1. الدكتور سعد يونس سليمان كلية طب نينوى
Infection of the
pharyngeal spaces
الدكتور
سعد يونس سليمان
كلية طب نينوى

2. Infection of Pharyngeal Spaces Peri-tonsillar Abscess
Parapharyngeal Abscess
Retro-pharyngeal Abscess
(Acute & Chronic)
Ludwig’s Angina

3. Parapharyngeal Abscess
Collection of pus in the
PARA-PHARYNGEAL Space
Def
What is parapharyngeal 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

4. The infection passes through the Superior constrictor muscle
Etiology:
Acute Tonsillitis or peritonsillar abscess or after tonsillectomy
Infection &extraction of last lower molar tooth
Infection of the parotid salivary gland
Extension of mastoid infection
( Bezold's abscess).
- Spread from retropharyngeal abscess.
The infection passes through the
Superior constrictor muscle
Symptoms
Occurs mostly in adolescents and adults
The patient is feverish, ill and toxic.
Acute sore throat.

5. Signs: Investigations: CBC General; fever S.Urea &electrolyte
Pharyngeal:
Cervical
Investigations:
CBC
S.Urea &electrolyte
FBS
Lateral soft tissue neck radiograph, CT & MRI.
- The lateral pharyngeal wall & tonsil are
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 diseased side

6. - Skull base  meningitis
Complications
Spread to
- Skull base  meningitis
carotid sheath thrombophlebitis of IJV with septicaemia and erosion of carotid artery
Mediastinum Mediastinitis
Larynx laryngeal edema
Rupture into the pharynx aspiration Bronchopneumonia
Cranial nerves and sympathetic chain involvement  Horner's syndrome.

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

8. Acute Retropharyngeal Abscess
It is a connective tissue space between :
the buccopharyngeal fascia & pre-vertebral fascia
It extends from the skull base to the posterior mediastinum
The space is divided into 2 compartments by a fibrous raphe (spaces of Gillette). Each space contains retropharyngeal lymph node one on each side
The Retropharyngeal LN atrophy at the age of 5
Collection of pus in the retropharyngeal space
BuccoPharyngeal
Fascia
The Retropharyngeal space
Prevertebral fascia

9. 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 or penetrating injury of posterior pharyngeal wall.

10. Symptoms In A child below 5 years General: High pyrexia. Pharyngeal:
Severe sore throat
Dysphagia
Difficult breathing, stridor and croupy cough
Abscess

11. Signs General: fever Pharyngeal Swelling of the posterior
Pharyngeal wall to one
side of the midline
Cervical:
Torticollis. The neck becomes stiff and the head is kept extended.
Cervical lymphadenopathy.

12. Normal Patient Lateral view of the Neck
Look for
The vertebral column
( for any destruction e.g in Pott’s disease)
The pre-vertebral space (3/4 the width of the body of the vertebra)
The airway

13. Investigations: plain X ray & CT scan Complications:
Spread to mediastinummediastinitis
Rupture………….
Widening of
prevertebral space
Normal vertebral
bodies

14. Treatment Medical: massive antibiotic therapy Surgical drainage
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

15. Formation of a cold abscess in the pre-vertebral space
Chronic Retropharyngeal Abscess (Pre-vertebral Abscess or Pott's Abscess )
Formation of a cold abscess in the pre-vertebral space
What is the pre-vertebral space?
A space between:
The cervical vertebrae
The pre-vertebral fascia

16. Etiology: Pott’s Disease
i.e tuberculosis of cervical vertebrae  the abscess rupture through the prevertebral fascia  the abscess reaches the Retropharyngeal space
prevertebral fascia

17. Symptoms In an adult General: Tuberculous Toxaemia Pharyngeal:
Pharyngeal discomfort rather than pain.
Mild dysphagia.
Cervical:
limited painful neck movement
-Night sweets
-Night fever
-Loss of weight
-Loss of appetite

18. Signs: The patient looks pale with low grade fever and loss of weight.
Painless swelling lies in the midline of the posterior pharyngeal wall.
Enlarged painless cervical lymph nodes.

19. Investigations Plain X ray & CT scan Widening of the
Prevertebral space
Destruction of the
cervical vertebrae

20. Treatment: Medical: Antituberculous therapy Surgical Drainage
Orthopedic Management
The drainage should never be
through the mouth
to avoid secondary infection.
Through a vertical incision along
the posterior border of the
sternomastoid muscle

21. Ludwig’s Angina Definition: Infection of submandibular space.
What is submandibular space?
A space lies between the mucus membrane of the floor of the mouth and tongue on one side and superficial layer of deep cervical fascia extending between the hyoid bone and mandible on the other.
Divided into two compartments by the mylohyoid muscle:
1- Sublingual compartment ( above the mylohyoid)
2- Submaxillary and submental compartment (below the mylohyoid).
The Tongue

23. Etiology
Infection of the floor of
the mouth e.g:
Lower teeth (the commonest 80%)
Tongue
Mandible
Sublingual or submandibular salivary gland

24. Symptoms
General ; The patient is ill, toxic (fever > 38°C)
Local:
As the tongue is pushed upwards &
Backwards  obsrtuct:
The Air Passage & The Food Passage
Severe Odynophagia with drooling of saliva
Severe Dyspnoea
There is varying degree of trismus.

25. Signs
General:Fever
Local: Swelling in the floor of the mouth which pushes the tongue upwards & backwards
Cervical :
Tender indurated swelling
of both submandibular
regions.
Suppuration seldom
occurs

27. Treatment Tracheostomy Medical: Surgical drainage: If indicated
massive Antibiotic therapy
Bed rest in semi-sitting position to avoid airway obstruction and,
Surgical drainage:
By a horizontal incision below the mandible
Usually there is no or little frank pus
Tracheostomy
If indicated

28. Tumors of the pharynx Juvenile Nasopharyngeal Angiofibroma(JNA)
Nasopharyngeal Carcinoma (NPC)

29. Juvenile Nasopharyngeal Angiofibroma(JNA)
Is a vascular tumor of the nasopharynx occurring almost entirely in adolescent males (7-19 years with a mean of 14 years). The tumor has a tendency to regress after puberty.
Although the tumor is benign, it is locally invasive and behaves as malignant due to the anatomical structure of the nasopharynx.

30. Aetiology
The exact cause is unknown.
As the tumor is predominantly seen in adolescent males in the 2nd decade of life, it is thought to be testosterone dependent. Such patients have a hamartomatous nidus of vascular tissue in the nasopharynx and this is activated to form angiofibroma when male sex hormone appears.

31. Clinical picture
The patient is nearly always a young boy with a mean age of 14 years.
Repeated attacks of epistaxis which can be extremely profuse due to absence of muscular coat from the sinusoids.
Progressive nasal obstruction.
Nasal speech (Rhinolalia aperta).
5. Conductive deafness due to pressure on Eustachian tube.

32. Examination
Posterior rhinoscopy: smooth, rubbery lobulated mass in the nasopharynx.
Middle ear effusion.
Mass in the nasal cavity or on the check if the tumor has extended anteriorly or laterally.
Proptosis results from extension of the tumor to the orbit through the infraorbital fissure.

33. because of fatal bleeding.
Investigation
X-ray of the base of the scull and a lateral view of the skull.
CT scan, MRI and MRA.
External carotid angiography.
Biopsy is
Contraindicated
because of fatal bleeding.

34. Differential diagnosis
Antrochoanal polyp.
Nasopharyngeal carcinoma.

35. Treatment
Surgical excision: Haemorrhage is the main danger of operation, so adequate blood should be prepared before operation.
Embolization: is indicated preoperatively to control the vascularity of the tumor.
Radiotherapy: should be reserved for patients with inoperable intracranial extension.

36. Nasopharyngeal Carcinoma (NPC)
common in South East Asia especially in China.
maximum age incidence is in the 5th decade
males >females.
Most tumors arise from fossa of Rosenmuller.
Aetiology
The exact etiology is unknown. The factors responsible are:
Genetic: The Chinese have a higher genetic susceptibility to NPC.
Viral: Epstein-Barr virus is closely associated with NPC.
Environmental: Ingestion of salted fish and indoor cooking in homes without chimneys are common in china.

37. Spread of Nasopharyngeal Carcinoma
Direct:
Anteriorly: Into the nasal cavity and paranasal sinuses leading to nasal symptoms.
Posteriorly: to the retropharyngeal space and lymph node of Rouviere.
Laterally: into the parapharyngeal space involving the last 4 cranial nerves.
Superiorly through the base of the skull involving the optic nerve and the cavernous sinus.
Inferiorly to the oral cavity and retrotonsillar region.
Lymphatic spread to the cervical lymph node,
Blood born (rare).

38. Clinical picture
Cervical lymphadenopathy: is often the presenting feature which may be unilateral or bilateral.
Nasorespiratory symptom: nasal obstruction, nasal speech and epistaxis.
Tinnitus and aural symptoms due to Eustachian tube obstruction. This may proceed to secondary otitis media.
Neurological symptoms: the most frequently involved nerves are 5th, 6th, 9th and 10th cranial nerves. The latter two nerves paralysis leads to immobility of soft palate. Involvement of the sympathetic chain results in Horner's syndromes.
Pain and headache due to intracranial extensions or sphenoidal sinusitis.

39. Examination Investigation
Posterior rhinoscopy: a large exophytic tumor may be seen.
The palate is pushed downward and paralyzed.
The neck should be palpated for metastatic lymph nodes.
Middle ear effusion.
Parapharyngeal spread can cause trismus.
Investigation
Imaging:
X-ray of the base of the skull ----bony destruction involving the petrus bone, foramen lacerum and carotid canal.
CT scan and MRI: MRI is superior to CT scan in finding soft tissue.
Biopsy under GA,

40. Treatment
Radiotherapy is the treatment of choice because surgical removal of the primary growth is impossible.
Chemotherapy as an adjuvant to radiotherapy is of contraverse.
Surgery in form of radical neck dissection is reserved for patients where lymph nodes are not controlled by radiation or when enlarged lymph nodes appear after the primary tumor has been controlled.

41. Thanks