See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/258113602

Parapharyngeal Abscess After Dental

Extraction

Article June 2013

CITATIONS READS

0 31

1 author:

Guilherme Machado de Carvalho

Hospital Lusadas Porto
123 PUBLICATIONS 69 CITATIONS

SEE PROFILE

All in-text references underlined in blue are linked to publications on ResearchGate, Available from: Guilherme Machado de Carvalho
letting you access and read them immediately. Retrieved on: 15 November 2016
 www.orljournal.in /Vol- 3/ISSUE-2/ORL- 12290513/Pg 6-8

ORL Journal
-pursuit beyond knowledge

Parapharyngeal Abscess After Dental Extraction

aCarlosEduardo Monteiro Zappelini*, bCinthia Kim, bTammy Fumiko Messias Takara,
aAlexandre Caixeta Guimara es, aMario
Bazanelli Junqueira Ferraz, bFelipe Yazawa,
aCarlos Takahiro Chone, aAgrcio Nubiato Crespo, aGuilherme Machado de Carvalho
aDepartment of Otorhinolaringology, Head and Neck Surgery, Faculty of Medical Sciences

(FCM),Clinics Hospital (HC) - Campinas University (UNICAMP), BRAZIL

bMedical Student at Faculty of Medical Sciences of Santa Casa , So Paulo, BRAZIL (FCMSCSP)

Accepted 29 March, 2013

Abstract:

Background: Deep neck space infections may be caused
by lymph nodes that lie in this space. Its occurrence may
be associated with significant risks of morbidity and
mortality, mainly due to its multiple complications. This
case report suggests that suggestive signs of complications
following dental procedures should always be
investigated.
Case Report: Male, age 21 a surgical removal of the lower
third molar (wisdom teeth) was performed seven days
before the start of the clinical frame that was persistent
odynophagia (SIC) and high fever (> 39.5 ), physical
examination revealed trismus, uvular edema enlargement
of left tonsil projecting towards the middle line. After less
than 24 hours of discharge, he returned to our service
reporting intense odynophagia. The patient was
submitted a closed and spontaneous drainage in the
posterior region of the palatine tonsil. Analysis of
parapharyngeal abscess secretion revealed the presence of
Streptococcus viridans, sensitive to penicillin, vancomycin
and levofloxacin and resistant to clindamycin and
erythromycin. In 24 hours, he had significant clinical
improvement and significant reduction of tonsillar lodge
bulging.
Discussion and Final Comments: The initial focus of
infection was not a simple streptococcal pharyngitis, as
commonly described by other authors, but rather a
complication of tooth extraction. Although considering
the possibility of surgical approach to the caseit was
decided to elect a closed drainage procedure due to
patients good general condition and absence of
comorbidities
Keywords:
Parapharyngeal abscess; dental extraction complications;
dental extraction; deep neck space infections
* Corresponding author: Carlos Eduardo Monteiro Zappelini*
E-mail address: czappelini2@hotmail.com
Copyright: 2013 ORL Journal
Introduction:
Deep neck space infections may be caused by
lymph nodes that lie in this space, which are infected by
bacteria which lie primarily in the oral cavity, pharynx, nose
and paranasal sinuses and spread through the lymphatic
system.[1,2] Its occurrence may be associated with significant
morbidity and mortality rates, mainly due to its multiple
complications, including airway obstruction, paryngeal or
tracheal abscesses rupture, empyema, mediastinitis, carotid
artery erosion, jugular vein thrombophlebitis or cavernous
sinus thrombosis. [3,4,5,6]
This paper goals to describe a case and perform a
literature review about a parapharyngeal abscess after dental
extraction.
Case report:
Male, age 21, white, single, computer technician
born and raised in Campinas. Patient complained of persistent
odynophagia (SIC) and high fever (> 39.5 ), after two days
of symptoms the patient sought medical attention.
Physical examination revealed trismus, uvular
edema and enlargement of left tonsil projecting towards the
middle line. After evaluation by a doctor on duty at another
hospital, he was admitted with signs of periamigdalian
abscess being treated with crystalline penicillin,
metronidazole, hydrocortisone and painkillers. Remained in
hospital for three days, showing significant clinical
improvement and was discharged with amoxicillin with
clavulanic acid and analgesia.
After less than 24 hours of discharge, he returned to
our service reporting intense odynophagia. On examination,
the patient was slightly prostrate, no fever, with trismus,
sialohrrea, swelling on the left side of submandibular
triangle, parotidmasseteric and infratemporal regions,
significant uvular edema and ipsilateral tonsillar enlargement.
He was admitted to conduct additional tests.
Surgical removal of the lower third molar (wisdom teeth) was
performed seven days before the start of the clinical frame
that led to the first hospitalization. He denied a family history
of sinonasal and oropharynx deseases. Examination on
admission: CBC with 10,000 leukocytes and left nuclear
deviation. VSH: 44 mm / h, C-reactive protein: 18.54 mg /
dL, lactate dehydrogenase: 130 U / L; Antistreptolysin O:
210 IU / dL. Computed tomography scan (Figs. 1 and 2),
showing area obliterating left parapharyngeal space with a

6

ORL Journal
-pursuit beyond knowledge
hypotenuse signal in its interior, near the palatine tonsil,
compatible with encysted collection and dimensions of 3.3 x
2.9, x 2, 7 cm. The patient was submitted to a closed and
spontaneous drainage in the posterior region of the palatine
tonsil, it was drained around 150 ml (mixed with saliva). Part
of secretion, properly collected, was sent for analysis. In 24
hours, he had significant clinical improvement and significant
reduction of tonsillar lodge bulging. Control CT scan was
performed after 48hours.
Fig 1: Paranasal Sinuses CT before drainage into
axial slice showing beginning of epiglottis at level of
parapharyngeal abscess.
Fig 2: Paranasal Sinuses CT before draining into
coronal (2 A), sagittal (2 B) and axial (2 C) slices
and after 48 hours of drainage (2 D, 2 E, 2 F),
respectively
Analysis of parapharyngeal abscess secretion
revealed the presence of Streptococcus viridans, sensitive to
penicillin, vancomycin and levofloxacin and resistant to
7
www.orljournal.in /Vol- 3/ISSUE-2/ORL- 12290513/Pg 6-8
clindamycin and erythromycin. Clindamycin (D3) was
exchanged for Crystalline Penicillin remaining for another 48
hours until discharge, and being prescribed amoxicillin with
clavulanic acid.
Discussion:
The initial focus of infection was not a simple
streptococcal pharyngitis, as commonly described by other
authors, but rather a complication of tooth extraction.
Although considering the possibility of surgical approach to
the case, it was decided to elect a closed and spontaneous
drainage associated with broad-spectrum antibiotic coverage,
due to good therapeutic response, absence of comorbidities
and the good general condition of the patient.
Fig 3: Oroscopy after 24 hour parapharyngeal
abscess dranaige
Final Considerations:
This case report suggests that suggestive signs of
complications following dental procedures, such as edema
involving the cervical, parotidmasseteric and submandibular
triangle regions, among others, associated with trismus and
decreased general condition should always be investigated.
Conflicts of Interest:
None declared
Reference:
1) Filho ACNN, Pereira MC, Malucelli DAB, Fonseca VR,
Baptistella E, Selonke I, Junior JLP, Widolin LC, Trotta FT,
Franceschi F (2008). Abscesso Retrofarngeo: Relato de Caso.
ACTA ORL/Tcnicas em Otorrinolaringologia - Vol. 26 (3:
164-168).
2) Cmejrek RC, Cotoccihia JM, Arnold, JE (2002). Presentation,
diagnosis and mangment of deep-neck abscesses in infants.
Arch. Otolaryngol Head Neck Surgery. Vol.128, 1361-1364.
3)
 www.orljournal.in /Vol- 3/ISSUE-2/ORL- 12290513/Pg 6-8

ORL Journal
-pursuit beyond knowledge

4) Marques PMS, Spratley JEF, Leal LMM, Cardoso E, Santos M

(2009). Abscesso Parafaringeo na infncia: estudo retrospectivo
de 5 anos. Braz J Otorhinolaryngol. 75(6):826-30.
5) Herzon FS, Martin AD (2006). Medical and surgical treatment
of peritonsillar, retropharyngeal, and parapharyngeal abscesses.
Curr Infect Dis Resp. 8:196-202.
6) Sethi DS, Stanley ES (1994). Deep neck abscesses. J Laryngol
Otol. 108:138-43.
7) Broughton RA (1992). Nonsurgical management of deep neck
infections in children. Pediatr Infect Dis J.11:14-8.