Interopharyngeal phlegmon: causes, symptoms, diagnosis, treatment

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

Pathogenesis of interopharyngeal phlegmon. Most often, lateropharyngeal phlegmon is iatrogenic and occurs when the tonsil capsule is injured during puncture of a paratonsillar abscess with transmission of infection beyond the lateral wall of the pharynx. Another cause of lateropharyngeal phlegmon is thrombosis of the tonsil veins with its spread to the venous pterygoid plexus and from there to the connective tissue of the lateral region of the neck (hence the name cellulophlegmon). Lateropharyngeal phlegmon may also occur during abscess-tonsillectomy performed in the "warm" period (according to M.A. Belyaeva, 1948, out of 411 cases of abscess-tonsillectomy, not a single case of lateropharyngeal cellulophlegmon was observed; in 1% of cases, bleeding of varying intensity was observed, which does not exceed that during tonsillectomy performed in the "cold" period). During tonsillectomy in the "cold" period after a history of paratonsillar abscesses, lateropharyngeal cellulophlegmon may occur during rough separation of the palatine tonsils by blunt means. In this case, ruptures of scars can lead to a violation of the integrity of the lateral wall of the pharynx in the area of the bed of the palatine tonsils and the spread of infection in the direction of the vascular-nerve bundle. In extremely rare cases, lateropharyngeal phlegmon can occur when the tubal tonsil is injured during catheterization of the auditory tube. Laryngopharyngeal phlegmon can occur not only as a complication of paratonsillitis, but also as a consequence of conventional or extended tonsillectomy, when, upon rupture of the adhesions between the parenchyma of the tonsil and its pseudocapsule, the peripharyngeal space is exposed and a gate is created for the penetration of infection through the lateral wall of the pharynx.

Symptoms and clinical course of interopharyngeal phlegmon. In the above case, on the 2nd day after surgery, the usual postoperative pain when swallowing is accompanied by acute pulsating pain radiating to the ear and neck, dysphagia increases, and increasing signs of trismus appear. During pharyngoscopy, the tonsil niche is filled with swelling, which is not typical for the usual postoperative picture of the pharynx, spreading mainly towards the posterior palatine arch. The reaction from the lymph nodes is insignificant. Palpation reveals pain in the neck area under the angle of the lower jaw. With further development

The inflammatory process causes swelling above the PC on the side of the inflammation, and in the pharynx, corresponding to this swelling, the swelling that arose in the first phase sharply increases due to the inflammatory infiltrate. At this stage, the patient's breathing becomes difficult, especially if the infiltrate and swelling reach the laryngopharynx. The maturation of the abscess leads to the formation of a purulent cavity, during puncture of which pus is obtained.

In lateropharyngeal phlegmon, pharyngeal symptoms prevail over cervical ones; dysphagia, sharp pain when swallowing, pronounced hyperemia of large infiltrates, edema of the mucous membrane occupying the entire half of the lower parts of the pharynx dominate. It is here that all subjective and objective signs of lateropharyngeal phlegmon are localized. Body temperature rises above 38 ° C, the general condition is moderate, the resulting constrictive respiratory dysfunction can be manifested by external signs of respiratory failure (retractions on inhalation and bulging on exhalation in the supraclavicular fossa, cyanosis of the lips, general anxiety of the patient, etc.).

With mirror hypopharyngosconia, a protrusion is revealed in the area of the lateral wall of the lower parts of the pharynx, in the area of the laryngopharyngeal groove, and accumulation of saliva. External examination does not reveal any significant pathological changes in the area of the lateral surface of the neck, but palpation at the level of pharyngeal changes reveals pain identical to that which occurs when swallowing. This is evidence of the formation of lateropharyngeal phlegmon.

Complications of interopharyngeal phlegmon. Unopened lateropharyngeal phlegmon matures within 5-8 days, resulting in a massive swelling in the neck area, compressing the surrounding veins with the formation of collateral venous blood flow (expansion and strengthening of the superficial veins of the neck on the side of inflammation). The purulent-necrotic process leads to the destruction of the aponeurotic cervical septa and can simultaneously spread in different directions, causing the occurrence of widespread phlegmon of the neck. The same process can reach the trachea and cause the destruction of its upper ring with massive pus flowing into the respiratory tract and mediastinum, which inevitably leads to death. However, these complications are extremely rare in our time 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 damage to the submandibular salivary gland, penetration of pus into the area of space behind the digastric muscle with penetration into the vascular-nerve connective tissue sheath, giving rise to deep phlegmon of the neck, manifested by severe dysphagia and dyspnea caused by laryngeal edema.

Treatment of interopharyngeal phlegmon. In the usual course of lateropharyngeal phlegmon, its opening is carried out "internally" by blunt means after the corresponding diagnostic puncture of the abscess cavity. After this, the patient should be under observation for 3-5 days to detect a possible relapse of the disease or the manifestation of a previously unidentified purulent abscess.

When an abscess forms in the submandibular region, it is opened externally by a "figured" incision, starting anteriorly from the angle of the lower jaw, enveloping it and continuing posteriorly to the anterior edge of the sternocleidomastoid muscle, then directed anteriorly, but not more than 1 cm, so as not to damage the facial artery. In some cases, it is necessary to cut the external jugular vein (between two ligatures). Then, using a Farabeuf retractor, the edges of the wound are spread apart, and after several manipulations with a raspatory, the parotid gland appears in its upper corner, under the posterior pole of which the abscess is searched for. The technique of this search consists of inserting the end of the Kocher clamp under the digastric muscle obliquely upward, inward and posteriorly, where the desired abscess cavity is located. The operation is completed by removing the pus, washing the abscess cavity with a sterile furacilin solution and applying drainage from a rubber glove folded into a tube. Sutures are applied to the corners of the wound, while most of it remains unsutured. A sterile bandage is applied. Dressings are applied daily until purulent discharge ceases and the wound is filled with "physiological" granulations. In this case, it is possible to apply a secondary-delayed suture to the wound.

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