Late-pharyngeal adenophlegon

Lateral parapharyngeal abscess, in contrast to the peroretic abscess, occurs equally often at all ages and develops the lateral lateral wall of the pharynx. There are two forms of this complication of angina and paratonlesillar abscess:

1. lateropharyngeal adenophlegmon arising in the chain of the sleepy-jugular lymph nodes, manifested by cervical symptoms with a favorable outcome, and
2. phlegmon of the lateral cellulose of the neck, arising between the lateral wall of the pharynx and the connective tissue "plate" that separates the said fiber from the large vessels of the neck. These two forms of purulent inflammation of parafaringsalnogo space differ both in their clinical course and in the methods of treatment of patients.

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Causes of the lateropharyngeal adenophlegony

Late-pharyngeal adenophlegmon most often occurs as a complication of severe septic form of angina or infectious diseases such as scarlet fever, diphtheria, erysipelas, in which streptococcus plays a leading role in the inflammatory process.

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Symptoms of the lateropharyngeal adenophlegony

Symptoms of lateropharyngeal adenophlegmonia are manifested primarily from the neck, and then from the latero-pharyngeal space. The first phase of the disease is characterized by the increase and soreness of the lymph nodes located in the angle of the lower jaw, then the inflammatory process extends to the lymph nodes located along the sternocleidomastoid muscle. The second phase is the occurrence of peritonsillar infiltration, causing severe pain, difficulty and pain when opening the mouth, raising body temperature to 39-40 ° C. The irritation of the sensitive nerves of the cervical plexus and the spinal nerves leads to the forced position of the head (slight turning to the sick side and back) and pains during movements in the cervical spine.

With pharyngoscopy, a swelling in the side wall of the pharynx, located behind the posterior palatine arch, is determined. When palpation of this swelling creates the impression of its consolidated connection with a package of lymph nodes of the lateral surface of the neck. With diphtheria or scarlet fever, the process can be two-sided.

In the phase of abscessing of the lymph nodes the general condition of the patient deteriorates sharply, the infiltration of the pharynx and its edema descend towards the laryngopharynx, a sharp violation of swallowing, respiration and contracture of the temporomandibular joint. Purulent inflammation of the deep lymph nodes of the neck is manifested by flushing of the skin and painful upon palpation, infiltration and swelling of the tissues in the region of the anterior margin of the sternocleidomastoid muscle. It should be noted that, in comparison with the massive perifocal edema of the tissue, the abscess itself is small in size, so it is very difficult to detect it during surgery.

Severe forms of lateropharyngeal adenophlegmons occur with streptococcal and anaerobic infection, light forms - in pneumococcal and staphylococcal banal angina and paratonsillar abscesses.

Complications of lateropharyngeal adenophlegmons. An uncovered abscess with lateropharyngeal adenophlegmon in most cases extends toward the outer edge of the sternocleidomastoid muscle with a breakout outward and the formation of a dermal fistula that may also appear in the region of the posterior edge of this muscle. A spontaneous dissection of the abscess can occur in the pharynx, behind the posterior palatine arch and the ingress of pus into the larynx and lungs. In this case, laryngospasm and severe purulent complications from the lungs are possible.

The protracted course of lateropharyngeal adenophlegony can lead to an arrosive bleeding from a common or external carotid with fatal outcome or to a jugular vein thrombophlebitis followed by pyemia and septicemia.

Often, with the lateropharyngeal adenophlegmon, cranial nerves are involved in the inflammatory process, passing in close proximity to the affected lymph nodes (glossopharyngeal, vagal, accessory, sublingual), first revealing their irritation and then suppression and paralysis, which is manifested by a number of syndromes (Avellis- with lateropharyngeal adenophlegmone occurs with lesions of the glossopharyngeal and vagus nerves on the side of the focus and is manifested by paralysis of the palatine arch and vocal folds, and the artery of the lateral fossa, the branch of the vertebral artery, manifests itself hemiplegia, loss of pain and temperature sensitivity on the opposite side). The irritation of these nerves leads to spastic contractions of the innervated muscles with the phenomena of suffocation, oppression and paralysis to the syndromes described in the footnotes. In the last stage of development of lateropharyngeal adenophlegony, cardiac arrest is possible.

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Diagnostics of the lateropharyngeal adenophlegony

Diagnosis of lateropharyngeal adenophlegmonia in a typical course of the disease of difficulty does not cause and is based on anamnesis, patient complaints, the presence of functional and organic changes in the pharynx and surrounding tissues. 

Differential diagnosis

To differentiate the lateropharyngeal adenophlegmon of tonsillar genesis follows from angustomaxillary osteophlegms of odontogenic origin, which are manifested by the contracture of the corresponding temporomandibular joint, while adenophlegmon first manifests itself as a forced position of the head and only with the further development of the inflammatory process - the so-called trism. Osteophlegmon of odontogenic origin develops in the zone of the angle of the lower jaw and manifests itself as a dense infiltrate that is integral with the latter without any pharyngeal phenomena, while lateropharyngeal adenophlegmon initially manifests as a swelling in the region of the posterior palatal arch.

The lateropharyngeal adenophlegmon is also differentiated from the Bezold mastoidite, in which the infiltrate occupies the apex of the mastoid process and extends along the inner surface of the sternocleidomastoid muscle. The appearance of pus in the external auditory canal with pressure on the area of swelling on the neck indicates the presence of an otogenic complication. We should not forget about the inflammation of the parotid and submandibular salivary glands (sialoadenitis), which has its pathogmonic signs (cessation of salivation, the appearance of pus from the salivary ducts, and soreness with their palpation).

Treatment of the lateropharyngeal adenophlegony

Treatment of lateropharyngeal adenophlegmons in the stage of infiltrative inflammation - physiotherapy and medication (see treatment of paratonsillitis), with the formation of an abscess or phlegmon - is an exclusively surgical outward access by a cut of the skin at the site of the largest sex of the protrusion behind the sternocleidomastoid muscle. Further, the search and opening of the abscess are performed only in an obtuse way by means of the clamps of Mikulich, Koher, Pean, etc., or with the help of a drop-shaped probe.

The subangular-mandibular phlegmon is opened with a cut of the skin and a superficial aponeurosis, produced at the anterior margin of the sternocleidomastoid muscle, which moves backward and outward, then bluntly, stripping the tissues with instrument movements from the top down, searching for the abscess and emptying it with the help of the suction wound (prevention of pus spreading through the tissues). Posterior adenophlegmy is opened by cutting along the posterior edge of the sternocleidomastoid muscle.