Retropharyngeal adenoflegona: causes, symptoms, diagnosis, treatment

There are abscesses and adenophlegmones, lateral abscesses and adenophlegmons of the okolobloccal space, intrapharive (visceral) phlegmon, phlegmonous lingual periamigdalitis, Ludwig's angina, abscess of the epiglottis, abscess of the lateral grooves of the pharynx, defeat of the thyroid gland, cervical mediastinitis.

According to AHMinkovsky (1950), in the pathogenesis of these complications of phlegmonous angina, the following mechanisms occur:

1. as a result of a spontaneous breakout of pus from the peri-min-diabetic abscess directly into the near-pharyngeal space;
2. when the lateral wall of the pharynx is injured during the dissection of the abscess;
3. as a complication of abscess-tonsillectomy;
4. when there is thrombosis of the amygdala veins and metastasis of purulent emboli into the near-pharyngeal space;
5. with suppuration of the lymph nodes of the near-pharyngeal space.

An important factor that plays a significant role in the appearance of phlegmon parapharyngeal space is the connective tissue that fills it and the loose fiber, which is a favorable environment for the development of pathogenic microorganisms. By means of the shillopharyngeal muscle, which is running obliquely down and inward from the cervical process to the pharynx, the okolobloccal space can be conditionally divided into the anterior and posterior parts. Most often, a breakthrough of pus from the paratonsillar abscess occurs in the anterior section. Along the near-pharyngeal space, large vessels and nerves pass through the vagina of which the infection can spread both in the head and in the thoracic direction, causing purulent complications (napters) of the corresponding localization. These complications are also facilitated by the fact that the peripheral space is associated with the retropharyngeal space formed by the gap between the pharyngeal and pre-invertebrate fascia, the penetration of infection into which is caused by deep pharyngeal abscesses that extend along the spine. The endocellular space passes into the middle slot of the neck located under the body of the PC between the middle and superficial fasciae of the neck on one side and the deep fascia of the neck on the other. The presence of this gap causes the infection to spread to the mediastinum, since it (the cleft) in the upper cut of the sternum passes into the anterior mediastinum. Between the inner and outer pterygoid muscles there is a pterygoid venous plexus, which receives twigs from the palatine tonsils and parapharyngeal formations, communicating with the lower orbital vein and through the medial cerebral vein with the dura mater. Thrombophlebitis of these veins of tonsillogenic nature can lead to ocular and intracranial purulent complications.

A predisposing factor for retrofaringeal adenoflegmona is the presence of the peropharyngeal lymph nodes, closely associated with epipharyngeal lymph nodes and lymph nodes located on the back of the soft palate, which primarily react to paratonsillar purulent processes. These swallowing lymph nodes located on either side of the medial plane of the forefoot space are reduced to 3-4 years of age, but before that they play an important pathogenetic role in the occurrence of retrofaringe phlegmon in early childhood. The same lymph nodes are present in the loose connective tissue and the pharyngeal space that stratify it, located in layers between the mucosa, connective tissue, the muscular layer of the pharynx constrictors, the prevertebral fascia and muscles, and just in front of the cervical vertebral bodies. Thus, retrofaringeal adenoflegmon can be defined as purulent inflammation of retrofaringeal lymph nodes and loose connective tissue of the peropharyngeal space, bounded laterally by the vascular-neural bundle and developing in the pharynx-mandibular space of the corresponding side. Sometimes pus penetrates the perivascular tissue, resulting in the formation of a lateral pharyngeal abscess. The occlusion space communicates with the posterior mediastinum.

The main source of infection in the abscesses of the okolothril space is pathologically altered palatine tonsils or paratonsillar abscess. However, it should be borne in mind that parapharyngeal abscesses may have odontogenic or auricular origin. With abscesses of dental origin, the greatest changes in the pharyngeal tissues are located next to the diseased tooth (its periodontitis, pulmonary gangrene or deep caries), decreasing towards the palatine tonsils. In abscesses of amygdala origin, the greatest changes occur in the "causal" tonsil and in the surrounding tissues.

Retropharyngeal adenophlegmon, depending on the age of the patient, occurs in two forms: retrofaringeal adenoflegmon of early childhood and retrofaringualnyaya adenoflegmon adults.

Retropharyngeal adenophlegmon of early childhood occurs in the form of abscess formation of lymph nodes, most often in infants aged 2-7 months. The cause of its occurrence may be acute rhinitis or angina adenovirus etiology, but most often it provokes acute adenoiditis.

Symptoms and clinical course of retrofaringeal adenoflegmona. The child, in addition to fever and runny nose, observe a violation of sucking and swallowing, a violation of nasal or guttural swallowing. Because of these violations, the child "does not take the breast" or the horn, because it can not swallow milk that is poured out of the mouth or nose. The child's sleep is disturbed and accompanied by screaming, snoring and purring. An abscess can be localized in the nasopharynx, and then a nasal breathing disorder and closed nasal discharge come to the fore. With the localization of the abscess in the lower parts of the pharynx, there are attacks of suffocation due to the edema of the laryngopharynx, compression of the larynx and swallowing disorders due to compression of the entrance to the esophagus.

With pharyngoscopy on the back wall of the pharynx, the fluctuating swelling, covered by the hyperemic mucosa, is located somewhat laterally. The nasopharyngeal abscess, which is defined in children palnatorially, is also located somewhat laterally, since the retrofaringal space located at the level of the nasopharynx and pharynx is divided into two halves by a medially located fibrous septum.

The abscess evolves within 8-10 days and can be opened independently, while the pus flows into the larynx and trachea, getting into the lower respiratory tract. The child at the same time dies of suffocation, which occurs as a result of laryngeospasm and the filling of purulent masses of small bronchi.

The diagnosis is established on the basis of the clinical picture and the result of puncture or dissection of the abscess. If a retropharyngeal abscess occurs during diphtheria of pharynx or scarlet fever, then direct diagnosis causes great difficulties, since the signs of the abscess are masked by the symptoms of these infectious diseases. Retropharyngeal adenophlegmy should be differentiated from suppuration of the lipoma of the posterior pharyngeal wall.

Treatment of retrofaringualnoy adenoflegmona - immediate surgical, by opening an abscess without any anesthesia. With massive abscesses and breathing disorders, the child, wrapped in a sheet, is placed in the position of Rose (lying on his back with shoulder blades on the edge of the table with a stained back head), and he is held by an assistant. The mouth is opened with the help of a rotor expander, and the abscess is opened in the place of the largest protrusion bluntly with the help of an appropriate tool with a rapid dilution of its jaw. Immediately after opening the abscess at the command of the surgeon, the assistant instantly turns the child face down and legs up, so that the pus is poured into the mouth. When breathing is stopped, which is rarely observed, rhythmic twitchings are made for the tongue or artificial ventilation is performed, intubating the trachea. For this purpose, the room in which the operation is performed must be equipped and equipped with appropriate resuscitation facilities.

With small abscesses of a child wrapped in a sheet, sit on the hips of the assistant, like with an adenotomy, with the head tilted forward, the tongue is squeezed down with a spatula and the abscess is opened with a quick incision upwards with a wrapped scalpel, the length of the incision is 1 cm. After opening, the assistant immediately tilts the head child forward and down to prevent the ingress of pus in the respiratory tract. H

The next and the next days after the dissection of the abscess, the wounds are diluted. Recuperation occurs within a few days, but if the body temperature does not decrease, the general condition of the child is unsatisfactory, the positive dynamics of the disease is not noticeable, then another abscess, pneumonia, pus penetration into adjacent tissues or into the mediastinum should be suspected. In the latter case, the forecast is critical.

Retropharyngeal adenophlegon of an adult is a rare phenomenon, as well as general infectious diseases (eg, flu), foreign pharyngeal bodies or its thermal or chemical burn, various ulcerous processes (from vulgar aphthous to specific ones), and pharynx traumas, along with the parathonsillar abscess. These complications in adults are difficult and often complicated by mediastinitis.

Secondary retropharyngeal adenophlegons as complications of purulent processes in neighboring anatomical formations is also a rare phenomenon, like the osteitis of the base of the skull, the anterior arch of the atlant, pharyngeal abscesses of the rhinogenic etiology.

Surgical treatment of older children and adults is performed by the method of opening an abscess with pre-application anesthesia with 5% cocaine solution or 3% solution of dicaine, or after infiltration anesthesia of the mucous membrane with 1% solution of novocaine. External access to the parapharyngeal abscess is used extremely rarely with extensive lateral phlegmon of the neck, when a wide drainage of the abscess cavity is necessary, followed by open wound management. The external method is used for cervical mediastinotomy when cervical mediastinitis is diagnosed.

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