Parapharyngitis

Parapharyngitis (parapharyngeal phlegmon, deep phlegmon of the neck) is an inflammatory process in the tissues of the near-hypopharyngeal space.

ICD-10 code

• J39.0 Retropharyngeal and parapharyngeal abscess.
• J39.1 Other pharyngeal abscess.
• J39.2 Other pharyngeal diseases.

Epidemiology of parapharynitis

Acute parapharyngitis is relatively rare, occurs as a complication of paratonzillar abscess and odontogenic diseases.

Causes of parapharynitis

The etiology of parapharynitis is the same as in paratonsillitis.

Pathogenesis of parapharynitis

The spread of infection is not cellulose of the near-pharyngeal space possible with angina, especially complicated by external (lateral) paratonzillitis, with traumatic lesions of the pharyngeal mucosa; possible odontogenic nature of parapharyngitis; finally, the pus can spread from the mastoid process through the mastoid and the pharynx-jaw space. Most often, the parapharyngeal abscess develops with a deep outer paratonsillar abscess, since with this form there are the least favorable conditions for spontaneous breakout of pus into the pharyngeal cavity.

The penetration of the infection from the amygdala into the near-pharyngeal space can be carried out through the lymphatic pathways with the suppuration of the lymph nodes of the near-pharyngeal space; hematogenous pathway in the dissemination of thrombosis of veins of the palatine tonsils to larger veins with subsequent purulent melting of the thrombus and involvement of the peripheral space into the process of tissues; finally, when the inflammatory process passes from the tonsils or when a pus breakthrough directly into the near-pharyngeal space.

Symptoms of parapharynitis

If parapharyngitis has developed as a complication of a long-term unresolved parathonsillar abscess, this is manifested by a worsening of the general condition of the patient, a further increase in temperature, an increase in pain in the throat, which increases with swallowing. Becomes more pronounced trismus chewing musculature, there is a painful swelling in the angle of the mandible and posteriorly from it. Intoxication with parapharynitis is usually more pronounced than with paratonzillitis; to the pain of swallowing sometimes involves the irradiation of pain in the teeth due to the defeat of the lower alveolar perinas, there is pain in the ear. There may be an exaggerated position of the head with an inclination to the sore side, movements of the head are sharply painful.

Screening

Patients with complaints of sore throat, difficulty swallowing, difficulty opening the mouth, as well as with submandibular lymphadenitis, an increase in body temperature should be sent to a consultation with the otorhinolaryngologist.

Diagnosis of parapharynitis

When examined, first determine the smoothening of the submaxillary region and in the projection of the angle of the lower jaw, subsequently it is possible to detect an enlarged painful palpation of the infiltrate. Sometimes diffuse infiltration of the submaxillary region and the lateral surface of the neck up to the clavicle with the spread of swelling in the region of the parotid gill and the chin area is noted.

With mesopharyngoscopy, a characteristic protrusion of the lateral wall of the pharynx is determined, sometimes in the region of the posterior arch.

A parapharyngeal abscess that has not been opened in a timely manner can lead to the development of even more serious complications - mediastin, purulent parotitis. "

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Laboratory diagnosis of parapharynitis

In the blood, leukocytosis is determined (up to 20 * 10 ⁹ / l and above), a shift of the leukocyte formula to the left, an increase in ESR.

Instrumental studies: ultrasound, CT, MRI. X-ray examination of the neck on the roentgenogram in the lateral projection often reveals the displacement of the trachea anteriorly, especially if the infection has spread from the hypopharyngea. Sometimes bubbles of gas in soft tissues are determined.

Differential diagnosis of parapharynitis

Conducts with diphtheria, malignant neoplasms [trays. Spreading the purulent process can lead to the development of mediastinitis.

[10], [11], [12]

Indications for consultation of other specialists

• Surgeon - if suspected of developing mediastinitis.
• Infectionist - for differential diagnosis with diphtheria.
• Maxillofacial surgeon - in the presence of an odontogenic cause of parapharyngitis.
• The oncologist - at suspicion on a malignant neoplasm of pharynx.
• Endocrinologist - with a combination of purulent disease with diabetes mellitus or other metabolic disorders.

Treatment of parapharynitis

The goals of parapharyngitis treatment are opening and draining the purulent process in the peripheral space and preventing complications; treat the disease that caused the development of parapharyngitis.

Indications for hospitalization

Hospitalization of the patient is compulsory.

Non-pharmacological treatment of parapharynitis

At the stage of resolving the process and suppressing inflammatory phenomena, UHF therapy can be prescribed.

Medical treatment of parapharynitis

The appointment of large doses of antibiotics (cephalosporins II-III generation, fluoroquinolones, macrolides), and after receiving the data of a microbiological study - antibiotics, taking into account the sensitivity of microflora. In addition, detoxication therapy, correction of water-electrolyte disorders are carried out.

Surgical treatment of parapharynitis

If the process has developed against the background of paratonzillitis, removal of the "causal" palatine tonsil is indicated. In those cases when conservative therapy does not stop the development of parapharyngitis and form a parapharyngeal phlegmon. It is necessary to perform an emergency opening of the near-pharyngeal space through the side wall of the pharynx (with tonsillectomy) or an external approach.

Opening of the parapharyngeal abscess or infiltrate through the oropharynx is performed immediately after tonsillectomy. Often, after removal of the amygdala, it is possible to detect necrotic tissues and fistula leading to the peripheral space. In this case, the fistula is enlarged, providing an outflow of pus. If the fistula is not found, then in the place of the largest bulging or in the middle part of the side wall of the tonsillar niche, a blunt path, more often with the aid of the Hartmann instrument, exfoliate the pharyngeal fascia and the muscle fibers of the upper or middle throat compressor and penetrate into the near-pharyngeal space. It should be borne in mind the possibility of injury to large vessels and not to perform an opening with sharp instruments.

With an external opening of the parapharyngitis, which is best performed under anesthesia, the incision is performed along the anterior edge of the sternocleidomastoid muscle, during its upper third, beginning at the level of the angle of the mandible. Dissect the skin and superficial fascia of the neck. Somewhat below the angle of the lower jaw, a site is found where the tendon of the digastric muscle perforates the fibers of the dorsal sublingual muscle. Above these fibers, a blunt instrument, and preferably an index finger, pass in the direction of an imaginary line running from the corner of the lower jaw to the tip of the nose. Separate the tissues of the near-pharyngeal space, examining the area corresponding to the position of the palatine tonsil region of the styloid process and the silo-lingual muscle. Depending on the nature of the inflammation in the peripheral space, serous, purulent, putrefactive or necrotic changes are detected. Sometimes putrefactive inflammation occurs with the formation of gas and an unpleasant odor. Sometimes the abscess is delimited by a granulation tissue.

The opening of the abscess should be wide (6-8 cm, sometimes more), and for large sizes, an autopsy is performed from different sides (form a counter -perture) to ensure reliable drainage. After opening and emptying the abscess, the cavity is washed with a solution of antibiotics and drained with a glove rubber. In the coming days, dressings are done twice a day. In the postoperative period, massive doses of antibiotics are prescribed, often combining them with metronidazole. Assign parenteral detoxification therapy, vitamins, etc.

Further management

Treatment of concomitant diseases (metabolic disorders, etc.).

Prevention of parapharynitis

Parapharyngitis can be prevented if the timely and adequate treatment of patients with acute inflammatory diseases of the pharynx, odontogenic diseases.

Forecast

With the timely opening of the parapharyngeal abscess and the use of active antibacterial therapy, the prognosis is favorable in most cases. However, with the development of mediastinitis, the prognosis worsens. Approximate terms of incapacity for work after treatment 14-18 days.

[13], [14]