who all received a tracheostomy. The duration of hospitalization for patients with complications was significantly longer.
Conclusion:
Close attention must be paid to the management of patients with deep neck infections, especially patients with diabetes mellitus and cardio/pulmonary diseases or patients with multiple space infections.
... Antibiotics use has led to a decrease in the number of infections of paraphangeal space, these days it is usually seen secondary to dental infections or parotiditis [5]. Such infections pose the danger of spread to carotid axis and respiratory tract along with the pericardial region [6]. In our case the venous walls were involved in the infection, leading to mycotic aneurysms. ...
We report a 31 year old woman presented with three months history of large untreated parapharyngeal abscess and bleeding from the mouth. On evaluation chest CT scan identified the abscess extending down to the superior mediastinum and multiple small lung abscesses. Echocardiography showed tricuspid valve insufficiency. Patient was brought to the operating room (OR) and intra-operatively it was found that she had multiple large mycotic pseudoaneurysms of the internal jugular vein and right brachiocephalic veins. All these pseudoaneurysms were repaired with pericardial patches under cardiopulmonary bypass. Patient did well in the short postoperative follow up and was then referred to plastic surgery and ENT for further surgical interventions.
... Untreated infections may result in abscess formation that can spread through different levels in and between the facial spaces and result in life-threatening situations including mediastinitis, pericarditis, meningitis, septic shock, airway compromise, jugular vein thrombosis, and arterial erosion. 1,2 The origin of facial space infections is often unclear, as the primary infection focus may have a diffuse presentation. Several studies written on parapharangeal space infections have shown that tonsillitis and pharyngitis are the predominant nidus in children, whereas dental infections are more common in adults. ...
Anatomically, within the deep neck are 11 spaces created by planes of greater and lesser resistance between the fascial layers. These include the submandibular space, parapharyngeal space (PPS), retropharyngeal space, peritonsillar space, danger space, prevertebral space, pretracheal space, carotid space, masticator space, temporal space, and the parotid space. Deep neck space infections (DNSIs) most commonly arise from a septic focus of the mandibular teeth, tonsils, parotid gland, deep cervical lymph nodes (LNs), middle ear, or sinuses. These DNSIs often have a rapid onset and can progress to life-threatening complications. They present a challenging problem because of the difficult localization of infection, the risk of surgical injury to the intervening neurovascular and soft tissue structures, and the possible complicated sequelae of inflammatory involvement of the vital surrounding tissues such as neural dysfunction, vascular erosion, thrombosis, and osteomyelitis. This chapter focuses on the etiology, clinical presentation, diagnosis, management, and prognosis of certain inflammatory lesions such as Ludwig’s angina, peritonsillar abscess (PTA), parapharyngeal abscess, and retropharyngeal abscess (RPA).
Kranial Travma Mustafa Hızal Konjenital Serebral Malformasyonlar Elif Gözgeç Nörokutanöz Sendromlar İlyas Dündar Vasküler Oklüziv Hastalıklar Fatih Kılınç Non Oklüziv Vasküler Patolojiler Seray Akçalar Dural ve Leptomeningeal Tutulum ile Seyreden Hastalıklar Ezra Çetinkaya Hidrosefali ve Diğer Bos Bozuklukları Temel Fatih Yılmaz Epilepsi Berrak Barutcu Asfuroğlu Umut Asfuroğlu Demiyelinizan ve Dismiyelinizan Hastalıklar Zakir Sakcı Metabolik Hastalıklar Saliha Çıracı Nörodejeneratif Hastalıklar Yusuf Can Baş Boyun Enfeksiyon ve İnflamasyonları Cansu Öztürk Ekstraaksiyel Tümörler Aydın Aslan Elif Günaydın İntraaksiyel Supratentorial Tümörler Ali Murat Koç İntraaksiyel İnfratentorial Bölge Tümörleri Ezel Yaltırık Bilgin Tedaviye İkincil Değişiklikler Okan Dilek Sinonazal Kavite Hastalıkları İsa Çam Ural Koç Pituiter Bez Patolojiler Ali Can Yalçın Orbita ve Görme Yolları Patolojileri Hüseyin Alper Kızıloğlu Anıl Kaya Temporal Kemik Ve Kulak Patolojileri Fuldem Mutlu Suprahyoid Boyun Patolojileri Özgür Çakır İnfrahiyoid Boyun Patolojileri Gülen Burakgaz Konjenital Spinal Anomaliler Büşra Şeker Maksude Esra Kadıoğlu Spinal Bölge Enflammatuar Ve Enfeksiyöz Durumlar Fatma Can Omurganın Dejeneratif Hastalıkları Eray Atlı Postoperatif Omurga Görüntülemesi Engin Dinç Spinal Kanal Neoplazmları Ayşe Gül Alımlı
Objective:Many problems of parapharyngeal abscess (PPA), such as etiology, predisposing factors, and therapeutic methods, are still controversial. We aim to investigate the characteristics of PPA to better understand the therapeutic effects of the disease. Methods: We retrospectively collated the medical record reviews of 49 PPA patients who were treated as PPA inpatients when a patient was hospitalized and diagnosed with PPA, and empiric antibiotics were used. Only if the drug treatment was ineffective, the abscess was large, or the disease continued to progress, and surgical treatment was adopted. Results: In total, 49 patients who met the research criteria were identified. Streptococcus was the most common organism in PPA patients. The morbidity of diabetes in PPA patients was higher than the prevalence of diabetes in the overall population. Interestingly, the length of hospital stay was shorter in the antibiotic-only group than in the surgery group (P < 0.05). Furthermore, the duration from onset to treatment in the antibiotic-only group was shorter than in the surgery group. Conclusion: Our treatment protocol is effective. Antibiotic-only method is also recommended for the PPA which was effective for the empiric antibiotics and localized. Early diagnosis and treatment of PPA could ultimately reduce the severity of PPA.
Objectives:
To summarise current practices in the diagnosis and management of deep neck space infections (DNSIs). To inform future studies in developing a framework in the management of DNSIs.
Design:
This review was registered on PROSPERO (CRD42021226449) and reported in line with PRISMA guidelines. All studies from 2000 that reported the investigation or management of DNSI were included. The search was limited to English language only. Databases searched included AMED, Embase, Medline and HMIC. Quantitative analysis was undertaken with descriptive statistics and frequency synthesis with two independent reviewers. A qualitative narrative synthesis was conducted using a thematic analysis approach.
Setting:
Secondary or tertiary care centres that undertook management of DNSIs.
Participants:
All adult patients with a DNSI.
Main outcome measures:
The role of imaging, radiologically guided aspiration and surgical drainage in DNSIs.
Results:
Sixty studies were reviewed. Thirty-one studies reported on imaging modality, 51 studies reported treatment modality. Aside from a single randomised controlled trial, all other studies were observational (n = 25) or case series (n = 36). Computer tomography (CT) was used to diagnose DNSI in 78% of patients. The mean percentage of management with open surgical drainage was 81% and 29.4% for radiologically guided aspiration, respectively. Qualitative analysis identified seven major themes on DNSI.
Conclusions:
There are limited methodologically rigorous studies investigating DNSIs. CT imaging was the most used imaging modality. Surgical drainage was commonest treatment choice. Areas of further research on epidemiology, reporting guidelines and management are required.
Purpose
Although parapharyngeal and retropharyngeal abscesses are potentially fatal deep neck abscesses, there is limited evidence for the treatment courses for adult patients with these abscesses. We aimed to describe the practice patterns and clinical outcomes of adult patients undergoing an emergency surgery for parapharyngeal or retropharyngeal abscesses using a nationwide database.
Materials and methods
We identified patients aged ≥18 years who underwent emergency surgery for parapharyngeal (para group, n = 1148) or retropharyngeal (retro group, n = 734) abscesses from July 2010 to March 2020, using a nationwide inpatient database. We performed between-group comparisons of the baseline characteristics, treatment course, and outcomes.
Results
Compared with the retro group, the para group was more likely to be older (median, 66 vs. 60 years; P < 0.001) and have several comorbidities, such as diabetes (21 % vs 16 %; P = 0.010) and epiglottitis (33 % vs. 26 %; P = 0.002), except for peritonsillar abscess (14 % vs. 22 %; P < 0.001) and tonsillitis (2.1 % vs. 13 %; P < 0.001). Regarding intravenous drugs administered within 2 days of admission, approximately half of the patients received steroids, non-antipseudomonal penicillins, and lincomycins. The para group received more comprehensive treatments, such as tracheostomy, intensive care unit admissions, and swallowing rehabilitation, within total hospitalization than the retro group. Moreover, it demonstrated higher in-hospital mortality (2.7 % vs. 1.1 %; P = 0.017) and morbidity (16 % vs. 9.7 %; P < 0.001), and longer length of hospitalization than the retro group.
Conclusion
The current nationwide study provided an overview of the characteristics, treatments, and outcomes for patients who underwent an emergency surgery for parapharyngeal or retropharyngeal abscess.
Non-traumatic head and neck emergencies include several disease processes such as infectious, inflammatory, and malignant. Infections are among the most common pathological processes that affect the head and neck, and are particularly important due to their acute, severe, and potentially life-threatening nature. Radiologists need to be well acquainted with these entities because any delay or misdiagnosis can lead to significant morbidity and mortality. Having a general understanding of such diseases is crucial, their prevalence, clinical presentation, common causative pathogens, route of spread, potential complications, and multimodality radiological appearance. Furthermore, understanding the relevant anatomy of the region, including the various fascial planes and spaces, is essential for radiologists for accurate image interpretation and assessment of potential complications. Our aim is to review the most common severe infections affecting the head and neck as well as other rare but potentially life-threatening infections. We will also describe their imaging features while focusing on the anatomy of the regions involved and describing their potential complications and treatment options.
Riassunto
Con circa 9 milioni di casi all’anno in Francia, le angine acute rappresentano una patologia estremamente frequente nella pratica quotidiana. Le angine eritematose o eritematopultacee sono di origine virale nel 60-80% dei casi. Le eziologie batteriche sono dominate dallo streptococco β-emolitico di gruppo A (SBGA). Le angine da SBGA sono rapidamente rilevabili in visita con l’uso del test diagnostico rapido (RDT) per le infezioni da streptococco e richiedono una terapia antibiotica per evitare le complicanze post-streptococciche, essenzialmente il reumatismo articolare acuto (RAA). La terapia antibiotica non ha dimostrato alcun ruolo preventivo sulla comparsa di suppurazioni perifaringee (flemmoni peritonsillari, ascessi prestiloidei e celluliti cervicali). Le angine pseudomembranose e ulceronecrotiche presentano eziologie varie e richiedono trattamenti diversi.
Resumen
En Francia, por ejemplo, las faringoamigdalitis agudas representan una afección extremadamente frecuente en la práctica cotidiana, con cerca de 9 millones de casos anuales. Las faringoamigdalitis eritematosas o eritematopultáceas son de origen viral en un 60-80% de los casos. Entre las etiologías bacterianas, predomina el estreptococo betahemolítico del grupo A (EBGA). Las faringoamigdalitis causadas por esta bacteria pueden detectarse en la consulta mediante la prueba de diagnóstico rápido (PDR) para infecciones por estreptococos y requieren una antibioticoterapia para evitar complicaciones postestreptocócicas, principalmente el reumatismo articular agudo (RAA). El tratamiento antibiótico no tiene ningún papel preventivo demostrado frente a la aparición de supuraciones perifaríngeas (flemones periamigdalinos, abscesos preestiloideos y celulitis cervicales). Las faringoamigdalitis seudomembranosas y ulceronecróticas tienen etiologías y tratamientos diversos.
A 50-year-old Caucasian man presented to the emergency department during the early stages of the COVID-19 pandemic with a rapidly progressive facial swelling, fever, malaise and myalgia. The patient had recently travelled to a COVID-19-prevalent European country and was therefore treated as COVID-19 suspect. The day before, the patient sustained a burn to his left forearm after falling unconscious next to a radiator. A CT neck and thorax showed a parapharyngeal abscess, which was surgically drained, and the patient was discharged following an intensive care admission. He then developed mediastinitis 3 weeks post-discharge which required readmission and transfer to a cardiothoracic unit for surgical drainage. This report discusses the evolution of a deep neck space infection into a mediastinitis, a rare and life-threatening complication, despite early surgical drainage. This report also highlights the difficulties faced with managing patients during the COVID-19 pandemic.
Parapharyngeal abscess (PPA) may cause life-threatening complications and peritonsillar abscess (PTA) and tonsillitis frequently precede PPA. The optimal management of PPA caused by PTA has been the subject of debate with respect to the surgical approach. We present three cases of PPA concomitant with PTA in elderly patients. In two cases, the abscesses in parapharyngeal space were drained by abscess tonsillectomy followed by intraoral incision of the tonsillar bed. On the other hand, the third case did not undergo abscess tonsillectomy because of his refusal of surgery and needed extraoral drainage after the aggravation of PPA. Based on the experience of those three cases, it was suggested that abscess tonsillectomy followed by intraoral incision of the tonsillar bed might be a useful surgical approach for the drainage of PPA concomitant with PTA, especially in elderly patients.
Deep neck space infection is a relatively common condition with potentially catastrophic, life-threatening complications. A detailed understanding of the topography of the neck, relationships between compartments of the neck, and the propagation of infection is essential for accurate assessment and formulation of a propitious and timely treatment plan. This article focuses on approaches to the deepest spaces in the anterior neck-the parapharyngeal space and retropharyngeal space (RPS). Treatment starts with assessment and assurance of a safe, stable airway, broad spectrum intravenous antibiotics, and contrasted imaging to formulate a surgical plan. The parapharyngeal space and retropharyngeal space may be approached transorally or transcervically. Sound surgical principles, namely wide incision and dependent drainage, may prevent the further spread and associated morbidity.
Deep neck space infections (DNSIs) most commonly arise from a septic focus of the mandibular teeth, tonsils, parotid gland, deep cervical lymph nodes (LNs), middle ear, or sinuses. Before the widespread use of antibiotics, nearly 70 % of DNSIs were caused by spread from tonsillar and pharyngeal infections. Currently, tonsillitis remains the most common cause of DNSI in children, whereas odontogenic origin is the most common cause in adults [1–4]. These DNSIs often have a rapid onset and can progress to life-threatening complications. Clinicians must thus be aware of such infections and should not underestimate their significant risks of morbidity and mortality, particularly that they have become relatively uncommon in the postantibiotic era. Moreover, with the widespread use of antibiotics and/or profound immunosuppression, the classic local and/or constitutional manifestations of these infections may be absent [5].
To evaluate differences anatomical location and age groups on CT and clinical data in deep neck abscess.
Parapharyngeal abscess is rare deep neck infection that may be difficult to diagnose clinically and therefore often mismanaged. It is associated with a high morbidity and mortality as patients are at a high risk of airway obstruction and other life-threatening complications. Early diagnosis and treatment are important as they can result in a good clinical outcome, and a low mortality rate especially if uncomplicated. Therefore, early surgical drainage and debridement of the neck and mediastinum, with aggressive antibiotic treatment and medical management on an intensive care unit are important for preventing serious complications and fatal outcome. We report a case of parapharyngeal abscess in a healthy patient who presented with progressive obstructive symptoms, with relevant discussion.
Parapharyngeal abscess is a life-threatening infection. It occurs due to spread of infection form anatomical locations in the vicinity of the space. Management of the deep neck infection is governed by the general condition of the patient, the extent of disease and patency of airway. In treatment of deep neck infections intensive antibiotic therapy and surgical drainage are complementary to each other.
How to cite this article
Tubachi J, Hakeem A, Pradeep DC, Nayak P. Surgical Management of Parapharyngeal Abscess. Int J Otorhinolaryngol Clin 2012;4(3):122-124.
Acute epiglottitis is a common condition in children but is a rare entity in adults. Both in children and adults this is a life threatening condition as it can lead to complete airway obstruction. It is therefore vital that this condition is kept in mind when patients, both children and adults are admitted with severe airway obstruction to the emergency room. A case of adult acute epiglottitis complicated with abscess formation is described where timely intervention and correct diagnosis with appropriate treatment saved the life of the patient.
The Veneto region's database of hospital discharge records was queried for ICD-9 codes corresponding to: peritonsillar abscess (PTA), PTA incision and drainage, tonsillectomy, pharyngeal-retropharyngeal abscess, cervical phlegmon, cervical abscess, and mediastinitis recorded from 1997 to 2006. All these codes were considered to identify cases of PTA recurrence and severe infectious complications occurring in conservatively treated patients. Among 4,199 patients whose PTA was incised and drained on admission to hospital, 1,532 were treated with tonsillectomy, while 2,667 were treated conservatively (without tonsillectomy). Abscess tonsillectomy was carried out almost exclusively in children (0-14 years of age), and only in 40 young and adult patients (0.95 %). The relapse rate after a single episode of PTA was 11.7 %, while potentially fatal complication occurred in 0.41 % of cases. Incidence of PTA hospital admission has remained stable in the considered period despite a 45 % reduction in the tonsillectomy rate. In conclusion, our data seem to show that conservative treatment for PTA is not associated with a significant risk of recurrence (and becomes minimal after 6-12 months), provided that patients have not suffered from previous PTA episodes.
Con circa 9 milioni di casi per anno in Francia, le angine acute rappresentano una patologia estremamente frequente nella pratica quotidiana. Le angine eritematose o eritematopoltacee sono di origine virale nel 60-80% dei casi. Le eziologie batteriche sono dominate dallo streptococco β-emolitico di gruppo A (SBGA). Le angine da SBGA sono rapidamente rilevabili in visita con l’utilizzo del test di diagnosi rapida (TDR) delle infezioni da streptococchi e richiedono una terapia antibiotica per evitare le complicanze poststreptococciche, principalmente il reumatismo articolare acuto (RAA). La terapia antibiotica non ha alcun ruolo preventivo dimostrato sulla comparsa di suppurazioni perifaringee (flemmoni peritonsillari, ascessi prestiloidei e celluliti cervicali). Le angine pseudomembranose e ulceronecrotiche presentano diverse eziologie e gestioni.
La amigdalitis aguda es una afección muy frecuente en la práctica diaria. La amigdalitis eritematosa o eritematopultácea es de origen viral en el 60-80% de los casos. Las etiologías bacterianas están dominadas por el estreptococo β-hemolítico del grupo A (SBGA). Las amigdalitis por SBGA pueden detectarse con rapidez en la consulta utilizando la prueba de diagnóstico rápido (PDR) de las infecciones estreptocócicas y requieren un tratamiento antibiótico para evitar las complicaciones postestreptocócicas, esencialmente el reumatismo articular agudo (RAA). La antibioticoterapia no tiene ningún papel preventivo demostrado frente a la aparición de supuraciones parafaríngeas (flemones periamigdalinos, abscesos preestiloideos y celulitis cervicales). Las amigdalitis seudomembranosas y ulceronecróticas se deben a varias etiologías y sus tratamientos son diversos.
Parapharyngeal space infections (PPSI) often arise from pharyngeal or dental infections and, if left untreated, can result in serious complications ranging from mediastinitis to Lemierre syndrome to death. The parapharyngeal space is an inverted triangle spanning the skull base to the greater cornu of the hyoid, the inferior constrictor medially and the ramus of the mandible laterally with many vital structures contained within. Treatment begins with assessing the airway, considering the need for CT or MRI imaging with IV contrast and broad spectrum antibiotics. With evidence a PPSI has resulted in an abscess, there is failure of conservative management with 24 – 48 hours of IV antbiotics or in severe cases, surgical drainage is performed. This is done via the traditional transcervical route or, if the abscess is medial to the great vessels, a transoral approach. Complications of surgery are rare and resolution of symptoms with prompt antibiosis and surgical treatment prevent the possibility of infectious spread and its dangerous sequelae.
The clinical features and management of eight patients with parapharyngeal space infection who presented with swelling of
the neck subsequent to sore throat are described. In four patients the interval between the initial throat symptoms and swelling
was 2 days or less, and the disease was rapidly progressive with stridor or a descending mediastinitis. In the other four
cases, this interval was longer (4 to 14 days) and the infection was fairly localized. Computed tomography was useful for
making the diagnosis, establishing that the infection had spread into other deep neck spaces and the mediastinum, distinguishing
abscesses from diffuse cellulitis, guiding drainage aspiration, and assessing the reponse to therapy. None of the patients
underwent extensive surgical drainage of the deep neck spaces. A nonsurgical approach with antibiotics, including high doses
of benzylpenicillin, and computed tomography-guided selective needle aspirations proved successful. Even patients with distinct
abscesses were completely cured.
Orofacial and odontogenic infections are diverse in etiology and clinical presentation. Elderly patients are particularly at risk because of poor oral health and relatively high prevalence of dental caries and periodontal disease. Such infections in the elderly may be localized and indolent, or invasive and life-threatening. Patients with systemic underlying diseases such as diabetes mellitus are also prone to more serious infections. The increasing need for valvular and joint replacements in the elderly also exposes this population to a greater risk for serious complications such as infective endocarditis or prosthetic infections from hematogenous seeding of odontogenic infections (1).
Life threatening infections of odontogenic or upper airway origin may extend to potential spaces formed by fascial planes of the lower head and upper cervical area. The incidence of these “space infections” has been greatly reduced by modern antibiotic therapy. However, serious morbidity and even fatalities continue to occur.
Two cases of deep neck infection, (one of odontogenic and one tonsillar in origin) with subsequent mediastinitis, empyema, pericarditis and ultimate survival are reported. One case of deep neck infection, (of odontogenic etiology) and suppurative thrombophlebitis of the internal jugular vein with ultimate fatal outcome is also reviewed.
Review of the literature reveals only one previous case report of a survivor of an odontogenic deep neck infection complicated by mediastinitis, empyema and pericarditis. The anatomy, etiology and treatment of complications of these “space infections” of the head and neck are briefly reviewed.
The purpose of this communication is to summarize the available information relating to anaerobic infections of the head and neck and to provide guidelines for diagnosis and antimicrobial treatment.
Fifty-five patients with deep neck infections treated consecutively over a period of six and a half years between January 1983 and July 1989 were reviewed. Nine of these patients had abscesses localized to the pharapharyngeal space and form the basis of this study. The aetiology of the parapharyngeal abscess was odontogenic in two patients and remained unknown in the other seven. Five patients had associated systemic disease; four were diabetics and one patient had non-Hodgkin's Lymphoma.
High dosage intravenous antibiotics directed towards the causative micro-organisms, airway control and early surgical intervention was the mainstay of treatment. All patients underwent open surgical drainage of the parapharyngeal abscess within 24 h of admission. Bacteriology results showed Klebsiella sp. to be the dominant micro-organism cultured in four patients. Morbidity was low; seven patients had no post-operative complications and were discharged from the hospital between 7–24d (mean 12.9 d). There were two deaths.
Early open surgical drainage remains the most appropriate method of treating parapharyngeal space infections; it avoids life threatening complications with rapid recovery.
At the recent meeting of the Eastern Section of the Triological Society in Toronto, Canada, Drs Linda Brodsky, F. Glen Seidel, J. Brian Same, and Debby Korwin of The Children's Hospital of Buffalo (NY) presented a study on comparing the use of computed tomography, ultrasound, and magnetic resonance imaging in the evaluation of inflammatory masses of the neck in children. Ten patients who presented with a primary clinical diagnosis of neck abscess were compared for clinical/radiologic presentations and treatment outcome. Computed tomography and magnetic resonance imaging were comparable in the depiction of the overall size of the mass, while ultrasound usually showed a mass of much smaller dimension when compared with computed tomography and magnetic resonance imaging. Computed tomography was positive for abscess in all 10 patients, while magnetic resonance imaging was only able to accurately predict an abscess when there was a large collection of purulent material present. Ultrasound
Anaerobic gram-negative bacillary bacteremia and multiple septic pulmonary emboli developed rapidly in two previously healthy
young men after an episode of pharyngitis. One patient developed proptosis and subsequent uniocular blindness. In both cases
facial swelling was an early sign of jugular vein involvement. In patients not responding to antibiotic therapy, systemic
anticoagulation or surgical venous ligation may be potentially useful as an additional therapeutic measure. Septic jugular
vein phlebitis is a serious condition that requires early recognition and rapid institution of appropriate therapy.
A retrospective analysis of deep neck abscesses managed at the Los Angeles County-USC Medical Center was performed. Fifty-one patients met the criteria and were reviewed as to presentation, etiology, location, and microbiology. Hemolytic streptococci and anaerobic species, especially Bacteroides and peptostreptococci, were the most common organisms isolated. Intravenous drug abuse was the most common etiology, and was an important source of primary carotid space infection. This group was most commonly infected with Streptococcus species (50%).
The previously unreported occurrence of necrotizing fasciitis following the extraction of a tooth is presented. The synergistic roles of aerobic Escherichia coli and anaerobic Streptococcus viridans in this acute infection resulted in a deadly invasiveness of fascia that could not be controlled by massive antibiotics and radical operation. The presence of diabetes and an unfortunate delay in operation were factors in the fatal outcome.
Pharyngomaxillary space abscess complicated by carotid artery erosion is now an uncommon disease. Two cases recently came under our care within a short period of time. The history of tonsillitis or other oropharyngeal infection followed by an enlarging tender neck mass with neurological involvement of cranial nerves IX through XII and the cervical sympathetic chain should alert one to the correct diagnosis. Treatment must be aggressive. A Mosher-type incision is most satisfactory, and the surgeon must be prepared to ligate the great vessels of the neck if any severe hemorrhage is encountered.
Abscesses of the peritonsillar region rarely lead to serious complications. Incision and drainage, antibiotic therapy, and subsequent tonsillectomy is the accepted method of treatment.
Two cases of fatal necrotizing fasciitis following peritonsillar abscess are presented. The entity of necrotizing fasciitis in the head and neck is discussed with respect to its presentation, diagnosis, and treatment.
A 38-year-old male suffered from mediastinitis, pericarditis, and bilateral sudden pyopneumothorax as a complication of the parapharyngeal abscess that ruptured into the hypopharynx. The full diagnosis remained obscure until the complete clinical picture evolved. Antibiotics and pleural and cervical drainage failed to alleviate the symptoms. Recovery commenced only after tamponade of the retropharyngeal space, which terminated the flow of air and saliva from the neck to the thorax. The anatomic relation of the spaces concerned are discussed, as well as the therapeutic and surgical approaches. the importance of the retropharyngeal space, which may serve as a conduit between the neck and the mediastinum, is pointed out.
Although vascular involvement by deep neck space infections occurs very rarely today with the widespread use of antibiotics, they often pose a significant challenge to the modern otolaryngologist, who most likely will have had no previous experience with either the diagnosis or treatment of these potentially life-threatening infections. We describe the case of a young female presenting with fevers, dysphagia, and blood-tinged sputum, who was diagnosed by contrast-enhanced computerized tomography, to possess a mycotic pseudoaneurysm of her right extracranial internal carotid artery, for which ligation of her common carotid artery was required. We also discuss both the clinical findings which should lead one to suspect that a neck infection may be involving the extracranial carotid arteries, and the English literature, on the morbidity and mortality of ligating a common carotid artery.
A three-year-old boy with a swelling on the right side of his neck was suspected of having a parapharyngeal abscess after clinical examination and CT scan (computed tomography scan) of this region. Later it became clear, that the swelling was caused by an aneurysm of the internal carotid artery. This case report describes the pitfalls and difficulties encountered in the diagnostic course and treatment planning.
A retrospective review was conducted of 64 patients with deep neck abscesses. Based on clinical and operative findings, these abscesses were categorized as retropharyngeal abscess (29 patients), parapharyngeal abscess (10 patients), Ludwig's angina (19 patients), or necrotizing cervical fasciitis (six patients). Regional trauma from an ingested foreign body was the cause for 59 per cent of the patients with a retropharyngeal abscess. In 90 per cent of subjects with Ludwig's angina, an odontogenic cause was established; however, in the majority of cases of parapharyngeal abscess (80 per cent) and necrotizing fasciitis of the neck (85 per cent), aetiology was unknown.
Fifty-five patients (86 per cent) required open neck drainage. In the remaining nine (14 per cent) endoscopic drainage of the abscess was possible. Eight patients (12 per cent) needed a tracheotomy for airway control. The overall mortality was eight per cent despite aggressive anti-microbial therapy and early surgical intervention. Thirty-four cultures grew aerobic organisms. Seventy-six per cent of these were gram-negative microorganisms. The bacteriological pattern of deep neck abscesses is changing and may be responsible for the considerable mortality rate with which the abscesses are still associated despite anti-microbial therapy.
Parapharyngeal abscess (PPA) in children is an uncommon deep neck space infection. Computerized tomography (CT) is an important diagnostic aid. However, CT scan is not specific in differentiating an abscess from cellulitis or inflammatory edema. A retrospective review of eight children with a CT diagnosis of PPA was undertaken. In three patients an abscess was surgically confirmed. In two patients surgical exploration did not reveal an abscess and in three the infection resolved with intravenous antibiotic therapy only. Although CT is a useful diagnostic tool for PPA, surgical intervention should be based mainly on the clinical status of the patient and the non-responsiveness to i.v. antibiotic therapy.
Deep neck infections continue to be seen despite the wide use of antibiotics. These infections follow along fascial planes to create deep neck space abscesses. The clinical presentation often points to the space involved. Understanding the regional anatomy gives the surgeon the ability to treat these grave infections. The records of 24 patients with a diagnosis of deep neck space abscess admitted to Hermann Hospital between 1988 and 1993 were reviewed. Fifty percent of the patients had received antibiotics for an infection of the ear, nose, or throat before the development of a neck space abscess. Ten patients had parapharyngeal abscesses, seven had retropharyngeal abscesses, six had submandibular space abscesses, and one had parotid space abscess. Thirty-five organisms were isolated in 18 cases (1.9 isolates per patient). The most common organism cultured was Streptococcus (13 of 18), followed by Staphylococcus (6 of 18), Bacteroides (5 of 18), Micrococcus (2 of 18), and Neisseria (2 of 18). One case each of Candida, Enterobacter, Enterococcus, Peptostreptococcus, Proteus, Proprionobacter, and Pseudomonas was cultured. Six patients had no growth on culture but did have organisms found on Gram's stain. The operative techniques and antibiotics used are discussed. The main complications of jugular vein thrombosis, carotid artery rupture, and mediastinitis are described, as well as an unusual case of meningitis from a large retropharyngeal-parapharyngeal abscess.
Pseudoaneurysm formation of the cervical internal carotid artery (ICA) is a rare, potentially lethal complication of deep neck space infection. This entity typically occurs following otolaryngological or upper respiratory tract infection. The pseudoaneurysm is heralded by a pulsatile neck mass, Horner's syndrome, lower cranial neuropathies, and/or hemorrhage that may be massive. The recommended treatment includes prompt arterial ligation.
The authors present a case of pseudoaneurysm of the cervical ICA complicating a deep neck space infection. A parapharyngeal Staphylococcus aureus abscess developed in a previously healthy 6-year-old girl after she experienced pharyngitis. The abscess was drained via an intraoral approach. On postoperative Day 3, the patient developed a pulsatile neck mass, lethargy, ipsilateral Horner's syndrome, and hemoptysis, which resulted in hemorrhagic shock. Treatment included emergency endovascular occlusion of the cervical ICA and postembolization antibiotic treatment for 6 weeks. The patient has made an uneventful recovery as of her 18-month follow-up evaluation.
Conclusions drawn from this experience and a review of the literature include the following: 1) mycotic pseudoaneurysms of the carotid arteries have a typical clinical presentation that should enable timely recognition; 2) these lesions occur more commonly in children than in adults; 3) angiography with a view to performing endovascular occlusion should be undertaken promptly; and 4) endovascular occlusion of the pseudoaneurysm is a viable treatment option.
Parapharyngeal infections, which can potentially cause life-threatening complications, may, in certain cases, be treated conservatively with no need for surgical drainage. A review of the literature reveals that the most recommended treatment of parapharyngeal infection is surgical drainage combined with intravenous antibiotic therapy. Several retrospective reports recommend conservative treatment with no surgical drainage.
Prospective, nonrandomized.
A prospective study was performed on all patients with an infection limited to the parapharyngeal space.
Twelve patients presented with clinical and radiological diagnosis of parapharyngeal infection during a 5-year period. Five patients showed obvious presence of pus in other spaces and therefore were excluded. Seven patients with no gross extension into other spaces and with no respiratory distress or septic shock were treated with intravenous amoxicillinclavulanic acid for 9 to 14 days (average period, 11 days). All patients except one were children. All were cured with conservative management, and no surgical drainage was needed. None had any complications.
Our results confirm the effectiveness of nonsurgical treatment of infections limited to the parapharyngeal space, at least in the pediatric population.
To clarify the presenting signs and symptoms, clinical course, pathogenic organisms, and management of deep-neck-space abscesses in infants.
Retrospective chart review.
Tertiary care academic children's hospital.
Records of 25 patients 9 months or younger with deep-neck-space abscesses from July 1989 through May 1999 were reviewed.
Resolution of abscess.
Presenting symptoms included neck mass, 92% (n = 23); fever, 60% (n = 15); and dysphagia and/or poor intake by mouth, 36% (n = 9). Overall, patients were symptomatic for a mean duration of 3.8 days before presenting to the hospital; 21 of 22 evaluated patients had elevated white blood cell counts. Imaging included 68% computed tomographic scan (n = 17) and 44% plain radiographs (n = 11). On the basis of radiology and operative findings, locations of the abscesses were as follows: anterior triangle, 8; parapharyngeal, 5; posterior triangle, retropharyngeal, and undefined, 3 each; submandibular, 2; and parotid, 1. Of 17 scanned patients, 13 had some degree of airway compromise evident on computed tomography. All were treated with incision and drainage, 3 of 25 intraorally and 22 of 25 externally. Pus was identified in all 25; 20 of these grew Staphylococcus aureus, 1 grew group A Streptococcus, and 4 grew no organism. All patients received intravenous antibiotics for a mean of 4.8 days and oral antibiotics for a mean of 11 days. Only 1 patient required a second procedure.
Deep-neck-space abscesses in infants are rapidly progressive, often cause airway compromise, and usually present with fever and neck mass. The most common pathogen is S aureus. Patients are effectively treated with incision and drainage coupled with intravenous followed by oral antibiotics.
Endovascular occlusion of a carotid pseudoaneurysm complicating deep neck space infection in a child
- Reisner A Marshall
- Bryant K Gs
- Gc
- Eberly
- Sm
Reisner A, Marshall GS, Bryant K, Postel GC, Eberly SM (1999) Endovascular occlusion of a carotid pseudoaneurysm complicating deep neck space infection in a child. J Neurosurg 91:510–514
Orofacial odontogentic infections
- Aw Chow
- Sm Rosen
- Fa Bradly