Abscesses related to the

pharynx
Peritonsillar abscess (quinsy)
• Collection of pus in the peritonsillar space
• Lies between the capsule of tonsil and the superior
constrictor muscle.
• Possible complication of acute tonsillitis but can arise de
novo.
First, one of the tonsillar crypts, usually the crypta magna,
gets infected and sealed off. It forms an intratonsillar
abscess which then bursts through the tonsillar capsule to
set up peritonsillitis and then an abscess.
Culture of pus: Streptococcus pyogenes, S. aureus or
anaerobic organisms. Often mixed.
• If untreated it may lead to deep neck space
infection.
• Mostly adults.
• Usually unilateral

Clinical features are divided into:

• 1. General. They are due to septicemia and resemble
• any acute infection. They include fever (upto 104 °F),
• chills and rigors, general malaise, body aches,
headache, nausea and constipation.
• 2. Local
• (a) Severe pain in throat. Usually unilateral.
• (b) Odynophagia. It is so marked that the patient
cannot even swallow his own saliva which dribbles
• from the angle of his mouth. Patient is usually
dehydrated.
• (c) Muffled and thick speech, often called “hot potato
• voice.”
• (d) Foul breath due to sepsis in the oral cavity and
• poor hygiene.
• (e) Ipsilateral earache. This is referred pain via CN IX
• which supplies both the tonsil and the ear.
• (f) Trismus due to spasm of pterygoid muscles which
• are in close proximity to the superior constrictor.
EXAMINATION
1. The tonsil, pillars and soft palate are congested and
swollen. Tonsil itself may not appear enlarged as it gets
buried in the oedematous pillars
2. Uvula is swollen and oedematous pushed to the
opposite side.
3. Bulging of the soft palate and anterior pillar above the
tonsil.
4. Mucopus may be seen covering the tonsillar region.
5.Cervical lymphadenopathy, involves jugulodigastric
lymph nodes.
6. Torticollis. Patient keeps the neck tilted to the side
of abscess.
INVESTIGATION
• CT or MRI shows the abscess for extent
• Needle aspiration for culture

TREATMENT
• 1. Hospitalization.
• 2. Intravenous fluids
• 3. Antibiotics.
• 4. Analgesics
• 5. Oral hygiene should be maintained by hydrogen peroxide or saline mouth
washes.
• The above conservative measures may cure peritonsillitis. If a frank abscess
has formed, incision and drainage
will be required.
Incision and drainage of abscess.
Abscess is opened at the point of maximum bulge above the upper pole of tonsil or just lateral to the point of
junction of anterior pillar with a line drawn through
the base of uvula (Figure 52.5).
With the help of a guarded knife, a small stab incision is made and then a sinus forceps inserted to open the
abscess.
Putting sinus forceps the following day
may also be necessary to drain any re-
accumulation.
•Interval tonsillectomy. Tonsils are
removed 4–6 weeks
•Abscess or hot tonsillectomy. Abscess
tonsillectomy has the risk of rupture of
the abscess during anaesthesia and
excessive bleeding at the time of
operation.
COMPLICATIONS
Rare with modern therapy.
1. Parapharyngeal abscess
2. Oedema of larynx. Tracheostomy may be required.
3. Septicaemia. Other complications like endocarditis,
nephritis, brain abscess may occur.
4. Pneumonitis or lung abscess. Due to aspiration of pus,
if spontaneous rupture of abscess has taken place.
5. Jugular vein thrombosis.
6. Spontaneous haemorrhage from carotid artery or
jugular vein.
Retropharyngeal abscess
• The retropharyngeal space (RPS):
• Base of the skull to the bifurcation of trachea in mediastinum.
• Anterior to the prevertebral muscles
• Posterior to the pharynx and esophagus.
• It's bounded anteriorly by the buccopharyngeal fascia, laterally by the carotid sheath, and posteriorly by the
prevertebral fascia.
The RPS is divided by the alar fascia into two components–the “true” retropharyngeal space and the “danger
space.” The true RPS is located anterior to the danger space and extends from the base of the skull and
terminates at T1-T6 vertebrae (variable).
• The danger space courses more inferiorly than the true RPS, running into the posterior mediastinum until
the level of the diaphragm. This anatomical connection between the pharynx and the mediastinum is where
the danger space acquires its name as it serves as a potential channel for infection to spread between these
two sites.
Prevertebral space:
• It lies between the vertebral bodies posteriorly and the prevertebral fascia anteriorly.
• Abscess of this space produces a midline bulge in contrast to abscess of retropharyngeal space which causes
unilateral bulge
ACUTE RETROPHARYNGEAL ABSCESS
• Children below 3 years.
• It is the result of suppuration of retropharyngeal lymph nodes secondary to
infection in the adenoids, nasopharynx, posterior nasal sinuses or nasal cavity.
• In adults, it may result from penetrating injury of posterior pharyngeal wall or
cervical oesophagus. Rarely, pus from acute mastoiditis tracks along the
undersurface of petrous bone to present as retropharyngeal abscess.
Radiograph of soft tissue, lateral
view of the neck shows
widening of prevertebral shadow • CLINICAL FEATURES
and possibly even the
presence of gas • 1. Dysphagia and difficulty in breathing
are prominent symptoms as the
abscess obstructs
• 2. Stridor and croupy cough may be
present.
• 3. Torticollis. The neck becomes stiff
and the head is kept extended.
• 4. Bulge in posterior pharyngeal wall.
Usually seen on one side of the
midline.
TREATMENT
1. Incision and Drainage of Abscess. This is usually done without
anaesthesia as there is risk of rupture of abscess during intubation.
Child is kept supine with head low. Mouth is opened with a gag. A
vertical incision is given in the most fluctuant area of the abscess.
Suction should always be available to prevent aspiration of pus. If done
under GA, care should be taken that the abscess does not rupture
during intubation with aspiration of pus. The pharynx is always packed.
2. Systemic Antibiotics.
3. Tracheostomy.
CHRONIC RETROPHARYNGEAL ABSCESS
(PREVERTEBRAL ABSCESS)
It is tubercular in nature and is the result of (i) caries of cervical spine or (ii) tuberculous
infection of retropharyngeal lymph nodes secondary to tuberculosis of deep cervical
nodes.

CLINICAL FEATURES
Patient may complain of discomfort in throat. Dysphagia, though present, is not
marked.
Posterior pharyngeal wall shows a fluctuant swelling centrally or on one side of midline.
Neck may show tuberculous lymph nodes. In cases with caries of cervical spine, X-rays
are diagnostic
TREATMENT

1. Incision and drainage of abscess. It can be done through

a vertical incision along the anterior border of sternomastoid (for low
abscess) or along its posterior border (for high abscess).
2. Full course of antitubercular therapy should be given in
cases of tubercular abscess.
PARAPHARYNGEAL ABSCESS

APPLIED ANATOMY
Parapharyngeal space is pyramidal in shape with its base at the base of skull and
its apex at the hyoid bone.
RELATIONS (FIGURES 52.6, 52.7 AND 52.9)
• Medial. Buccopharyngeal fascia covering the constrictor muscles.
• Posterior. Prevertebral fascia covering prevertebral muscles and transverse
processes of cervical vertebrae.
• Lateral. Medial pterygoid muscle, mandible and deep surface of parotid gland.
Styloid process and the muscles attached to it divide the parapharyngeal space
into anterior and posterior compartments.
 CLINICAL FEATURES and diagnosis
Clinical features depend on the compartment involved.
• Anterior compartment infections produce a triad of symptoms: (i) prolapse of
tonsil and tonsillar fossa, (ii) trismus (due to spasm of medial pterygoid muscle)
and (iii) external swelling behind the angle of jaw. There is marked odynophagia
associated with it.
• Posterior compartment involvement produces (i) bulge of pharynx behind the
posterior pillar, (ii) paralysis of CN IX, X, XI, and XII and sympathetic chain, and (iii)
swelling of parotid region. There is minimal trismus or tonsillar prolapse.
• Fever, odynophagia, sore throat, torticollis (due to spasm of prevertebral
muscles) and signs of toxaemia.
DIAGNOSIS
• CT scan neck
• Magnetic resonance arteriography is useful if thrombosis of the internal jugular
vein or aneurysm of the internal carotid artery is suspected.
 TREATMENT
1. Systemic antibiotics. Antibiotics selected for treatment are amoxicillin–
clavulanic acid, imipenem or meropenem along with clindamycin or
metronidazole. Gentamicin is useful for Gram-negative bacteria. The
sensitivity of an antibiotic.
2. Drainage of abscess. This is usually done under general anaesthesia. If
the trismus is marked, preop tracheostomy becomes mandatory. Abscess is
drained by a horizontal incision, made 2–3 cm below the angle of mandible.
Blunt dissection along the inner surface of medial pterygoid muscle towards
styloid process is carried out and abscess evacuated. A drain is inserted.
Transoral drainage should never be done due to danger of injury to great
vessels which pass through this space
References
• https://www.aafp.org/afp/2017/0415/p501.html
• https://geekymedics.com/peritonsillar-abscess-quinsy/
• https://www.msdmanuals.com/professional/multimedia/image/
peritonsillar-abscess-with-uvular-deviation