Infection of pharyngeal spaces

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.
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.
Parapharyngeal Abscess
Retro-pharyngeal
Abscess
(Acute & Chronic)


Parapharyngeal Abscess
Def
What is parapharyngeal space?
Collection of pus in the
PARA-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
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
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
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

Treatment
Medical: massive antibiotic therapy
and,
Surgical drainage
A vertical incision
at the anterior border of
the sternomastoid muscle
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
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
Symptoms

In A child below 5 years
General: FHAM
Pharyngeal:
Severe sore throat
Dysphagia
Difficult breathing
Abscess
Signs
General: fever
Pharyngeal
Swelling of the posterior
Pharyngeal wall to one
side of the midline
Cervical: Neck inclination
due to muscle spasm
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 of
the vertebra)
- The airway
Investigations:
plain X ray & CT scan
Widening of
prevertebral space
Normal vertebral
bodies
Complications:
-Spread to mediastinummediastinitis
-Rupture.

Treatment
Medical: massive antibiotic therapy
and,
Surgical drainage
Tracheostomy 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 chest
to avoid aspiration of pus
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
Etiology:
- Potts Disease
i.e tuberculosis of cervical
vertebrae the abscess
rupture through the
prevertebral fascia the
abscess reaches the
Retropharyngeal space


prevertebral
fascia
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
Signs:
General: Tuberculous toxaemia
Pharyngeal:
Cervical: Tenderness over
cervical spines

- Pallor
- Low grade fever
- Loss of weight
The swelling lies in the midline of
the posterior pharyngeal wall
Investigations
Plain X ray & CT
scan
Widening of the
Prevertebral space
Destruction of the
cervical vertebrae
Treatment:
Medical: Antituberculous
therapy
Surgical Drainage
Orthopedic Management
Through a vertical incision along
the posterior border of the
sternomastoid muscle
Hypopharyngeal
Pouch
Hypopharyngeal pouch
Synonyms
Hypopharyngeal diverticulum
Zenkers diverticulum
Pharyngo-oesophageal pouch
Retropharyngeal pouch
Killians diverticulum
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.
Weak spots b/w muscles
Weak spots b/w muscles
Posterior: 1. Between Thyropharyngeus &
Crico-
pharyngeus: Killian's dehiscence
(commonest)
Origin of Zenkers diverticulum
History
First described in
1769 by Ludlow
Friedrich Zenker &
von Ziemssen first
described its picture
in their book in 1877
Etiology
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.
Clinical Features
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)
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)
Investigations
Chest X-ray: may show sac + air - fluid level
Barium swallow
Barium swallow with video-fluoroscopy
Rigid Oesophagoscopy
Flexible Endoscopic Evaluation of
Swallowing
Barium swallow
Barium swallow with Video-
fluoroscopy
Rigid Oesophagoscopy
Cricopharyngeal myotomy
Styalgia
(Eagle Syndrome)
Introduction
Normal length of styloid process is 2.02.5
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.
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
Normal Styloid Process
Elongated Styloid Process
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
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
X-ray neck lateral view
Coronal C.T. scan
Coronal 3-D C.T. scan
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
Styloid Process
Excision
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
Tonsillectomy & fossa
incision
Styloidectomy
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.