Surgical treatment of para-pharyngeal
and retropharyngeal abscess
Dr.MAAMON AMEEN
` Cervical fascia
Investing layer of deep cervical fascia
Attachments:
Deep Spaces of the Neck
SubmandibularPeritonsillarParapharyngealRetrophryngealPrevertebralDangerParotidMasticator
Para-pharyngeal abscess Definition :it is a collection of pus in
paraphayrngeal space
Parapharyngeal space A connective tissue space lies
lateral to the nasopharynx and oropharynx ,extending from skull base to the hyoid bone .
Shaped like an inverted pyramid
Clinically most important space
Parapharyngeal space
Boundries Base : Base of the skull Apex : Hyoid bone
Anterior : Petrygo-mandibular raphe Posterior : Pre vertebral fascia
Medial : Buccopharyngeal fascia,retropharyngeal space
Lateral : parotid gland,ramus of
mandible,medial pterygoid M. ,fascia covering posterior belly of digastric muscle
Parapharyngeal spaceIt communicates
directly with other deep neck spaces including the retropharyngeal space, parotid space, submandibular space and the carotid sheath.
Parapharyngeal spaceIt is divided by styloid process and its
attachments into prestyloid and poststyloid space
Prestyloid space contains parapharyngeal fat, lymph nodes and the deep lobe of the parotid gland.
Poststyloid space contains the internal jugular vein, internal carotid artery, cranial nerves IX, X, XIand XII, sympathetic trunk and superior sympathetic ganglion, ascending pharyngeal artery and lymph nodes
Parapharyngeal abscessETIOLOGY:-Acute/Chronic infections of tonsils and
adenoid, bursting of the peritonsillar abscess.
Dental infection usually from the lower last molar.
From Bezold abscess or Petrositis.Infections of parotid, retropharyngeal
and submaxillary spaces.Penetrating injuries of neck, injection
of L.A for mandibular nerve block or for tonsillectomy.
Parapharyngeal abscessClinical features
depend on the compartment involved.Anterior Compartment:- Prolapse of tonsil and tonsillar fossa. Trismus(due to spasm of medial pterygoid). External swelling behind the angle of jaw
associated with marked Odynophagia.
Posterior Compartment:- Bulge of pharynx behind the posterior pillar. Paralysis of CN 9,10,11,12 and sympathetic chain. Swelling of parotid region.
Fever, Odynophagia, Sore throat, Torticollis and signs of toxaemia are common to both compartments.
ComplicationsSpread to- Skull base meningitis - carotid sheaththrombosis of IJV and
rupture of carotid artery- Mediastinum Mediastinitis- Larynx laryngeal edema
Rupture into the pharynx aspiration Bronchopneumonia
Parapharyngeal abscess
Retropharyngeal abscessCollection of pus in
retrophayngeal spaces
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 regresses at the age of 5
BuccoPharyngeal Fascia
The Retropharyngeal space
Prevertebral fascia
Retropharyngeal abscessMore common in childrenAetiology:• In infants occurs due to lymphadenitis
secondary to an upper respiratory tract infection• In adults it is likely to be secondary to TB of
cervical spine• Other causes in adults include trauma,
instrumentation, extension from adjoining deep neck spaces
Can extend to mediastinum, danger space and parapharyngeal space
Retropharyngeal abscessClinical features in infants:• Elevated temperature• Difficulty in breathing• Stiff neck• Asymmetric swelling of posterior pharyngeal wallClinical features in adults:• Slow onset• Pharyngeal discomfort• Dysphagia• Cervical motion limitation• Noisy breathing
Retropharyngeal abscess
Retropharyngeal abscesscomplications
posterior extension to pre-vertebral space, osteomyelitis, epidural abscess
lateral extension involving carotid artery (haemorrhage, pseudoaneurysm, thrombosis) and jugular vein (thrombosis)
anterior compression and compromise of the airwayinferior extension into the mediastinum resulting in
mediastinitissystemic dissemination and development of sepsisGrisel syndromeLemierre syndrome
Investigations• CBC• X -ray ( neck ,chest )• USG• Needle aspiration and culture and sensitivity• CT.SCAN
Treatment Educate the patient and take consent for
surgical interventions that may arise Airway management IV antibiotic (pinicillin-
sulbactum,clindamycin,ceftriaxon+metronidazole)
Surgical drainage
Surgical drainage Done under GAIntubation
Trans-oral or trans-cervical approach
• Oral intubation • Fiberoptic intubation • Tracheostomy under
LA
Para-pharyngeal abscess drainage
Trans-oral approachIndicated for abscess located medial to great vessles Patient placed supine in trendelenburg positionMouth gag
Para-pharyngeal abscess drainagePalpate the swelling to localize the abscessInsert 14 gauge needle and aspirate Aspirated pus should be sent for cultureVertical incision given in the fluctuant areal(over
mucosa only)Long clamp used to dilate the opening and allow
for further drainage
• A rubber catheter attached to a 60cc syringe can be employed to irrigate the cavity
• The incision remains open to allow further drainage,• Suction must be at hand
Para-pharyngeal abscess drainageTranscervicalAfter securing the airway Patient placed in supine
position with shoulder rollHead turned to contralateral
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
Infiltrate with lidocain and adrenalinThe neck, face up to the oral commissure and
shoulder are preppedThe patient is then draped , exposing the
neck, clavicles, ear lobe, midline neck and the oral commissure
The skin and subcutaneous tissues are then sharply incised.
The platysma can be incised sharply or with electrocautery.
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
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
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.
Blunt dissection is continued to break up any remaining loculations
Abscess is drained wound bed is copiously irrigated with at least
one liter of warm saline.A drain should be placed into the abscess
cavity and exit the incisionskin partially closed, leaving an opening for
the drain,
Trans-oral approach of retropharyngeal abscess
Supine and extreme trendelburg position
Posterior pharyngeal wall
Trans-cervical approach of retropharyngeal abscess
Low abscess: along anterior border of sternocleidomastoid muscle
Transverse cervical skin incision is given
Raising subplatysmal flaps to expose the neck and dissecting along the anterior border of the sternomastoid
The sternocleidomastoid muscle and carotid sheath are then retrac-ted laterally
blunt dissection is done up to the level of hypopharynx to open the retro-pharyngeal space abscess.
Deep drain placed and maintain
High abscess: along posterior border of
sternocleidomastoid
muscle
Principles for neck abscess drainageEnsuring a secure airway is the first priority
in the management of a deep neck infectionTherefore, intubation with direct
laryngoscopy or tracheotomy should always be considered
An important principle of surgical drainage of a deep neck abscess is wide exposure
Identify landmarks
Blunt dissection should be used whenever possible.
Identifying the carotid sheath early is crucial for avoiding inadvertent damage to it and to the major neurovascular structures it contains.
The abscess should be completely drained, including blunt avulsion of any loculations
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