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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