Interopharyngeal phlegmon: causes, symptoms, diagnosis, treatment

Interpharyngeal (visceral) phlegmon, or lateropharyngeal cellulophlegmon, is much less common than the above described types of adenophlegmon neck. This type of purulent inflammation is characterized by the localization of the focus between the side wall of the pharynx and the connective tissue case, in which the large vessels of the neck are located.

Pathogenesis of interopharyngeal phlegmon. Most often, the lateropharyngeal phlegmon is iatrogenic in nature and occurs when the amygdala capsule is injured during the puncture of the paratonsillar abscess with the transmission of infection outside the lateral wall of the pharynx. Another cause of the occurrence of lateropharyngeal phlegmon is thrombosis of amygdala veins with its spread into the venous pterygoid plexus and hence into the connective tissue of the lateral region of the neck (hence the name of cellulophlegmon). The latero-pharyngeal phlegmon can also occur with abscess-tonzneltektomii produced in the "warm" period (according to the data of MA Belyaeva, 1948, in 411 cases of abscess-tonsillectomy no cases of the appearance of lateropharyngeal cellulophlegmone were observed, in 1% of cases there were bleedings of different intensity, which does not exceed those for tonsilectomy, given in the "cold" period). With tonsillectomy in the "cold" period after the paratonsillar abscesses that occurred in the anamnesis, laterofaringiemic cellulose phagmon may occur when the palatine tonsils are bluntly trimmed in a blunt way. In this case, rupture of the scars can lead to a violation of the integrity of the lateral wall of the pharynx in the region of the lining of the tonsils and the spread of infection in the direction of the neurovascular bundle. In extremely rare cases, lateropharyngeal phlegmon can occur when the tubal tonsil is injured during the catheterization of the auditory tube. Laryngopharyngeal phlegmon can occur not only as a complication of paratonzillitis, but also as a consequence of normal or expanded tonsillectomy, when a rupture of adhesions between the amygdala parenchyma and its pseudocapsule exposes the peripharyngeal space and creates a gateway for infection through the side wall of the pharynx.

Symptoms and clinical course of interopharyngeal phlegmon. In the above-mentioned case, on the 2nd day after surgery, to ordinary postoperative soreness, acute pulsating pain is added during swallowing, radiating into the ear and neck, dysphagia becomes worse, and there are growing signs of trism. With pharyngoscopy, the amygdala niche is filled with a swelling that is not typical of the usual postoperative pattern of throat, which extends mainly toward the posterior palatal arch. The reaction from the lymph nodes is negligible. When palpation is determined soreness in the neck at the angle of the lower jaw. With further development

Inflammatory process there is swelling over the PC from the side of inflammation, and in the throat, respectively, of this swelling, the swelling that appeared in the first phase increases sharply due to an inflammatory infiltrate. At this stage, the patient's breathing becomes difficult, especially if the infiltration and edema reach the laryngopharynx. Maturation of the abscess leads to the formation of a purulent cavity, with the puncture of which pus is obtained.

With the lateropharyngeal phlegmon, the pharyngeal symptoms predominate over the cervical; dominate dysphagia, sharp soreness in swallowing, severe hyperemia of large infiltrate, edema of the mucous membrane, occupying the entire half of the lower parts of the pharynx. It is here that all the subjective and objective signs of the lateropharyngeal phlegmon are localized. The body temperature rises above 38 ° C, the general condition of moderate severity, the constrictive respiratory dysfunction that develops may be manifested by external signs of breathing disorders (inhalation and exhalation in the area of the supraclavicular fossa, cyanosis of the lips, general anxiety of the patient, etc.).

With mirror hypopharyngoscopy, protrusion in the lateral wall of the lower sections of the pharynx, in the region of the laryngopharyngeal furrow, accumulation of saliva is revealed. External examination of any significant pathological changes in the area of the lateral surface of the neck does not reveal, however, with palpation at the level of pharyngeal changes, soreness identical to the one that occurs when swallowing is determined. This is evidence of the formation of lateropharyngeal phlegmon.

Complications of interopharyngeal phlegmon. Unopened latheropharyngeal phlegmon ripens within 5-8 days, as a result of which a massive swelling forms in the neck region, compressing the surrounding veins with the formation of collateral venous blood flow (enlargement and strengthening of the superficial veins of the neck on the side of inflammation). Purulent-necrotic process leads to the destruction of aponeurotic cervical septa and at the same time can spread in different directions, causing the emergence of a common phlegmon of the neck. This same process can reach the trachea and cause the destruction of the upper ring with massive pus flow into the respiratory tract and mediastinum, which inevitably leads to death. However, these complications in our time are extremely rare due to the early use of antibiotics, surgical treatment and the appropriate organization of the treatment process in the early stages of the disease.

Other complications include the defeat of the submandibular salivary gland, the penetration of pus into the region of space behind the digastric muscle with penetration into the neurovascular connective tissue case, giving rise to a deep neck phlegmon, manifested by pronounced dysphagia and dyspnoea due to edema of the larynx.

Treatment of interopharyngeal phlegmon. In the usual course of the latero-pharyngeal phlegmon, its opening is performed "in an internal way" in an obtuse manner after an appropriate diagnostic puncture of the abscess cavity. After that, the patient should be under observation for 3-5 days to detect a possible recurrence of the disease or manifestation of an unidentified purulent napte.

When an abscess is formed in the submaxillary region, the dissection is performed by the external method by means of a "figured" incision, starting anterior to the angle of the lower jaw that is bending and continuing posteriorly to the anterior margin of the sternocleidomastoid muscle, then directed anteriorly, but no more than 1 cm. Do not damage the facial artery. In some cases, there is a need to cut the external jugular vein (between the two ligatures). Further, with the help of the retractor Farabef, the edges of the wound are diluted, and after several manipulations of the rasporator, the parotid gland appears in its upper corner, under the back pole of which an abscess is searched. The technique of this search is that the end of the Kocher clamp is inserted under the dorsal muscle obliquely upward, inward and posteriorly, where the abscess cavity is located. The operation is completed by the removal of pus, by washing the abscess cavity with a sterile furacilin solution and applying drainage from the glove rubber that is folded into the tube. At the corners of the wound, sutures are applied, and most of it remains unshrouded. Apply a sterile bandage. The dressings are done daily until the purulent discharge stops and the wound is filled with "physiological" granulations. It is possible to superimpose a second-delayed suture on the wound.

[1], [2], [3], [4], [5], [6]