Parapharyngitis

Parapharyngitis (parapharyngeal phlegmon, deep phlegmon of the neck) is an inflammatory process in the tissue of the peripharyngeal space.

ICD-10 code

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

Epidemiology of parapharyngitis

Acute parapharyngitis is observed relatively rarely and occurs as a complication of peritonsillar abscess and odontogenic diseases.

Causes of parapharyngitis

The etiology of parapharyngitis is the same as that of paratonsillitis.

Pathogenesis of parapharyngitis

The spread of infection to the tissue of the peripharyngeal space is possible with tonsillitis, especially complicated by external (lateral) paratonsillitis, with traumatic damage to the mucous membrane of the pharynx; the odontogenic nature of parapharyngitis is possible; finally, pus can spread from the mastoid process through the mastoid notch and the pharyngeal-maxillary space. Most often, a parapharyngeal abscess develops with a deep external paratonsillar abscess, since this form has the least favorable conditions for spontaneous breakthrough of pus into the pharyngeal cavity.

Penetration of infection from the tonsil into the peripharyngeal space can occur through the lymphatic pathways when the lymph nodes of the peripharyngeal space become suppurated; by hematogenous means when thrombosis of the veins of the palatine tonsils spreads to larger veins with subsequent purulent melting of the thrombus and involvement of the tissues of the peripharyngeal space in the process; finally, when the inflammatory process moves from the tonsils or when pus breaks through directly into the peripharyngeal space.

Symptoms of parapharyngitis

If parapharyngitis develops as a complication of a long-term unresolved peritonsillar abscess, it is manifested by a deterioration in the patient's general condition, a further increase in temperature, and an increase in pain in the throat, which intensifies when swallowing. Trismus of the masticatory muscles becomes more pronounced, a painful swelling appears in the area of the angle of the lower jaw and behind it. Intoxication with parapharyngitis is usually expressed more intensely than with paratonsillitis; pain when swallowing is sometimes accompanied by irradiation of pain to the teeth due to damage to the lower alveolar ridge, and pain in the ear appears. A forced position of the head with a tilt to the painful side may be observed, head movements are sharply painful.

Screening

Patients with complaints of sore throat, difficulty swallowing, difficulty opening the mouth, as well as submandibular lymphadenitis, increased body temperature should be referred for consultation to an otolaryngologist.

Diagnosis of parapharyngitis

During examination, the flattening of the submandibular region and the projection of the angle of the lower jaw are determined first, and subsequently an enlarged, painful infiltrate may be detected here. Sometimes, diffuse infiltration of the submandibular region and the lateral surface of the neck up to the collarbone is noted, with swelling spreading to the parotid region and the chin area.

Mesopharyngoscopy reveals a characteristic protrusion of the lateral wall of the pharynx, sometimes in the area of the posterior arch.

A parapharyngeal abscess that is not opened in time can lead to the development of even more severe complications - mediastinitis, purulent parotitis."

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Laboratory diagnostics of parapharyngitis

Leukocytosis (up to 20*10 ⁹ /l and higher), a shift in the leukocyte formula to the left, and an increase in ESR are determined in the blood.

Instrumental examinations: ultrasound, CT, MRI. When X-raying the neck, the lateral projection X-ray often reveals an anterior displacement of the trachea, especially if the infection has spread from the hypopharyngeal region. Sometimes gas bubbles are detected in soft tissues.

Differential diagnosis of parapharyngitis

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

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Indications for consultation with other specialists

• Surgeon - if there is a suspicion of mediastinitis.
• Infectious disease specialist - to conduct differential diagnostics with diphtheria.
• Maxillofacial surgeon - if there is an odontogenic cause for the development of parapharyngitis.
• Oncologist - if there is a suspicion of a malignant neoplasm of the pharynx.
• Endocrinologist - in case of a combination of purulent disease with diabetes mellitus or other metabolic disorders.

Treatment of parapharyngitis

The goals of treating parapharyngitis are to open and drain the purulent process in the peripharyngeal space and prevent complications; treatment of the disease that caused the development of parapharyngitis is carried out.

Indications for hospitalization

Hospitalization of the patient is mandatory.

Non-drug treatment of parapharyngitis

At the stage of resolution of the process and subsidence of inflammatory phenomena, UHF therapy can be prescribed.

Drug treatment of parapharyngitis

Prescribing high doses of antibiotics (second- and third-generation cephalosporins, fluoroquinolones, macrolides), and after receiving microbiological test data - antibiotics taking into account the sensitivity of the microflora. In addition to this, detoxification therapy and correction of water-electrolyte disorders are carried out.

Surgical treatment of parapharyngitis

If the process has developed against the background of paratonsillitis, removal of the "causative" palatine tonsil is indicated. In cases where conservative therapy does not stop the development of parapharyngitis and parapharyngeal phlegmon is formed, it is necessary to urgently open the parapharyngeal space through the lateral wall of the pharynx (during tonsillectomy) or by an external approach.

Opening of a parapharyngeal abscess or infiltrate through the oropharynx is performed immediately after tonsillectomy. Often, after removal of the tonsil, it is possible to detect necrotic tissue and a fistula leading to the peripharyngeal space. In this case, the fistula is widened, ensuring the outflow of pus. If the fistula is not detected, then at the site of the greatest bulge or in the middle part of the lateral wall of the tonsillar niche, the pharyngeal fascia and muscle fibers of the upper or middle constrictor of the pharynx are dissected bluntly, most often using a Hartmann instrument, and the peripharyngeal space is penetrated. It is necessary to keep in mind the possibility of injury to large vessels and not to perform an opening with sharp instruments.

During external dissection of the parapharyngitis, which is best done under general anesthesia, the incision is made along the anterior edge of the sternocleidomastoid muscle, along its upper third, starting at the level of the angle of the lower jaw. The skin and superficial fascia of the neck are dissected. Slightly below the angle of the lower jaw, the area is found where the tendon of the digastric muscle pierces the fibers of the stylohyoid muscle. Above these fibers, a blunt instrument, or better yet, the index finger, is passed in the direction of an imaginary line running from the angle of the lower jaw to the tip of the nose. The tissues of the peripharyngeal space are separated, examining the area corresponding to the position of the palatine tonsil, the area of the styloid process and the stylohyoid muscle. Depending on the nature of the inflammation, serous, purulent, putrefactive or necrotic changes are found in the peripharyngeal space. Sometimes putrefactive inflammation occurs with the formation of gas and an unpleasant odor. Sometimes the abscess is bordered by granulation tissue.

The abscess opening should be wide (6-8 cm, sometimes more), and if it is large, the opening is made from different sides (counter-apertures are formed) to ensure reliable drainage. After opening and emptying the abscess, its cavity is washed with an antibiotic solution and drained with a rubber glove. 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. Parenteral detoxification therapy, vitamins, etc. are prescribed.

Further management

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

Prevention of parapharyngitis

Parapharyngitis can be prevented if acute inflammatory diseases of the pharynx and odontogenic diseases are treated in a timely manner and adequately for the patient’s condition.

Forecast

With 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 periods of disability after treatment are 14-18 days.

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