Infection of pharyngeal spaces

• The retropharyngeal space lies behind the pharynx and esophagus, just anterior to the prevertebral fascia. It extends superiorly to the base of the skull and inferiorly to the bifurcation of the trachea.

• Patients generally present with trismus, drooling, dyspnea, dysphagia, and a mass, often fluctuant, on one side of the posterior pharyngeal wall.

• Lateral radiographs of the neck are also helpful in diagnosis. It is important, however, to have proper positioning of the patient at the time of X-ray; otherwise the results may be misleading. The patient should have the neck extended in a true lateral position for the X-ray.

• The parapharyngeal space is cone shaped. Superiorly it starts at the base of the skull and inferiorly its margin ends at the hyoid bone. The superior constrictor muscle is the medial boundary, and the parotid gland, the mandible, and the pterygoid muscle are its lateral margins , the prevertebral fascia is present posteriorly.

• A parapharyngeal space abscess can develop when infection or pus from the tonsillar region goes through the superior constrictor muscle. The abscess then forms between the superior constrictor muscle and deep cervical fascia.

• Patients can present with toxemia and pain in the throat and neck, with tender swelling of the neck in the region of the angle of the mandible. Examination may reveal tonsillitis and/or medial displacement of the tonsil.

Parapharyngeal AbscessRetro-pharyngeal

Abscess(Acute & Chronic)

Parapharyngeal Abscess

Def

What is parapharyngeal space?

Collection of pus in thePARA-PHARYNGEAL Space

A connective tissue space which:-Lies on the lateral side of the nasopharnx and oropharynx-Extends from skull base to hyoid bone

-Contains:-Internal carotid artery-Internal jagular vein-Last 4 cranial nerves-Cervical sympathetic trunk-Deep cervical lynph nodes

Etiology:- Acute Tonsillitis or after

tonsillectomy- Infection of last lower molar

tooth- Infection of the parotid

salivary gland

Etiology:- Acute Tonsillitis or after

tonsillectomy- Infection of last lower molar

tooth- Infection of the parotid

salivary gland

The infection passes through the Superior constrictor muscle

Symptoms

Same as in Quinsy

Signs:General; fever

Pharyngeal:

Cervical

Investigations:CT & MRI

- The lateral pharyngeal wall & tonsil is pushed medially - Trismus due to spasm of ptrygoid muscles

A unilateral diffuse tender swelling :-Below & behind the angle of the mandible-Deep to the anterior border of the sternomastoid-The neck is tilted to the diseases side

Complications

Spread to

- Skull base meningitis - carotid sheaththrombosis of IJV

and rupture of carotid artery- Mediastinum Mediastinitis- Larynx laryngeal edema

Rupture into the pharynx aspiration Bronchopneumonia

TreatmentMedical: massive antibiotic therapy

and,

Surgical drainage

A vertical incision at the anterior border of

the sternomastoid muscle

Stern

om

astoid

Acute Retropharyngeal Abscess

Collection of pus in the retropharyngeal space

BuccoPharyngeal Fascia

Prevertebral fascia

The Retropharyngeal space

• It is a connective tissue space between :

the buccopharyngeal fascia & pre-vertebral fascia• The two fasciae are attached to each side by median raphe.• It extends from the skull base to the posterior mediastinum• It contains retropharyngeal lymph node one on each side• The Retropharyngeal LN atrophy at the age of 5

• Age: below the age of 5 (The Retropharyngeal LN atrophy at the

age of 5)• Site: at one side of the midline (The two fasciae are attached

to each other at the midline by median raphe.)

• Etiology

• Upper Rrspiratory Tract Infection with suppuration of Retropharyngeal LN

• After Adenoidectomy operation• Impacted FB

Symptoms

In A child below 5 years

General: FHAM

Pharyngeal:• Severe sore throat• Dysphagia• Difficult breathing

Abscess

SignsGeneral: fever

Pharyngeal

Swelling of the posterior

Pharyngeal wall to one

side of the midline

Cervical: Neck inclination due to muscle spasm

Normal PatientLateral view of the Neck

• Look for- The vertebral column

( for any destruction e.g in Pott’s disease)

- The pre-vertebral space (3/4 the width of the body of the vertebra)

- The airway

• Investigations:

plain X ray & CT scan

Widening of prevertebral space

Normal vertebralbodies

Complications:-Spread to mediastinummediastinitis-Rupture………….

Treatment Medical: massive antibiotic therapy and,

Surgical drainageTracheostomy if indicated

Incision in the posterior pharyngeal wall with the patient in the Trendlenberg position Why?

In this position the head is lower than the chestto avoid aspiration of pus

Chronic Retropharyngeal Abscess

Pre-vertebral Abscess

What is the pre-vertebral space?

A space between:- The cervical vertebrae- The pre-vertebral fascia

Formation of a cold abscess in the pre-vertebral space

Etiology:- Pott’s Disease i.e tuberculosis of cervical

vertebrae the abscess rupture through the prevertebral fascia the abscess reaches the Retropharyngeal space

prevertebral fascia

Symptoms In an adult

General: Tuberculous Toxaemia

Pharyngeal: Mild sore throat

Cervical: limited painful neck movement

-Night sweets

-Night fever

-Loss of weight

-Loss of appetite

Signs:General: Tuberculous toxaemiaPharyngeal: Cervical: Tenderness over

cervical spines

- Pallor- Low grade fever- Loss of weight

The swelling lies in the midline of the posterior pharyngeal wall

Investigations

Plain X ray & CT scan

Widening of the Prevertebral space

Destruction of the cervical vertebrae

Treatment:Medical: Antituberculous

therapy

Surgical Drainage

Orthopedic Management

Through a vertical incision along the posterior border of the

sternomastoid muscle

Hypopharyngeal Pouch

Hypopharyngeal pouch

Synonyms

Hypopharyngeal diverticulum

Zenker’s diverticulum

Pharyngo-oesophageal pouch

Retropharyngeal pouch

Killian’s diverticulum

Introduction

• Hypopharyngeal pouch is an acquired pulsion

diverticulum caused by posterior protrusion of

mucosa through pre-existing weakness in muscle

layers of pharynx or esophagus.

• In contrast, congenital diverticulum like Meckel's

diverticulum is covered by all muscle layers of

visceral wall.

Weak spots b/w muscles

Weak spots b/w muscles

Posterior: 1. Between Thyropharyngeus &

Crico-

pharyngeus: Killian's dehiscence

(commonest)

Origin of Zenker’s diverticulum

History

• First described in

1769 by Ludlow

• Friedrich Zenker &

von Ziemssen first

described its picture in

their book in 1877

Etiology

1. Tonic spasm of cricopharyngeal sphincter:

C.N.S. injury Gastro-esophageal reflux

2. Lack of inhibition of cricopharyngeal sphincter

3. Neuromuscular in-coordination between Thyro-

pharyngeus & Cricopharyngeus

4. Second swallow against closed cricopharynx

These lead to increased intra-luminal pressure in

hypopharynx & mucosa bulges out via weak areas.

Clinical Features

1. Entrapment of food in pouch: sensation of food

sticking in throat & later dysphagia

2. Regurgitation of entrapped food: leads to foul

taste bad odor nocturnal coughing choking

3. Hoarseness: due to spillage laryngitis or sac

pressure on recurrent laryngeal nerve

4. Weight loss: due to malnutrition

5. Compressible neck swelling on left side:

reduces with a gurgling sound (Boyce sign)

Complications

1. Lung aspiration of sac contents

2. Bleeding from sac mucosa

3. Absolute oesophageal obstruction

4. Fistula formation into:

trachea major blood vessel

5. Squamous cell carcinoma within Zenker

diverticulum (0.3% cases)

Investigations

• Chest X-ray: may show sac + air - fluid level

• Barium swallow

• Barium swallow with video-fluoroscopy

• Rigid Oesophagoscopy

• Flexible Endoscopic Evaluation of Swallowing

Barium swallow

Barium swallow with Video-fluoroscopy

Rigid Oesophagoscopy

Cricopharyngeal myotomy

Styalgia (Eagle Syndrome)

Introduction

• Normal length of styloid process is 2.0–2.5 cm

• Length >30 mm in radiography is considered

an elongated styloid process

• 5-10% pt with elongated styloid have pain

• Increased angulation of styloid process both

anteriorly & medially, can also cause pain

• Commonly seen in females over 40 years.

Classical Variety

• Occurs several years after tonsillectomy

• Pharyngeal foreign body sensation

• Dysphagia

• Dull pharyngeal pain on swallowing, rotation of

neck or protrusion of tongue

• Referred otalgia

• Due to scar tissue in tonsillar fossa engulfing

branches of glossopharyngeal nerve

Normal Styloid Process

Elongated Styloid Process

Theories for pain

• Irritation of glossopharyngeal nerve

• Irritation of sympathetic nerve plexus around

internal carotid artery

• Inflammation of stylo-hyoid ligament

• Stretching of overlying pharyngeal mucosa

Diagnosis

1. Digital palpation of styloid process in tonsillar

fossa elicits similar pain

2. Relief of pain with injection of 2% Xylocaine

solution into tonsillar fossa

3. X-ray neck lateral view

4. Ortho-pan-tomogram (O.P.G.)

5. Coronal C.T. scan skull

6. 3-D reconstruction of C.T. scan skull

X-ray neck lateral view

Coronal C.T. scan

Coronal 3-D C.T. scan

Medical Treatment

1. Oral analgesics

2. Injection of steroid + 2% Lignocaine into

tonsillar fossa

3. Carbamazepine: 100 – 200 mg T.I.D.

4. Operative intervention reserved for:

• failed medical management for 3 months

• severe & rapidly progressive complaints

Styloid Process Excision

Intra-oral route

• via tonsil fossa

• no external scarring

• poor visibility due to difficult access

• high risk of damage to internal carotid artery

• iatrogenic glossopharyngeal nerve injury

• high risk of deep neck space infection

Tonsillectomy & fossa incision

Styloidectomy

Styloidectomy

• Tonsillectomy done. Styloid process palpated.

• Incision made in tonsillar fossa just over the tip.

• Styloid attachments elevated till its base with

periosteal elevator.

• Styloid process broken near its base with bone

nibbler, avoiding injury to glossopharyngeal nv.

• Tonsillar fossa incision closed.