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Surgical management of parapharyngeal spaceinfections
Jeffrey M. Blumberg MD, Benjamin L. Judson MD
PII: S1043-1810(14)00037-2DOI: http://dx.doi.org/10.1016/j.otot.2014.04.014Reference: YOTOT642
To appear in: Operative Techniques in Otolaryngology
Cite this article as: Jeffrey M. Blumberg MD, Benjamin L. Judson MD, Surgicalmanagement of parapharyngeal space infections, Operative Techniques in Otolaryngol-ogy, http://dx.doi.org/10.1016/j.otot.2014.04.014
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Manuscript Title: Surgical management of parapharyngeal space infections Authors: Jeffrey M. Blumberg, MD1, Benjamin L. Judson, MD1 1Department of Surgery, Yale University School of Medicine, New Haven, CT CORRESPONDING AUTHOR/REQUESTS FOR REPRINTS: Benjamin L. Judson, MD 800 Howard Ave, YPB 425 Department of Surgery Yale University School of Medicine New Haven, CT 06519 Telephone: 203-785-2593 Fax: 203-785-3970 Email: [email protected] FINANCIAL DISCLUSIONS/CONFLICTS OF INTEREST: The authors have nothing to declare SOURCES OF SUPPORT: None.
ABSTRACT:
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.
Introduction:
Parapharyngeal space infections (PPSI) are a serious, though rare, complication of many types of
oral cavity or orpharyngeal infections, such as tonsillitis and dental abscesses1. Untreated
infections may ultimately result in abscess formation that can travel along deep fascial planes of
the neck resulting in life threatening sequelae including mediastinitis, pericarditis, meningitis,
Lemierre syndrome, septic shock, internal carotid artery rupture or aneurysm, airway
obstruction, empyema, Horner syndrome and death 2-4.
The extent and severity of the complications associated with untreated PPSI accent the
importance of the anatomic structures contained within the space. The parapharyngeal space,
historically referred to as pharyngomaxillary or lateral pharyngeal space, is commonly described
as an inverted pyramid spanning the distance between the skull base and the greater cornu of the
hyoid bone5 (Figure 1A). The lateral border of the space, from posterior to anterior, are the deep
lobe of the parotid gland and the ramus of the mandible covered with the medial pterygoid
muscle and more inferiorly by the fascia of the posterior belly of the digastrics muscle. Medially
it is bounded by the superior pharyngeal constrictor (pharynx) and abuts the retropharyngeal
space. Anteriorly, the space is limited by the pterygomandibular raphae and posteriorly by the
prevertebral fascia, carotid sheath and retropharyngeal space. Traditionally, the space is divided
into an anterior and posterior compartment divided by the styloid process and fascial
condensation called the aponeurosis of Zuckerkandl and Testut, joining the styloid process to the
tensor veli palatine, referred to as the pre and post-styloid spaces 6. The pre-styloid space
contains parapharyngeal fat, lymph nodes and the deep lobe of the parotid gland. The post-
styloid space contains the internal jugular vein, internal carotid artery, cranial nerves IX, X, XI
and XII, sympathetic trunk and superior sympathetic ganglion, ascending pharyngeal artery and
lymph nodes7-8 (Figure 1B). In addition to the vital structures contained within this space, it
communicates directly with other deep neck spaces including the retropharyngeal space, parotid
space, submandibular space and the carotid sheath3 (Figure 1C).
The origin of PPSIs is often unclear as the offending primary infections may have resolved at
presentation. Several studies have shown tonsillitis and pharyngitis as the predominant nidus in
children whereas dental infections are more common in adults. Although deep neck infections
are rare, up to 50% occur in or communicate with the parapharyngeal space making it the second
most common deep neck space infection following retropharyngeal infections in children and
peritonsillar abscesses overall2,9. The most common presenting symptoms are dysphagia, sore
throat, painful cervical mass, swelling, trismus, lymphadenopathy, pyrexia, odynophagia and
medial displacement of the lateral pharyngeal wall1-2. The average age at presentation depends
on the population with pediatric reviews demonstrating an average age of 5 years old with
decreasing incidence with increasing age10-11 and adult’s average age between 32 – 35.8y2-12 with
a male predominance. The most common bacterium associated with PPSI range from mixed
anaerobes to beta-hemolytic strep, methicillin resistant and sensitive staphylococcus aureus and
fusobacterium necrophorum13.
Preoperative planning:
The work up for a patient with a potential PSSI starts with a thorough history paying special
attention to recent history of pharyngitis, dental work, history of abscesses, immune status
(including diabetes and other immunosuppressive conditions and medications), prior antibiotic
treatment, length of symptoms and clinical course14. Physical exam should evaluate for all the
most common signs with careful inspection of the oral cavity for tonsillar or pharyngeal wall
displacement, poor dentition or tender, loose teeth, trismus, torticollis and airway obstruction. A
special note should be made of airway evaluation. Many studies have evaluated the best mode of
airway management in deep neck space infections. Historically, tracheotomy under local
anesthesia has been considered the gold standard for airway management in these patients.
However, many of these studies, particularly in the anesthesia literature, fail to clearly classify
the neck space infected. Of those that do, airway compromise and need for tracheotomy is most
often related to patients suffering from Ludwig Angina or retropharyngeal space abscesses.
Since the parapharyngeal space communicates with both the reotrpharyngeal and submandibular
space an evaluation of the upper airway should be performed on patients with suspected PPSIs
using indirect fiberoptic laryngoscopy. Those with threatened airways should be secured
emergently and as possible by the experience at the institution either via awake fiberoptic
intubation or, if needed, awake tracheotomy15-16. Once the airway is secure, basic lab work
should be obtained including chemistry, PT/PTT and CBC (WBC > 15,000 common with
abscesses). If the patient appears to suffer from particularly poor dentition an evaluation by
dentistry or oral surgery should be considered. In a retrospective analysis of 106 patients with
deep neck infections, Daramola showed 44 of these patients underwent dental extraction in
addition to incision and drainage further underlining the importance of dental examination17.
Imaging plays a critical role in evaluation and management of PPSI. The most widely used and
studied method is CT with contrast enhancement. This modality has been found to be best for
diagnosis and follow-up of parapharyngeal abscesses2. Because a significant amount of these
infections occur in children, there may be some hesitation to proceed directly with CT scanning
because of radiation exposure. However, several studies have demonstrated the superiority and
speed of CT scan in diagnosing these infections. One study of 57 children with deep neck space
infections showed a 100% sensitivity of CT scans for identifying the presence and location of an
infectious process and an 88 – 95% sensitivity for distinguishing between cellulitis and
abscess18. The ability of a contrast enhanced CT scan to show location of a PPSI as pre or post-
styloid, potential source in evaluation of the dentition and the infection’s relationship to the
major vessels is just as important as the diagnosis itself as it provides crucial information for
surgical planning (Figure 2A and B).
Once a diagnosis of a PPSI has been confirmed clinically and radiographically the patient should
be admitted to a monitored unit and placed on broad spectrum IV antibiotics, eg: clindamycin,
third generation cephalosporin (ceftriaxone) or ampicillin-sulbactam17. With the patient stable,
the decision to surgically drain the abscess or not becomes one of significant discussion in the
literature, especially for children. In 1989 De Marie et al published a case series of eight adult
patients with parapharyngeal space infections treated with antibiotics, diagnostic “punctures”
and, in one case, a small cervical incision19. From this they advocated for a more conservative
management of PPSI. Since then, the role on non-surgical management of PPSI, particularly in
children, has become an accepted option through multiple small case series8,20. Wong et al, in
2012, published an analysis of 54 children with deep neck space infections. Of the 27 children
with abscesses <2.5cm on CT, 13 resolved in antibiotics alone. Based on these finding, they
suggested criteria for surgical intervention in children: abscess >2.5cm on CT, airway
compromise, severe neck immobility, bulging pharyngeal wall, mediastinitis, meningitis,
multiple abscesses and significant co-morbities10. Sichel et al added further anatomic
correlation to surgical indication. They suggested separating PPSI infections into two entities,
anterior and posterior, essentially pre and post styloid. From their series of 29 patients, 22 had
posterior PPS infections, the majority of which resolved with antibiotics alone. They feel these
infections are usually a result of acute lymphadenitis resulting in an abscess confined within the
capsule of the lymph node with rare extension. However, abscesses of the anterior PPS are a
result of liquification of the pre-styloid fat and replacement with pus with no borders to limit
extension into other deep neck spaces. They considered these cases surgical emergencies3. With
these studies and others in mind, the literature is tending towards antibiotic trials for all clinically
stable patients for 24 – 48 hours before surgical intervention1,2,8,10,20.
Transcervical Technique:
This approach has long been the gold standard for draining PPSI. First described in 1929 by
Mosher and has changed little in the ensuing years. It provides for excellent visualization,
control of the major vessels and allows for a drain to be placed.
After securing the airway either via enotracheal intubation or tracheotomy, making sure to
communicate with the anesthesiologist not to administer long acting neuromuscular blockade,
the patient remains in the supine position with a shoulder roll placed to extend the neck. The
head is then carefully turned to the contralateral side. The patient can be approached in a midline
orientation with both arms tucked or can be rotated 90 degrees towards the affected side. An
incision 2 – 4cm in length is drawn approximately two fingers breadths (3cm) below the inferior
border of the mandible on the affected side (to protect the marginal mandibular nerve) in a pre-
existing skin crease. Without historical or medical contraindication, the proposed incision is
infiltrated with a few milliliters of 1% lidocaine with epinephrine (1:100,000). The neck, face up
to the oral commissure and shoulder are prepped with the surgeons preferred sterilization
solution, povidine-iodine or chlorhexadine. The patient is then draped with towels exposing the
neck, clavicles, ear lobe, midline neck and the oral commissure. Exposure of the oral
commissure either within the prepped area or visible under a clear drape is important so any
stimulation of the marginal mandibular nerve is able to be detected.
The skin and subcutaneous tissues are then sharply incised. The platysma can be incised sharply
or with electrocautery. Subplatysmal flaps may be elevated minimally to provide more mobility
of a smaller incision, particularly in a child, but are not necessary. The submandibular gland
should be identified and dissected along its inferior border. The gland and its overlying fascia
can then be retracted superiorly thus protecting the marginal mandibular nerve. Next, the
anterior border of the sternoclidomastoid muscle and great vessels are retracted posteriorly.
Levitt and Mosher suggest the greater cornu of the hyoid is a particularly important landmark to
identify next. Once identified, the posterior belly of the digrastric muscle should be apparent.
With vital structures protected (including the hypoglossal nerve if identified) the surgeons finger
can be used to bluntly dissect along the medial border of the posterior belly of the digastric
muscle towards the styoid process and skull base. Any pus encountered should be sent for
culture. Blunt dissection is continued to break up any remaining loculations. With the surgeon
satisfied with adequate drainage, the wound bed is copiously irrigated with at least one liter of
warm saline. A ¼ or ½ inch Penrose drain (depending on the age of the patient) should be
placed into the abscess cavity and exit the incision. The platysmal layers can be partially closed
with buried, interrupted 3-0 vicryl sutures and the skin partially closed, leaving an opening for
the drain, in a simple interrupted fashion either with 5-0 fast absorb sutures for children or 5-0
prolene for adults. A “ghost” stitch may be placed where the Penrose exits in order to
reapproximate the skin once the drain is removed. With smaller incisions or as determined by
the need for additional drainage the incision may also be left open. The Penrose drain can be
sutured to the skin with a 4-0 nylon. Then, balled up super-sponge gauze should be placed
around the Penrose drain and covered with a clear obsite type or other dressing. If the airway
was restricted or obstructed by the PPSI and the patient was intubated rather than having a
tracheotomy performed, consideration should be given to leaving the patient intubated for a
period before extubation. Otherwise, the patient can then be awakened from anesthesia5,9,21
(Figure 3) .
Transoral Technique:
With the accuracy a CT scan provides for localizing PPSI, recently, many authors are suggesting
drainage of parapharyngeal space abscesses located medial to the great vessels in a transoral
fashion. The idea that neurovascular structures were at risk with transoral drainage have been
addressed with high resolution preoperative CT scans. Amar demonstrated medially located
abscesses in children could be easily drained transorally and resulted in decreased hospital stays
and operative time. Furthermore, several other authors have described transoral techniques
utilizing endoscopes and image guidance22, transtonsillar23 and one report of transnasal
endoscopic drainage of a high PPSI24. For selective cases of medially located abscesses,
infections originating in the pharynx or tonsil and an isolated abscess, a transoral route are an
acceptable approach.
After successful induction of anesthesia via endotracheal intubation or tracheotomy the patient is
turned 90 degrees. As with tonsillectomy, extension of the neck should be performed selectively
depending on patient history, eg: down syndrome. If acceptable, a shoulder roll is placed. The
surgeon’s preferred mouth gag (crowe-davis etc.) is carefully inserted into the patient’s mouth
and expanded. The mouth gag can be suspended from a mayo stand or using rolled towels on the
patient’s chest. The oropharynx and lateral pharyngeal wall of the involved site is inspected and
palpated to help localize the abscess. Once identified, an 18 gauge needle is carefully inserted
through lateral pharyngeal wall under constant suction to aspirate abscess contents. The
preoperative CT should be carefully reviewed to know approximately the depth of needle
insertion and prevent injury to neurovascular structures. Aspirated pus should be sent for
culture. The mucosa overlying the abscess is then incised longitudinally with a knife and a tonsil
or other long clamp is used to dilate the opening and allow further drainage of the abscess cavity.
A red rubber catheter attached to a 60cc syringe can be employed to irrigate the cavity. The
incision remains open to allow further drainage, the mouth gag is removed and the patient is
awakened from anesthesia2,9,23.
Complications:
Major complications for both approaches result from inadequate abscess drainage and can result
in the sequelae noted above. If the patient does not improve significantly after surgery with
continued antibiotic treatment a repeat CT scan should be obtained to look for residual abscess.
The transcervical approach can be complicated by injury to neurovascular structures, particularly
the marginal mandibular nerve and pseudoaneursym of the carotid artery. However, careful
dissection should alleviate these complications. There is a small potential for spread of infection
via the carotid sheath and sinus tract formation. Many of the studies evaluating transoral
drainage report no significant complications beyond abscess persistence. One study noted one
case of aspiration pneumonia after transoral drainage and there is a theoretical risk of reverse
contamination of the deep neck spaces from the oropharynx9.
Conclusions:
Parapharyngeal space infections are serious deep neck space infections that may require surgical
drainage for resolution. They can easily spread to adjoining neck spaces, the mediastinum and
beyond if not treated and can result in disastrous outcomes. However, with suspicion, prompt
medical treatment, imaging and surgical drainage patients can avoid these outcomes with
minimal morbidity.
Disclosure:
Neither author has any affiliations nor relationships, personal or financial, that could potentially
and inappropriately influence this work.
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Figures:
Figure 1. (A) Axial section through the oral pharynx demonstrating the contents of the
parapharyngeal space. The pre-styloid space contains the deep lobe of the parotid, fat and lymph
nodes. The post-styloid compartment contains the internal jugular vein, internal carotid artery,
cranial nerves IX, X, XI and XII, sympathetic trunk and superior sympathetic ganglion,
ascending pharyngeal artery and lymph nodes. Note its proximity and continuity with the
peritonsillar and retropharyngeal spaces. (B) Coronal section through the oropharynx showing
the vertical extent of the parapharyngeal space. (C) Coronal section sliced more anterior
demonstrating the continuity of the parapharyngeal and submandibular spaces.
Figure 2.
Typical axial CT scan with intravenous contrast demonstrating an abscess in the parapharngeal
space. Notice the containment of the infection within a defined border in the post-styloid space,
medial location in relation to the great vessels and the preservation of the pre-styloid fat pad.
Abscess denoted with an asterisk.
Figure 3.
Intraoperative drawing depicting the appropriate location for the incision for a transverical
approach to the parapharyngeal space. Key structures needing identification prior to blunt
dissection into the parapharyngeal space are labeled. The submandibular gland should be
reflected superiorly with its overlying fascia to protect the marginal mandibular nerve. The
greater cornu of the hyoid and posterior belly of the digastric muscle is key in directing the
dissection into the parapharyngeal space.
