Surgical treatment of paraphyrngeal and retropharyngeal abscesses

2. ` Cervical fascia

3. Investing layer of deep cervical fascia
 Attachments:

4. Deep Spaces of the Neck
 Submandibular
 Peritonsillar
 Parapharyngeal
 Retrophryngeal
 Prevertebral
 Danger
 Parotid
 Masticator

5. Para-pharyngeal abscess
 Definition :it is a collection of pus in paraphayrngeal
space

6. 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

7. 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

8. Parapharyngeal space
 It communicates directly
with other deep neck
spaces including the
retropharyngeal space,
parotid space,
submandibular space
and the carotid sheath.

9. Parapharyngeal space
 It 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

10. Parapharyngeal abscess
ETIOLOGY:-
 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.

11. Parapharyngeal abscess
Clinical 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.

12. Complications
Spread to
- Skull base  meningitis
- carotid sheaththrombosis of IJV and
rupture of carotid artery
- Mediastinum Mediastinitis
- Larynx laryngeal edema
Rupture into the pharynx aspiration
Bronchopneumonia
Parapharyngeal abscess

13. Retropharyngeal abscess
 Collection of pus in
retrophayngeal spaces

14. 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
Prevertebral fascia

15. Retropharyngeal abscess
 More common in children
 Aetiology:
• 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

16. Retropharyngeal abscess
 Clinical features in infants:
• Elevated temperature
• Difficulty in breathing
• Stiff neck
• Asymmetric swelling of posterior pharyngeal wall
 Clinical features in adults:
• Slow onset
• Pharyngeal discomfort
• Dysphagia
• Cervical motion limitation
• Noisy breathing

17. Retropharyngeal abscess

18. Retropharyngeal abscess
complications
 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 airway
 inferior extension into the mediastinum resulting in
mediastinitis
 systemic dissemination and development of sepsis
 Grisel syndrome
 Lemierre syndrome

19. Investigations
• CBC
• X -ray ( neck ,chest )
• USG
• Needle aspiration and culture and sensitivity
• CT.SCAN

24. Treatment
 Educate the patient and take consent for surgical
interventions that may arise
 Airway management
 IV antibiotic (pinicillin-
sulbactum,clindamycin,ceftriaxon+metronidazole)
 Surgical drainage

25. Surgical drainage
 Done under GA
 Intubation
 Trans-oral or trans-cervical approach
• Oral intubation
• Fiberoptic intubation
• Tracheostomy under LA

26. Para-pharyngeal abscess drainage
Trans-oral approach
 Indicated for abscess located medial to great vessles
 Patient placed supine in trendelenburg position
 Mouth gag

27. Para-pharyngeal abscess drainage
 Palpate the swelling to localize the abscess
 Insert 14 gauge needle and aspirate
 Aspirated pus should be sent for culture
 Vertical incision given in the fluctuant areal(over mucosa
only)
 Long clamp used to dilate the opening and allow for
further drainage

28. • 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

29. Para-pharyngeal abscess drainage
Transcervical
 After securing the airway
 Patient placed in supine
position with shoulder roll
 Head 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

30.  Infiltrate with lidocain and adrenalin
 The neck, face up to the oral commissure and
shoulder are prepped
 The 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.

31.  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

32.  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

33.  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 incision
 skin partially closed, leaving an opening for the
drain,

34. Trans-oral approach of retropharyngeal abscess
 Supine and extreme
trendelburg position
 Posterior pharyngeal wall

35. 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

36.  High abscess: along posterior border of
sternocleidomastoid muscle

37. Principles for neck abscess drainage
 Ensuring a secure airway is the first priority in
the management of a deep neck infection
 Therefore, 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

38.  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