pharyngeal abscess
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Infection of pharyngeal spaces
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The retropharyngeal space lies behind the pharynx andesophagus, just anterior to the prevertebral fascia. Itextends superiorly to the base of the skull and inferiorlyto the bifurcation of the trachea.
Patients generally present with trismus, drooling,dyspnea, dysphagia, and a mass, often fluctuant, on oneside of the posterior pharyngeal wall.
Lateral radiographs of the neck are also helpful in
diagnosis. It is important, however, to have properpositioning of the patient at the time of X-ray; otherwisethe results may be misleading. The patient should havethe neck extended in a true lateral position for the X-ray.
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The parapharyngeal space is cone shaped. Superiorly it startsat 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
The infection passes through the
Superior constrictor muscle
Symptoms
Same as in Quinsy
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Complications
Spread to
- Skull base meningitis- carotid sheaththrombosis of IJV
and rupture of carotid artery
- Mediastinum Mediastinitis
- Larynx
laryngeal edema
Ruptureinto the pharynxaspiration
Bronchopneumonia
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Treatment
Medical: massive antibiotic therapyand,
Surgical drainage
A vertical incision
at the anterior border of
the sternomastoid muscle
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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 attachedto each other at the midline by median raphe.)
Etiology
Upper Rrspiratory Tract Infectionwith suppuration of
Retropharyngeal LN
AfterAdenoidectomyoperation
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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Signs
General: 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 Patient
Lateral view of the Neck
Look for
- The vertebral column( for any destruction e.g in
Potts disease)
- The pre-vertebral space
(3/4 the width of the body ofthe 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 therapyand,
Surgical drainage
Tracheostomyif indicated
Incision in the posteriorpharyngeal wall with thepatient in the Trendlenbergposition Why?
In this position the head is lower than the chest
to avoid aspiration of pus
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Etiology:
- Pott
s Disease
i.e tuberculosis of cervical
vertebrae the abscessrupture through the
prevertebral fascia the
abscess reaches the
Retropharyngeal space
prevertebral
fascia
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Symptoms
In an adult
General: Tuberculous ToxaemiaPharyngeal: 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 overcervical 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 & CTscan
Widening of the
Prevertebral space
Destruction of the
cervical vertebrae
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Treatment:
Medical:Antituberculoustherapy
SurgicalDrainage
Orthopedic Management
Through a vertical incision alongthe 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
Killians diverticulum
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Introduction
Hypopharyngeal pouch is an acquired
pulsion diverticulumcaused 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 b all
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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 Zenkers diverticulum
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History
First described in
1769 by Ludlow
Friedrich Zenker&
von Ziemssen first
described its picture
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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
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Clinical Features
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1. Entrapment of food in pouch:sensation of
food sticking in throat & later dysphagia2. 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. Com ressible neck swellin on left side:
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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
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Barium swallow
B i ll i h Vid
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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 2.02.5
cm
Length >30 mmin 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
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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
en ulfin branches of losso har n eal
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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
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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
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