infection of pharyngeal spaces. the retropharyngeal space lies behind the pharynx and esophagus,...
TRANSCRIPT
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Infection of pharyngeal spaces
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• 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.
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• 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.
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Parapharyngeal AbscessRetro-pharyngeal
Abscess(Acute & Chronic)
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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
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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
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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
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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
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TreatmentMedical: massive antibiotic therapy
and,
Surgical drainage
A vertical incision at the anterior border of
the sternomastoid muscle
Stern
om
astoid
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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
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• 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
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Symptoms
In A child below 5 years
General: FHAM
Pharyngeal:• Severe sore throat• Dysphagia• Difficult breathing
Abscess
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SignsGeneral: fever
Pharyngeal
Swelling of the posterior
Pharyngeal wall to one
side of the midline
Cervical: Neck inclination due to muscle spasm
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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
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• Investigations:
plain X ray & CT scan
Widening of prevertebral space
Normal vertebralbodies
Complications:-Spread to mediastinummediastinitis-Rupture………….
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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
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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
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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
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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
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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
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Investigations
Plain X ray & CT scan
Widening of the Prevertebral space
Destruction of the cervical vertebrae
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Treatment:Medical: Antituberculous
therapy
Surgical Drainage
Orthopedic Management
Through a vertical incision along the posterior border of the
sternomastoid muscle
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Hypopharyngeal Pouch
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Hypopharyngeal pouch
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Synonyms
Hypopharyngeal diverticulum
Zenker’s diverticulum
Pharyngo-oesophageal pouch
Retropharyngeal pouch
Killian’s diverticulum
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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.
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Weak spots b/w muscles
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Weak spots b/w muscles
Posterior: 1. Between Thyropharyngeus &
Crico-
pharyngeus: Killian's dehiscence
(commonest)
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Origin of Zenker’s diverticulum
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History
• First described in
1769 by Ludlow
• Friedrich Zenker &
von Ziemssen first
described its picture in
their book in 1877
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Etiology
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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.
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Clinical Features
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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)
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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)
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Investigations
• Chest X-ray: may show sac + air - fluid level
• Barium swallow
• Barium swallow with video-fluoroscopy
• Rigid Oesophagoscopy
• Flexible Endoscopic Evaluation of Swallowing
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Barium swallow
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Barium swallow with Video-fluoroscopy
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Rigid Oesophagoscopy
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Cricopharyngeal myotomy
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Styalgia (Eagle Syndrome)
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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.
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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
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Normal Styloid Process
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Elongated Styloid Process
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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
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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
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X-ray neck lateral view
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Coronal C.T. scan
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Coronal 3-D C.T. scan
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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
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Styloid Process Excision
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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
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Tonsillectomy & fossa incision
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Styloidectomy
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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.
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