Retropharyngeal adenophlegmon: causes, symptoms, diagnosis, treatment

A distinction is made between retropharyngeal abscesses and adenophlegmons, lateral abscesses and adenophlegmons of the peripharyngeal space, intrapharyngeal (visceral) phlegmons, phlegmonous lingual periamygdalitis, Ludwig's angina, abscess of the epiglottis, abscess of the lateral pharyngeal folds, thyroid gland damage, and cervical mediastinitis.

According to A.Kh. Minkovsky (1950), the following mechanisms are present in the pathogenesis of the above complications of phlegmonous angina:

1. as a result of spontaneous rupture of pus from a peritonsillar abscess directly into the peripharyngeal space;
2. in case of injury to the lateral wall of the pharynx during opening of an abscess;
3. as a complication of abscess tonsillectomy;
4. in the event of thrombosis of the tonsil veins and metastasis of purulent emboli into the peripharyngeal space;
5. in case of suppuration of the lymph nodes of the peripharyngeal space.

An important factor that plays a significant role in the occurrence of phlegmon of the parapharyngeal space is the connective tissue and loose cellulose filling it, which are a favorable environment for the development of pathogenic microorganisms. By means of the styloglossus muscle, which goes obliquely downward and inward from the cervical process to the pharynx, the parapharyngeal space can be conditionally divided into anterior and posterior sections. Most often, a breakthrough of pus from a paratonsillar abscess occurs in the anterior section. Large vessels and nerves pass along the parapharyngeal space, through the sheaths of which the infection can spread both in the cephalic and thoracic directions, causing purulent complications (abscesses) of the corresponding localization. These complications are also facilitated by the fact that the parapharyngeal space is connected with the retropharyngeal space formed by the gap between the pharyngeal and prevertebral fascia, the penetration of infection into which causes deep retropharyngeal abscesses spreading along the spine. Inferiorly, the parapharyngeal space passes into the median fissure of the neck, located under the body of the PC between the middle and superficial fascia of the neck on one side and the deep fascia of the neck on the other. The presence of this fissure is the cause of the spread of infection into the mediastinum, since it (the fissure) at the superior notch of the sternum passes into the anterior mediastinum. Between the internal and external pterygoid muscles is the pterygoid venous plexus, receiving branches from the palatine tonsils and parapharyngeal formations, communicating with the inferior ophthalmic vein and, through the middle cerebral vein, with the dura mater. Thrombophlebitis of the above veins of a tonsillogenic nature can lead to orbital and intracranial purulent complications.

A predisposing factor for retropharyngeal adenophlegmon is the presence of retropharyngeal lymph nodes, closely associated with the epipharyngeal lymph nodes and lymph nodes located on the posterior surface of the soft palate, reacting primarily to paratonsillar purulent processes. These retropharyngeal lymph nodes, located on both sides of the medial plane of the retropharyngeal space, are reduced by the age of 3-4 years, but before that they play an important pathogenetic role in the occurrence of retropharyngeal phlegmon in early childhood. The same lymph nodes are present in the loose connective tissue and cellulose of the retropharyngeal space, which stratify it, located in layers between the mucous membrane, connective tissue, muscular layer of pharyngeal constrictors, prevertebral fascia and muscles and directly in front of the bodies of the cervical vertebrae. Thus, retropharyngeal adenophlegmon can be defined as a purulent inflammation of the retropharyngeal lymph nodes and loose connective tissue of the retropharyngeal space, limited on the lateral side by the vascular-nerve bundle and developing in the pharyngeal-mandibular space of the corresponding side. Sometimes pus penetrates into the perivascular tissues, resulting in the formation of a lateral pharyngeal abscess. Inferiorly, the retropharyngeal space communicates with the posterior mediastinum.

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

Depending on the age of the patient, retropharyngeal adenophlegmon occurs in two forms: retropharyngeal adenophlegmon of early childhood and retropharyngeal adenophlegmon of adults.

Retropharyngeal adenophlegmon of early childhood occurs in the form of abscess formation of lymph nodes, most often in infants aged 2-7 months. It can be caused by acute rhinitis or tonsillitis of adenoviral etiology, but most often it is provoked by acute adenoiditis.

Symptoms and clinical course of retropharyngeal adenophlegmon. In addition to elevated body temperature and runny nose, the child has problems sucking and swallowing, and problems with nasal or laryngeal swallowing. Because of these problems, the child "does not take the breast" or bottle, since he cannot swallow the milk that flows out of the mouth or nose. The child's sleep is restless and is accompanied by screaming, snoring, and wheezing. The abscess can be localized in the nasopharynx, and then problems with nasal breathing and closed nasal speech come to the fore. When the abscess is localized in the lower parts of the pharynx, attacks of suffocation occur due to swelling of the laryngopharynx, compression of the larynx, and problems with swallowing due to compression of the entrance to the esophagus.

Pharyngoscopy reveals a fluctuating swelling on the back wall of the pharynx, covered with hyperemic mucous membrane, located somewhat laterally. Nasopharyngeal abscess, determined in children by palpation, is also located somewhat laterally, since the retropharyngeal space, located at the level of the nasopharynx and pharynx, is divided into two halves by a medially located fibrous septum.

The abscess evolves over 8-10 days and can open up on its own, with pus flowing into the larynx and trachea, getting into the lower respiratory tract. The child then dies from suffocation, which occurs as a result of laryngeal spasm and filling of small bronchi with purulent masses.

The diagnosis is established based on the clinical picture and the result of a puncture or opening of the abscess. If a retropharyngeal abscess occurs during diphtheria of the 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 adenophlegmia should be differentiated from suppuration of a lipoma of the posterior pharyngeal wall.

Treatment of retropharyngeal adenophlegmon is immediate surgical, by opening the abscess without any anesthesia. In case of massive abscesses and respiratory failure, the child, wrapped in a sheet, is placed in the Rose position (lying on his back with his shoulder blades on the edge of the table with his head hanging back), and is held by an assistant. The mouth is opened with a mouth gag, and the abscess is opened at the site of the greatest protrusion by blunt means with the appropriate instrument with rapid spreading of its branches. Immediately after opening the abscess, on the surgeon's command, the assistant instantly turns the child face down and feet up so that the pus flows into the oral cavity. If breathing stops, which is rare, rhythmic twitching of the tongue is performed or artificial ventilation is performed, the trachea is intubated. For this, the room in which the operation is performed must be equipped and supplied with appropriate resuscitation equipment.

For small abscesses, the child, wrapped in a sheet, is seated on the assistant's thighs, as in adenotomy, with the head tilted forward, the tongue is pressed downwards with a spatula and the abscess is opened with a quick incision from the bottom up with a wrapped scalpel, the incision length is 1 cm. After opening, the assistant immediately tilts the child's head forward and downwards to prevent pus from entering the respiratory tract.

On the following and subsequent days after the abscess is opened, the edges of the wound are spread apart. Recovery occurs within a few days, but if the body temperature does not decrease, the child's general condition is unsatisfactory, and there is no noticeable positive dynamics of the disease, then one should suspect the presence of another abscess, pneumonia, or penetration of pus into adjacent tissues or into the mediastinum. In the latter case, the prognosis is critical.

Retropharyngeal adenophlegmon in adults is a rare phenomenon, its cause, along with paratonsillar abscess, can be general infectious diseases (for example, flu), foreign bodies in the pharynx or its thermal or chemical burn, various ulcerative processes (from vulgar aphthous to specific), pharyngeal trauma. These complications in adults are severe and are often complicated by mediastinitis.

Secondary retropharyngeal adenophlegmons as complications of purulent processes in adjacent anatomical structures are also a rare phenomenon, similar to osteitis of the base of the skull, anterior arch of the atlas, and pharyngeal abscesses of rhinogenic etiology.

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

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