Phlegmonous sore throat

Phlegmonous tonsillitis, or acute paratonsillitis (according to B.S. Preobrazhensky), is an acute purulent inflammation of the peritonsillar tissue, occurring primarily or secondarily, as a complication 1-3 days after follicular or lacunar tonsillitis.

In phlegmonous tonsillitis, the process is in the overwhelming majority of cases one-sided, most often it occurs in people aged 15-40 years, less often - at the age of under 15 years and very rarely - at the age of under 6 years.

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Cause of phlegmonous tonsillitis

The etiologic factor is pyogenic microorganisms, most often streptococci, which penetrate into the paratonsillar tissue and other extratonsillar tissues from the deep lacunae of the palatine tonsils, which are in a state of inflammation due to damage to the tonsillar pseudocapsule. Phlegmonous tonsillitis can also occur as a result of damage to the peritonsillar tissue in diphtheritic and scarlet fever tonsillitis.

There are three forms of paratonsillitis:

• edematous;
• infiltrative;
• abscessing.

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

Most often, phlegmonous tonsillitis is localized in the area of the upper pole of the tonsil, less often - in the retrotonsilar space or behind the tonsil in the area of the posterior arch. Bilateral phlegmonous tonsillitis, abscess in the area of the supratinsilar fossa or inside the parenchyma of the tonsil are also distinguished.

Symptoms of phlegmonous tonsillitis

Sharp pains in the throat on one side are noted, forcing the patient to refuse to take even liquid food. The voice becomes nasal, speech is slurred, the patient puts the head in a forced position with a forward tilt and towards the abscess, due to paresis of the soft palate, liquid food flows out of the nose when trying to swallow it. Contracture of the temporomandibular joint on the side of the abscess occurs, due to which the patient can open his mouth only a few millimeters. An unpleasant odor with an admixture of acetone is felt from the mouth, profuse salivation, swallowing saliva is accompanied by forced auxiliary movements in the cervical spine. Body temperature rises to 40 ° C, general condition is moderate, severe headache, severe weakness, fatigue, pain in the joints, behind the sternum, regional lymph nodes are sharply enlarged and painful on palpation.

On the 5th-7th day (approximately on the 12th day from the onset of angina, most often 2-4 days after the disappearance of all its symptoms), a distinct protrusion of the soft palate is detected, most often above the upper pole of the tonsil. In this case, examination of the pharynx becomes increasingly difficult due to contracture of the temporomandibular joint (swelling of the pterygomandibular ligament of the muscle of the same name). Pharyngoscopy reveals severe hyperemia and swelling of the soft palate. The tonsil is displaced toward the midline and downwards. In the area of the forming abscess, a sharply painful infiltrate is determined, which protrudes toward the oropharynx. With a mature abscess, at the top of this infiltrate, the mucous membrane and the wall of the abscess become thinner and pus shines through it in the form of a white-yellow spot. If an abscess is opened during this period, up to 30 ml of thick, foul-smelling, green pus is released from the cavity.

After spontaneous opening of the abscess, a fistula is formed, the patient's condition quickly normalizes, becomes stable, the fistula closes after cicatricial obliteration of the abscess cavity, and recovery occurs. With surgical opening of the abscess, the patient's condition also improves, but the next day, due to the adhesion of the edges of the incision and the accumulation of pus in the abscess cavity, the body temperature rises again, the pain in the throat intensifies again, and the general condition of the patient worsens again. Separation of the edges of the incision again leads to the disappearance of pain, free opening of the mouth and an improvement in the general condition.

The outcome of a peritonsillar abscess is determined by many factors, primarily its localization:

1. spontaneous opening through the thinned capsule of the abscess into the oral cavity, supratindalar fossa or, in rare cases, into the parenchyma of the tonsil; in this case, acute parenchymatous tonsillitis occurs, which is phlegmonous in nature with melting of the tonsil tissue and breakthrough of pus into the oral cavity;
2. penetration of pus through the lateral wall of the pharynx into the parapharyngeal space with the emergence of another nosological form - lateral phlegmon of the neck, which is very dangerous due to its secondary complications (penetration of infection into the muscular perifascial spaces, the ascent of infection to the base of the skull or its descent into the mediastinum;
3. general sepsis due to the spread of infected thrombi from the small tonsillar veins in the direction of the venous internal pterygopalatine plexus, then along the posterior facial vein to the common facial vein and to the internal jugular vein.

Cases of intracranial complications (meningitis, thrombosis of the superior longitudinal sinus, brain abscess) are described in peritonsillar abscesses, which arose as a result of the spread of a thrombus from the internal pterygopalatine venous plexus not downwards, i.e. not in the direction of the posterior facial vein, but upwards - to the orbital veins and further to the longitudinal sinus.

Complications of phlegmonous tonsillitis

A serious complication of peritonsillar abscess is thrombophlebitis of the cavernous sinus, the penetration of infection into which is carried out through the connections of the tonsillar veins with the said sinus through the pterygoid venous plexus, the veins passing into the cranial cavity through the oval and round openings, or retrogradely through the internal jugular vein and the inferior petrosal venous sinus.

One of the most dangerous complications of peritonsillar abscess and lateral phlegmon of the neck is arrosive bleeding (according to A.V. Belyaeva - in 0.8% of cases), which occurs as a result of the destruction of the vessels feeding the palatine tonsils, or larger blood vessels passing in the parapharyngeal space. Another equally dangerous complication is peripharyngeal abscesses.

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Treatment of phlegmonous tonsillitis and peritonsillar abscess

Treatment of peritonsillar abscess is divided into non-surgical, semi-surgical and surgical. Non-surgical treatment includes all the methods and measures described above in relation to the treatment of tonsillitis, 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, so many authors, on the contrary, offer various methods that accelerate the maturation of the abscess and bring it to the purulent stage, at which it is opened. A number of authors suggest performing a preventive "opening" of the infiltrate even before the stage of pus formation in order to reduce the tension of inflamed and painful tissues and accelerate the maturation of the abscess.

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

Puncture of peritonsillar abscess

After application anesthesia of the mucous membrane over the infiltrate by 2-fold lubrication with a 5% cocaine solution, a long and thick needle on a 10 ml syringe is injected at a point located slightly upward and inward from the last lower molar. The needle is advanced slowly at a slight angle from the bottom up and inward and to a depth of no more than 2 cm. During the advancement of the needle, attempts are made to aspirate the pus. When the needle enters the abscess cavity, a sensation of falling occurs. If it is not possible to obtain the contents of the abscess, 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 uvula with the last lower molar. If no pus is obtained, then the abscess is not opened and (against the background of non-surgical treatment) a wait-and-see attitude is adopted, since the puncture itself either promotes the reverse development of the inflammatory process or accelerates the maturation of the abscess with its subsequent spontaneous rupture.

Opening of peritonsillar abscess consists of blunt opening of the abscess through the supratinsilar fossa using nasal forceps, curved clamp or pharyngeal forceps: application anesthesia with 5-10% cocaine chloride solution or Bonin's mixture (menthol, phenol, cocaine 1-2 ml each), or aerosol anesthetic (3-5 sec with a 1 min break - 3 times in total). Anesthesia is performed in the area of infiltrated arches and the surface of the tonsil and infiltrate. Premedication may be used (diphenhydramine, atroin, sedalgin). Infiltration anesthesia of the abscess area with novocaine causes sharp pain, exceeding in intensity the pain that occurs during the opening itself, and does not produce the desired effect. However, the introduction of 2 ml of ultracaine or 2% novocaine solution into the retrotonsillar space, or infiltration of the soft palate and the posterior pharyngeal wall with 1% novocaine solution outside the zone of inflammatory infiltrate give positive results - they reduce the severity of pain, and most importantly, reduce the severity of the contracture of the temporomandibular joint and facilitate a wider opening of the mouth. If "trismus" persists, then you can try to reduce its severity by lubricating the posterior end of the middle nasal concha with a 5% cocaine solution or Bonin's mixture, which allows you to achieve a repercussive anesthetic effect on the pterygopalatine ganglion, which is directly related to the masticatory muscles of the corresponding side.

Blunt opening of the abscess is performed as follows. After achieving anesthesia, a closed nasal forceps is inserted into the supratindalar fossa with some effort, overcoming tissue resistance, to a depth of 1-1.5 cm. After this, the branches of the forceps are spread apart and 2-3 movements are made upward, backward and downward, trying to separate the anterior arch from the tonsil. This manipulation creates conditions for emptying the abscess cavity of pus, which immediately flows into the oral cavity. It is necessary to ensure that purulent masses are not swallowed or enter the respiratory tract. To do this, at the moment of pus discharge, the patient's head is tilted forward and downward.

A number of authors recommend performing blunt dissection not only after the abscess has formed, but also in the first days of infiltrate formation. This method is justified by numerous observations, which indicate that after such dissection the process reverses itself and an abscess does not form. Another positive result of infiltrate drainage is rapid relief of pain, relief when opening the mouth and improvement of the patient's general condition. This is explained by the fact that as a result of infiltrate drainage, bloody fluid containing a large number of active microorganisms and their waste products (biotoxins) is released from it, which sharply reduces the intoxication syndrome.

Immediately after opening the peritonsillar abscess by blunt means, the patient is offered rinses with various antiseptic solutions or herbal decoctions (chamomile, sage, St. John's wort, mint). The next day, the manipulation performed the day before is repeated (without preliminary anesthesia) by inserting a forceps into the previously made hole and opening its branches in the abscess cavity.

Surgical treatment of peritonsillar abscess is performed in a sitting position, with an assistant holding the patient's head in place from behind. A sharp scalpel is used, the blade of which is wrapped in cotton wool or adhesive tape so that a 1-1.5 cm long tip remains free (to prevent deeper penetration of the instrument). The scalpel is injected into the site of the greatest protrusion or into a point corresponding to the middle of a line drawn from the base of the uvula to the last lower molar. The incision is extended downwards along the anterior palatine arch for a distance of 2-2.5 cm. Then a blunt instrument (nasal forceps or pharyngeal arcuate forceps) is inserted into the incision, penetrated deep into the abscess cavity to the place from which the pus was obtained during the puncture, the branches of the instrument are spread apart with a certain amount of force, and if the operation is successful, thick, creamy, foul-smelling pus mixed with blood immediately appears from the incision. This stage of the operation is extremely painful, despite anesthesia, but after 2-3 minutes the patient experiences significant relief, spontaneous pain disappears, the mouth begins to open almost completely, and after 30-40 minutes the body temperature drops to subfebrile values, and after 2-3 hours it returns to normal.

Usually during the following night and by the morning of the following day, pain and difficulty opening the mouth reappear. These phenomena are caused by the adhesion of the edges of the wound and new accumulation of pus, so the edges of the incision are again spread apart by introducing forceps into the abscess cavity. It is advisable to repeat this procedure at 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 given a sulfanilamide drug or an antibiotic for oral (intramuscular) use for 3-4 days, or the treatment started is continued for the same period. Full recovery usually occurs by the 10th day after opening, but the patient, if the postoperative period is favorable, can be discharged from the hospital 3 days after the operation.

Retrotonsillar abscesses usually open on their own, or they are also opened using the method described above. In the case of an abscess of the anterior or posterior arch, an incision is made along it, the edges of the incision are moved apart with an instrument with thinner branches, the abscess cavity is penetrated and emptied in the usual way.

If, at the height of a peritonsillar abscess, there is relief in 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 swelling under the angle of the lower jaw, then this indicates a breakthrough of pus into the peripharyngeal space.

Any opening of a peritonsillar abscess should be considered a palliative, symptomatic treatment, since it does not lead to the elimination of the cause of the disease - the infected tonsil and surrounding tissues, therefore, each patient who has ever suffered a peritonsillar abscess should have their tonsils removed. However, removal of the tonsil after a peritonsillar abscess in the "cold" period is associated with great technical difficulties associated with the presence of dense scars, sometimes saturated with calcium salts and not amenable to cutting with a tonsillotomy loop. Therefore, in many clinics of the USSR, since 1934, removal of the palatine tonsils in the "warm" or even "hot" period of the abscess (abscess-tonsillectomy) has been practiced.

Surgery on the side of the abscess, if the operation is performed under local anesthesia, is characterized by significant pain, however, in the presence of pus in the peritonsillar space, it facilitates the separation of the tonsil, since the suppurative process itself, when spreading pus around the tonsil capsule, partially "does" this work. Surgery should be started on the diseased side. After removing the tonsil and revising the abscess cavity, it is necessary to carefully remove the remaining pus, rinse the oral cavity with a solution of cooled furacilin, treat the niche of the palatine tonsils and the abscess cavity with a 70% solution of ethyl alcohol and only then proceed to surgery on the opposite side. Some authors recommend performing abscess-tonsillectomy only on the "causal" tonsil.

According to B.S. Preobrazhensky, abscess-toisillectomy is indicated:

1. for recurrent tonsillitis and abscesses;
2. in case of protracted peritonsillar abscess;
3. in case of emerging or developed septicemia;
4. when, after surgical or spontaneous opening of an abscess, bleeding from the peritonsillar region is observed.

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