Infection of pharyngeal spaces

Retropharyngeal Space Infection 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.

Parapharyngeal Space Abscess 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.

Infection of Pharyngeal Spaces Parapharyngeal Abscess Retro-pharyngeal Abscess (Acute & Chronic)

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

The infection passes through the Superior constrictor muscle 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: Investigations: General; fever Pharyngeal: Cervical 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

- Skull base  meningitis 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

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

Acute Retropharyngeal Abscess 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 Collection of pus in the retropharyngeal space BuccoPharyngeal Fascia The Retropharyngeal space Prevertebral fascia

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 Pott’s disease) The pre-vertebral space (3/4 the width of the body of the vertebra) The airway

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

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

Chronic Retropharyngeal Abscess Pre-vertebral 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

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

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

The swelling lies in the midline of the posterior pharyngeal wall Pallor Low grade fever Loss of weight Signs: General: Tuberculous toxaemia Pharyngeal: Cervical: Tenderness over cervical spines 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

Through a vertical incision along the posterior border of the 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 Zenker’s diverticulum Pharyngo-oesophageal pouch Retropharyngeal pouch Killian’s 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 Zenker’s 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

Entrapment of food in pouch: sensation of food sticking in throat & later dysphagia Regurgitation of entrapped food: leads to  foul taste  bad odor  nocturnal coughing  choking Hoarseness: due to spillage laryngitis or sac pressure on recurrent laryngeal nerve Weight loss: due to malnutrition Compressible neck swelling on left side: reduces with a gurgling sound (Boyce sign)

Complications Lung aspiration of sac contents Bleeding from sac mucosa Absolute oesophageal obstruction Fistula formation into:  trachea  major blood vessel 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 2.0–2.5 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 Digital palpation of styloid process in tonsillar fossa elicits similar pain Relief of pain with injection of 2% Xylocaine solution into tonsillar fossa X-ray neck lateral view Ortho-pan-tomogram (O.P.G.) Coronal C.T. scan skull 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 Oral analgesics Injection of steroid + 2% Lignocaine into tonsillar fossa Carbamazepine: 100 – 200 mg T.I.D. 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.

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