BY

NI Ketut Ratih Nuryadi

Scientific Advisor

Dr Made Sudipta Sp.THT-KL

Introduction Parapharyngeal abcessis a dangerous disease,

that can be life-threatening causing mediastinitisand sepsis

Derived from infection of the surronding organs

Diagnosis anamnesis, physical examination, laboratory & radiologic examination (CT scan able to assess the extension of infection)

Introduction Rare case

Management of Parapharyngeal abcessincision-drainage, antibiotic administration according to culture and sensitivity test

One case of parapharyngeal abscess with extraoralincision approach was reported

Literature Deep neck space

Neck fascia consist of fibrous connective tissue that encloses the organs, muscles, nerves, blood vessels

divided into superficial and deep cervical fascia

The deep cervical fascia create space of neck related to other space infection one space can extend to other space

Figure 1. Sagital section of neck

Parapharyngeal Space

Parapharyngeal space also known as pharyngomaxilaris or pherypharyngeal space

Divided into two partanterior (prestyloid) and posterior (retrostyloid)

Paparella mention that parapharyngeal space as pyramid or cone shaped with four walls

Figure 2. Spasium parafaring

Parapharyngeal Space Anatomy

Medial m. superior pharyngeal constrictor Lateral m.pterygoid medial, ramus mandible,

medial surface of the parotid gland,m.sternocleidomastoid and posterior belly of digastric muscle

Anterior pterygo mandibular raphe Posterior fascia prevertebra

Etiology Infection of the pharynx, tonsils, adenoids, teeth,

parotid, or lymphatic glands

In many cases, parapharyngeal abscess was an extension of the adjacent neck abscess such asperitonsilar abscess, submandibular abscess, retropharyngeal abcess

Pathogenesis Parapharyngeal abscess occurs due to extension of

infection from the surrounding organs The inflammation process spread through 3 ways:1. Directly extention2. Suppuration process of the teeth, tonsils,

pharynx and mastoid3. Infection spread from peritonsillar space ,

retropharyx or submandibula

Microbiology Caused by aerob and anaerob bacteria

The most frequent pathogen in parapharyngealabscess are Streptococcus, Staphylococcus aureus, Haemophilus influenzae and sometimes caused Coliforms or Pseudomonas aeroginosa

Anaerobic bacteria Peptostreptokokus, Bakteriodes and Fusobakteria

Nicolai et al reported there were 62% of patients with polymicrobial cultures and 13% of patient with nobacterial growth on culture

Diagnosis Anamnesis

Physical Examination

Radiologic Examination

Laboratory Examination

Anamnesa

•Fever•Anorexia•Dysphagia•Trismus•Drooling•Headache

•Otalgia•Stifness of neck•Swelling and pain in infected area

•History of toothache andtooth extraction

•History of foreignbody puncture

Anterior parapharyngealabcess

Posterior parapharyngealabcess

• Trismus,

• Swelling and induration at the angle of mandible or at the lower end of the parotid gland

• Prolapsed of tonsil and tonsil fossa

• Swelling at the lateral pharyngeal wall of the posterior region

• Swelling at the parotid area

• There were no trismus dan prolapstonsil

Paparella

Physical examination

Laboratory

• Bacteria culture

• Antibiotic sensitivity test

Radiology examination

• Cervical AP/Lateral

• Thorax X ray

• CT scan

Management

Patient must be hospitalized

Antibiotic administration

Abcess incision and drainage

Elimination control of factors that can inhibit healing process like infection of teeth, comorbid disorders such as diabetes mellitus

Tonsilectomies for prevent a recurrence of parapharyngeal abcess

Abcess incision

Intraoral incision

Extraoralincision

Figure 3. Neck incision

Nicolai et al

• Parapharyngeal abcess usually drained through either a submandibular incision or an incision along the anterior border of the sternocleidomastoideus muscle

Antibiotic Antibiotic administration based on

Culture and sensitivity test

Emperical antibiotic

Penicillin G is a first choice

If allergic to penicillin, patient can give eritromycin, clindamycin or cephalosporin

Management Parapharyngeal Abscess

ComplicationMeningitis

Mediastinitis

Septicemia

Horners Sindrom

Cranial nerve IX-XII paralysis

Case report Female , 35 years old, admitted emergency

department Sanglah Hospital Denpasar on the 8th

December 2013 with referal from private hospital with parapharyngeal abcess

Chief complain of the patient were painfull during swallowing since six day before admission to the emergency department

Others complains were fever , swelling on the right neck, pus on throat, headache

She have always suffering from sore throat

But she has no sign of cough, flu, shorthness of breath

History of toothache , diabetes mellitus, hypertension, allergy of drug, history of oral surgery were denied.

History of tooth extraction 8 years ago

Before admision to the emergency department Sanglah hospital, patients went to private hospital and was admitted for 4 days

Medication given to the patient were baquinor, tricodazol, sanexon, heksadol

But complaints getting worsepatient can not eat and drink

Physical examinationPresent status :

Vital sign : T 110/70mmHg, N 76x/mnt

R 20x/mnt, temp 38ºC

ENT status:

Ear and nose within normal limit

Throat : swelling in the right lateral pharyngeal wall

with pus, tonsi T1/T1 hyperemi, uvula normal,

pharyngeal mucosa hyperemi

LI: Pus (+)

Neck: swelling behind the right angle mandible, size

5x5x4 cm, hyperemia, fluctuative, tenderness

Figure 4 swelling of the right lateral parapharyngeal wall and right neck swelling

Paracervical muscle spasm

Hearth and lung within normal limit

WBC 11,9 x 103/uL, other within normal limit

Ro cervical Ap/lateral

Thorax AP

Laboratory

Figure 5 thorax Ap, cervical Ap/Lateral

Diagnosis Right parapharyngeal abcess

Management Patient was hospitalized

Observation vital sign and sign s of airway obstruction

IVFD Nacl 0,9% and dextrosa 5% 1:1 20 gtt/ minute

Ceftriaxon injection 1 gram @ 12 hour

Metronidazol 500 mg injection @ 8 hour

Ketorolac 30 mg injection @ 8 hour

Trendelenberg position

9/12/13

• CT Scan

• Throat swab with pus culture and sensitivity test

11/12/13

• CT Scan result cystic mass with aerocelle projection at the soft tissue region right strenocleidomastoideus to the right paratracheabenign lession dd/ Abcess

• Incision and drainage with general anestesi was planned

12/12/14

• Internist consultation

• Anastesiology consultation

Figure 6 CT Scan

ceftriaxon 2x1 iv, metronidazol 3x500 mg iv, ketorolak 3x30 mg iv, metilprednisolon 2x62,5 mg iv, ranitidin 2x50 mg iv, Trendelenberg position

13/12/13

Incision drainage abcess with trancervicalapproach anterior sternocleidomastoideus

Figure 7 incision –drainage abcess

14/12/13

• The result of the culture from throat swab no growth

• puss of the drain was reduced

17/12/13

• No pus aff drain

• Culture result from trancervical incision no growth

19/12/13

• WBC 10,3 x 103/uL , others within normal limit

Day 8 post incision-drainage aff hecting, incision wound has a good condition, no swelling in the neck and no pain in swallowing

Patient can eat properly discharge from hospital

Three days later the patient control to the ENT clinic within good condition and no complain

Discussion

Literature case

Diagnosis:•Anamnesis•Physical examination

•Laboratory •Radiology

Diagnosis:•Anamnesis•Phyisicalexamination•Laboratory •Cervical AP/Lateral•CT scan

Literature Case

Anamnesa:Fever, anorexia, dysphagia, trismus, drooling, headache, otalgia, stifness of neck, swelling and pain in infection, history of toothache, and tooth extraction, history of foreign body punctured

Anamnesa:Painfull swallowing since sixth day ago, swelling on the right neck, pus in throat, headache

Literature Case

Etiology:Infection of the pharynx, tonsils, adenoids, teeth, parotid, or lymphatic glands, peritonsilarabscess, submandibularabscess, retrofaringabcess

Etiology:Reccurent infection from pharyx and tonsils

Literature Case

Physical examinationPosterior parapharyngealabcess swelling at the posterior palatoglossusplica, swelling at the lateral pharyngeal wall of the posterior region, swelling at the parotid area, there was no trismusand prolaps tonsil

Physical examinationPosterior parapharyngealabcess swelling in the right lateral pharyngeal wall with pus, swelling behind the right angle mandible, no trismus and prolaps tonsil

Laboratory leukositosis

Radiology CT scan benign lessiondd/ abcess

Parapharyngeal abcess are usually drained through either a submandibular incision or an incision along the anterior border of the sternocleidomastoideus muscle

Incision drainage abcess with trancervicalapproach anterior sternocleidomastoideusmuscle

Literature

Case

Management

Nicolai et al there are 62% of patients with polymicrobialcultures and 13% no found

bacterial growth on culture results

Culture result no growthemperical antibiotic

Literature

Case

Management

Conclusion One case with parapharyngeal abcess in adult

women

Diagnosis based on anamnesis, physical examination, laboratory, radiology (CT scan)

Management adequate incision drainage, antibiotic according to culture and sensitivity tesor empirical antibiotic

Cause of the infection need further investigation to prevent recurrence