Quinsy

Phlegmonous tonsillitis, or acute paratonsillitis (according to BS Perevozhensky), - acute purulent inflammation of the peripermaladic cellulose, arising primarily or secondary, as a complication 1-3 days after follicular or lacunar angina.

With phlegmonous tonsillitis, the process is overwhelmingly unilateral, most often it occurs in persons aged 15-40 years, less often - at the age of less than 15 years and very rarely - at the age of less than 6 years.

[1], [2],

The cause of phlegmonous sore throat

As an etiological factor are pyogenic microorganisms, most commonly streptococci, which penetrate into the paratonsillar tissue and other extrathonylar tissues from the deep lacunae of the tonsils, which are in a state of inflammation in violation of the integrity of the almond pseudocapsule. Phlegmonous tonsillitis can occur as a result of damage to zamindalic fiber in diphtheria and scarlet fever.

There are three forms of paratonzillite:

• edematous;
• infiltrative;
• abscessing.

In essence, these forms, with the full development of the peritonsillar abscess, act as stages of a single disease, resulting in an abscess or phlegmon. However, abortive forms of peritonzillitis, which are completed in the first two stages, are also possible.

Most often, phlegmonous angina is located in the upper pole of the amygdala, less often in the zamindalic space or behind the amygdala in the region of the posterior arch. There are also bilateral phlegmonous tonsillitis, an abscess in the area of the supramaxel fossa or inside the amygdala parenchyma.

Symptoms of phlegmonous sore throat

There are sharp pains in the forge on one side, which force the patient to refuse to take even liquid food. The voice becomes nasal, the speech is indistinct, the patient gives the head a forced position with an inclination forward and towards the abscess, because of the paresis of the soft palate, the liquid beggar, when it attempts to swallow, flows out of the nose. There is a contracture of the temporomandibular joint on the side of the abscess, because of which the patient can only open his mouth a few millimeters. From the mouth there is an unpleasant smell with an admixture of the odor of acetone, excessive salivation, swallowing of saliva is accompanied by forced auxiliary movements in the cervical spine. Body temperature rises to 40 ° C, general condition of moderate severity, severe headache, severe weakness, weakness, pain in the joints, behind the breastbone, regional lymph nodes sharply enlarged and painful on palpation.

On the 5th-7th day (approximately on the 12th day after the onset of the disease with angina, usually 2-4 days after the disappearance of all its symptoms), a clear protrusion of the soft palate, most often over the upper pole of the amygdala, is revealed. At the same time, the examination of the pharynx becomes more and more difficult due to the contracture of the temporomandibular joint (swelling of the pterygo-jaw ligament of the same muscle). With pharyngoscopy, sharp hyperemia and swelling of the soft palate are noted. The amygdala is displaced to the middle line and down. In the region of the developing abscess, a sharply painful infiltrate is defined, which protrudes toward the oropharynx. With a mature abscess on top of this infiltrate, the mucous membrane and the wall of the abscess are thinned and pus appears through it as a white-yellow spot. If an abscess is opened during this period, up to 30 ml of a thick, offensive pus of green is released from the cavity.

After a spontaneous dissection of the abscess, a fistula is formed, the patient's condition quickly normalizes, becomes stable, the fistula after the cicatricial obliteration of the abscess cavity is closed, and recovery comes. With an operative opening of the abscess, the patient's condition also improves, but the next day, due to the coalescence of the edges of the incision and the accumulation of pus in the abscess cavity, the body temperature rises again, the pain in the pharynx increases again, and the general condition of the patient deteriorates again. The dilution of the edges of the incision again leads to the disappearance of pain, free opening of the mouth and improvement of the general condition.

The outcome of the peri-min-dalic abscess is determined by many factors and, above all, by its localization:

1. spontaneous dissection through a thin capsule of the abscess into the oral cavity, overmandicular fossa or in rare cases in the parenchyma of the amygdala; in this case, there is acute parenchymal tonsillitis, which is phlegmonous in nature with melting of the tonsil tissue and a breakthrough of pus in the oral cavity;
2. penetration of pus through the side wall of the pharynx into the parapharyngeal space with the appearance of another nosological form - the lateral phlegmon of the neck, very dangerous for its secondary complications (penetration of infection into the muscle perifascial spaces, the ascent of infection to the base of the skull or its descent to the mediastinum;
3. general sepsis due to the spread of infected blood clots from small amygdala veins in the direction of the venous inner pterygoplasty, then the posterior facial vein to the common facial vein and the inner jugular vein.

Cases of intracranial complications (meningitis, upper longitudinal sinus thrombosis, cerebral abscess) are described with peritonsillar abscesses that result from the proliferation of a thrombus from the inner pterygoid venous plexus not downwards, that is, not in the direction of the posterior facial vein, but upwards towards the orbital vein veins and then to the longitudinal sinus.

Complications of phlegmonous sore throat

A serious complication of the peritonsillar abscess is thrombophlebitis of the cavernous sinus, the penetration of infection into which is effected by linking the amygdala veins with this sine through the pterygoid venous plexus, the veins passing into the cranial cavity through the oval and round holes, or retrograde through the internal jugular vein and inferior stony venous sinus .

One of the most dangerous complications of peritonsillar abscess and lateral phlegmon of the neck are the erosion bleeds (but according to AV Belyaeva - in 0.8% of cases) that arise as a result of destruction of the vessels feeding palatine tonsils or larger blood vessels passing in parapharyngeal space. Another no less dangerous complication is okologoblotnye abscesses.

[3], [4], [5], [6]

Treatment of phlegmonous sore throat and peritonsillar abscess

Treatment for peritonsillar abscess is divided into nonoperative, semi-surgical and surgical. Non-surgical treatment includes all the methods and activities outlined above with regard to the treatment of angina, but it should be noted that in most cases they do not affect the development of the inflammatory process and only prolong the painful condition of the patient, therefore many authors, on the contrary, offer various methods that accelerate maturation of the abscess, and bringing it to the purulent stage, at which its opening is performed. A number of authors propose to make a preventive "dissection" of the infiltrate even before the stage of pus formation in order to reduce the stress of inflamed and painful tissues and accelerate the maturation of the abscess.

If the location of the opening of the abscess is difficult to determine (its deep occurrence), then a diagnostic puncture is performed in the direction of the alleged infiltrate. In addition, when pus is obtained by puncture, it can be immediately sent to a microbiological examination and the determination of an antibioticogram (sensitivity of microorganisms to antibiotics).

Puncture of peritonsillar abscess

After the application of anesthesia of the mucosa over the infiltrate by 2-fold lubrication, a long and thick needle on a 10 ml syringe is injected with a 5% cocaine solution at a point several up and inside the last lower molar. The needle is advanced slowly at a small angle from the bottom up and inside and to a depth of no more than 2 cm. During the movement of the needle, attempts are made to aspirate the pus. When the needle hits the abscess cavity, there is a feeling of failure. If the contents of the abscess can not be obtained, then a new injection is made into the soft palate at a point located in the middle of the line connecting the base of the tongue with the last lower molar. If pus is not obtained, the abscess will not be opened and (depending on the background of nonoperative treatment) takes a wait-and-see attitude, as the puncture itself promotes either the reverse development of the inflammatory process or speeds up the maturation of the abscess followed by its spontaneous breakthrough.

The opening of the peritonsillar abscess consists in the blunt opening of the abscess through the supramaxillary fossa with the aid of a nasal coroncus, a curved clamp or pharyngeal forceps: an anesthetic application with 5-10% cocaine chloride solution or a Bonen mixture (menthol, phenol, 1-2 ml cocaine) or an aerosol anesthetic (3-5 seconds with a break of 1 minute - only 3 times). Anesthesia is performed in the area of infiltrated arch and surface of the amygdala and infiltrate. Possible use of premedication (dimedrol, atroin, sedalgin). Infiltration anesthesia with novocaine in the abscess area causes severe pain, which is higher in intensity than the pain that occurs at the autopsy, and does not produce the desired effect. However, the introduction of 2 ml of ultracaine or 2% solution of novocaine into the zamindalic space, or infiltration of the soft palate and posterior pharyngeal wall with 1% novocaine solution outside the inflammatory infiltrate zone, give positive results - reduce the severity of pain, and most significantly reduce the contracture of the temporomandibular joint and promote more wide opening of the mouth. If this "trismus" persists, you can try to reduce its severity by lubricating the posterior end of the middle nasal cone with a 5% solution of cocaine or a mixture of Bonen, which makes it possible to obtain a repercussive anesthetic effect on the vesicular knot, which is directly related to the chewing muscles of the corresponding side.

Opening the abscess in a blunt way is performed as follows. When the anesthesia is reached in the supramodal fossa, overcoming the resistance of the tissues, with a little effort, the nose corncang is introduced in a closed manner to a depth of 1-1.5 cm. The ingress into the cavity of the abscess gives a feeling of failure. After this, the rootsticks are bred and produced by them 2-3 upward, posterior and downward movements, while trying to separate the anterior arch from the amygdala. With this manipulation, conditions are created for emptying the abscess cavity from the pus, which immediately flows into the oral cavity. It should be ensured that the purulent masses are not swallowed or enter the respiratory tract. For this, when the pus is isolated, the patient's head is tipped forward and downward.

A number of authors recommend a blunt autopsy not only after the formation of the abscess, but also in the early days of the formation of the infiltrate. This technique is justified by numerous observations that indicate that after such an opening the process acquires a reverse development, and the abscess is not formed. Another positive result of the drainage of the infiltrate is the rapid relief of pain syndrome, relief when the mouth is opened and the general condition of the patient is improved. This is explained by the fact that as a result of the drainage of the infiltrate, a bloody liquid is isolated from it, containing a large number of active microorganisms and products of their vital activity (biotoxins), which drastically reduces the intoxication syndrome.

Immediately after the opening of the peritonsillar abscess, the patient is offered a blunt rinse with various antiseptic solutions or decoctions of herbs (chamomile, sage, St. John's wort, mint). The next day, the manipulation performed the previous day is repeated (without preliminary anesthesia) by inserting into the hole of the corncanga and opening it and opening it in the abscess cavity.

Surgical treatment of peritonsillar abscess is performed in the sitting position, where the assistant fixes the patient's head with the hands behind. Use a sharp scalpel, the blade of which is wrapped with cotton wool or adhesive plaster so that the tip of 1-1.5 cm long remains (preventing deeper insertion of the instrument). The scalpel is punctured into the place of greatest protrusion or to the point corresponding to the middle of the line drawn from the base of the tongue to the last lower molar. The incision is extended downward along the anterior palatal arch at a distance of 2-2.5 cm. Then a blunt instrument (nasal coroncus or pharyngeal arched forceps) is inserted into the incision, penetrate into the depth of the abscess cavity to the place from which the pus was obtained during puncture, a certain effort diluted, and with a successful operation from the cut immediately appears thick creamy fetid pus with an admixture of blood. This stage of the operation is extremely painful, despite anesthesia, but after 2-3 minutes the patient experiences considerable relief, the spontaneous pain disappears, the mouth begins to open almost in full, and after 30-40 minutes the body temperature drops to subfebrile values, and through 2-3 hours is normalized.

Usually during the following night and by the morning of the next day, pain and difficulty of opening the mouth again appear. These phenomena are caused by gluing the edges of the wound and a new accumulation of pus, so again, the edges of the incision are diluted by introducing into the cavity of the abscess the coronzanga. This procedure should be repeated for the night, at the end of the working day. After opening the abscess, the patient is prescribed warm (36-37 ° C) rinses with various antiseptic solutions and within 3-4 days gives any sulfanilamide preparation or antibiotic of oral (intramuscular) application, or continues during the same time the treatment begun. Complete recovery usually occurs on the 10th day after the autopsy, but the patient with a favorable course of the postoperative period can be discharged from the hospital 3 days after the operation.

Retetonsillar abscesses are usually opened independently, or they also perform an autopsy according to the procedure described above. In abscess of the anterior or posterior arch, the incision is made along it, the edges of the incision are moved apart with a tool with thinner branches, penetrate into the cavity of the abscess and empty it in the usual way.

If in the midst of the paratonsillar abscess there is a relief of opening the mouth and a sharp decrease in pain without opening the abscess, but with a progressive deterioration in the general condition of the patient and the appearance of a swelling at the angle of the lower jaw, this indicates a breakthrough of pus into the near-pharyngeal space.

Any autopsy of the paratonsillar abscess should be recognized as a treatment for the palliative, symptomatic, since it does not lead to the elimination of the cause of the disease - the infected tonsil and the surrounding tissues, so every patient who has ever undergone a perimondalic abscess should remove the tonsils. However, the removal of the amygdala after the transferred parathonsillar abscess in the "cold" period is associated with great technical difficulties associated with the presence of dense scars, sometimes impregnated with calcium salts and not amenable to cutting the tonsillotomy loop. Therefore, in many clinics of the USSR, since 1934, the removal of palatine tonsils in the "warm" or even "hot" period of abscess (abscess-tonsillectomy) is practiced.

Surgery on the side of the abscess, if the operation is performed under local anesthesia, is markedly painful, but in the presence of pus in the proximal-delimic space it facilitates the excision of the amygdala, since the suppuration itself during the spread of pus around the amygdala capsule partially "does" this work. To begin surgical intervention follows from the patient side. After removal of the amygdala and revision of the abscess cavity, the remains of pus should be carefully removed, rinse the oral cavity with a solution of chilled furacilin, the niche of the tonsils and the abscess cavity with 70% ethanol and then proceed to surgery on the opposite side. Some authors recommend to produce an abscess-tonsillectomy only "causal" tonsils.

According to BS Perevozhensky, an abscess-toizillectomy is shown:

1. with repeated angina and abscess;
2. with a protracted flow of the circumferenal abscess;
3. with advanced or developed septicemia;
4. when after a surgical or spontaneous dissection of an abscess bleeding from the proximal end zone is observed.

In the latter case, depending on the intensity of bleeding before removing the amygdala, it is advisable to take the external carotid artery on the provigrant ligature and in the most critical stages of the operation to clamp it with a special elastic (soft) vascular clamp. After ligation of the bleeding vessel in the wound, the clamp is released and the operating field is checked for lack of or presence of bleeding.