Lateral pharyngeal adenopharyngeal adenophlegmon.

Lateral parapharyngeal abscess, unlike retropharyngeal abscess, occurs equally often at all ages and develops lateral to the lateral wall of the pharynx. There are two forms of this complication of tonsillitis and paratonsillar abscess:

1. lateropharyngeal adenophlegmon, arising in the carotid-jugular lymph node chain, manifested by cervical symptoms with a favorable outcome, and
2. phlegmon of the lateral tissue of the neck, arising between the lateral wall of the pharynx and the connective tissue "plate" separating the said tissue from the large vessels of the neck. The two forms of purulent inflammation of the parapharyngeal space indicated differ both in their clinical course and in the methods of treating patients.

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Causes lateropharyngeal adenophlegmona.

Lateropharyngeal adenophlegmon most often occurs as a complication of severe septic tonsillitis or infectious diseases such as scarlet fever, diphtheria, erysipelas of the pharynx, in which streptococcus plays a leading role in the inflammatory process.

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Symptoms lateropharyngeal adenophlegmona.

Symptoms of lateropharyngeal adenophlegmon manifest themselves primarily in the neck, and then in the lateropharyngeal space. The first phase of the disease is characterized by enlargement and soreness of the lymph nodes located in the area of the angle of the lower jaw, then the inflammatory process spreads to the lymph nodes located along the sternocleidomastoid muscle. The second phase consists of the occurrence of peritonsillar infiltration, causing severe pain, difficulty and soreness when opening the mouth, an increase in body temperature to 39-40 ° C. Irritation of the sensory nerves of the cervical plexus and spinal nerves leads to a forced position of the head (slight turn to the painful side and back) and pain when moving the cervical spine.

Pharyngoscopy reveals a swelling on the lateral wall of the pharynx, located behind the posterior palatine arch. Palpation of this swelling gives the impression of a consolidated connection with the lymph nodes of the lateral surface of the neck. In diphtheria or scarlet fever, the process may be bilateral.

In the phase of lymph node abscess formation, the general condition of the patient sharply worsens, pharyngeal infiltration and edema descend in the direction of the laryngopharynx, there is a sharp violation of swallowing, breathing and contracture of the temporomandibular joint. Purulent inflammation of the deep lymph nodes of the neck is manifested by hyperemia of the skin and painful palpation, infiltration and edema of tissues in the area of the anterior edge of the sternocleidomastoid muscle. It should be noted that, in comparison with massive perifocal tissue edema, the abscess itself is small in size, so its detection during surgical intervention is very difficult.

Severe forms of lateropharyngeal adenophlegmon occur with streptococcal and anaerobic infections, mild forms - with pneumococcal and staphylococcal common tonsillitis and peritonsillar abscesses.

Complications of lateropharyngeal adenophlegmon. An unopened abscess in lateropharyngeal adenophlegmon in most cases spreads in the direction of the outer edge of the sternocleidomastoid muscle with a breakthrough to the outside and the formation of a cutaneous fistula, which can also occur in the area of the posterior edge of this muscle. Spontaneous opening of the abscess can also occur in the pharynx, behind the posterior palatine arch and the penetration of pus into the larynx and lungs. In this case, laryngospasm and severe purulent complications from the lungs are possible.

Prolonged course of lateropharyngeal adenophlegmon can lead to erosive bleeding from the common or external carotid artery with a fatal outcome or to thrombophlebitis of the jugular vein with subsequent pyemia and septicemia.

Often, with lateropharyngeal adenophlegmon, the cranial nerves passing in close proximity to the affected lymph nodes (glossopharyngeal, vagus, accessory, hypoglossal) are involved in the inflammatory process, with their irritation initially revealed, and then inhibition and paralysis, which is manifested by a number of syndromes (Avellis syndrome - with lateropharyngeal adenophlegmon, it occurs with damage to the glossopharyngeal and vagus nerves on the side of the lesion and is manifested by paralysis of the palatine arch and vocal folds; with damage to the artery of the lateral fossa, a branch of the vertebral artery, it is manifested by hemiplegia, loss of pain and temperature sensitivity on the opposite side). Irritation of these nerves leads to spastic contractions of the muscles innervated by them with suffocation phenomena, inhibition and paralysis - to the syndromes described in the footnotes. In the last stage of development of lateropharyngeal adenophlegmon, cardiac arrest is possible.

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Diagnostics lateropharyngeal adenophlegmona.

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

Differential diagnosis

Lateropharyngeal adenophlegmon of tonsillar genesis should be differentiated from angle-mandibular osteophlegmon of odontogenic origin, which manifests itself as contracture of the corresponding temporomandibular joint, while adenophlegmon initially manifests itself as a forced position of the head and only with further development of the inflammatory process - the so-called trismus. Osteophlegmon of odontogenic origin develops in the area of the angle of the lower jaw and manifests itself as a dense infiltrate, forming a single whole with the latter without any pharyngeal phenomena, while lateropharyngeal adenophlegmon initially manifests itself as swelling in the area of the posterior palatine arch.

Lateropharyngeal adenophlegmon is also differentiated from Bezold's mastoiditis, in which the infiltrate occupies the apex of the mastoid process and spreads along the inner surface of the sternocleidomastoid muscle. The appearance of pus in the external auditory canal when pressing on the area of swelling on the neck indicates the presence of an otogenic complication. One should not forget about inflammation of the parotid and submandibular salivary glands (sialoadenitis), which has its own pathognomonic signs (cessation of salivation, the appearance of pus from the salivary ducts, pain when palpating them).

Treatment lateropharyngeal adenophlegmona.

Treatment of lateropharyngeal adenophlegmon in the stage of infiltrative inflammation is physiotherapeutic and medicinal (see treatment of paratonsillitis), in case of formation of an abscess or phlegmon - exclusively surgical from external access by incision of the skin at the site of its greatest protrusion behind the sternocleidomastoid muscle. Further search and opening of the abscess is carried out only by blunt means using clamps of Mikulich, Kocher, Pean and others or using a teardrop-shaped probe.

Subangular-mandibular phlegmons are opened by an incision of the skin and superficial aponeurosis, made at the anterior edge of the sternocleidomastoid muscle, which is moved back and outward, then bluntly, stratifying the tissues with movements of the instrument from top to bottom, they search for the abscess and empty it with the help of a suction device located in the wound during the search (prevention of the spread of pus through the tissues). Posterior adenophlegmon is opened by an incision along the posterior edge of the sternocleidomastoid muscle.