Pharynx - Oropharynx Flashcards
Acute Tonsillitis
Acute inflammation of the palatine tonsils.
Aetiology :
* Predisposing factors :
- Bad hygiene.
- Low resistance.
- Rhinitis and sinusitis.
- Organisms :
- Mainly by B-haemolytic streptococcus.
- Less commonly staph. aureus and pneumococcus.
- Usually these organisms are secondary invaders following a virus infection.
Clinical picture :
* Symptoms :
-General : Malaise, fever (may be accompanied with convulsions especially in infants) and generalized bodyache.
- Local : sore throat, dysphagia, foetor oris and earache.
- Signs :
- Temperature : 39-40C.
- Full rapid pulse.
- Flushed face.
- Enlarged tender jugulo-digastric lymph nodes.
- Tonsils : according to type of tonsillitis :
1- Catarrhal type : Congestion of the tonsils and the adjacent pharyngeal mucosa.
2- Follicular type : The crypts are full of pus and epithelial debris (follicles) which may coalesce to form a membrane which confined to the tonsils (bilateral) and does not spread to the palate, pharynx or larynx.
3- Parenchymatous type : There is diffuse enlargement and swelling of the whole tonsil.
Complications :
* Local :
- Peritonsillar abscess (quinsy).
- Parapharyngeal abscess.
- Retropharyngeal abscess.
- Chronic tonsillitis.
* Near by :
- Acute otitis media.
- Laryngitis.
* General :
- Rheumatic fever.
- Nephritis.
Differential diagnosis :
Other causes of membrane on the tonsils : Diphtheria, vincente’s angina, agranulocytosis, leukaemia, glandular fever and fungal infection (moniliasis).
Treatment :
* Bed rest, soft diet ample fluid intake and warm antiseptic gargles.
* Systemic antibiotics for 10 days and analgesics.
Chronic tonsillitis
- Chronic inflammation of the tonsils due to recurrent attacks of acute tonsillitis and insufficient treatment of acute tonsillitis.
- It is more common in children between 4-15 years.
- Usually associated with enlargement of the nasopharyngeal tonsil (Adenoid).
- It may be hypertrophic or atrophic (from fibrosis).
Symptoms :
* Local :
- Persistent or recurrent sore throat.
-Bad mouth odour (due to pus in the crypts).
- Irritating cough.
- Snoring (sleep apnea), dysphagia and speech difficulties (if large).
* General : Symptoms of septic focus
- Fatigue, low grade fever, headache (due to chronic toxaemia) anorexia (due to swallowing of septic tonsillar materials).
- Skeletal system : arthritis, myositis, backache and joint pains.
- Cardiovascular system : carditis, anaemia and increased sedimentation rate.
- Urinary system : Nephritis.
- Skin : eczema and psoriasis.
- Eye : Iridocyclitis.
Signs :
* Persistent congested anterior faucial pillars.
* Persistent enlargement of the jugulodigastric lymph glands (tonsillar gland).
* Inequality of both tonsils and irregularity of the crypts.
* Intratonsillar abscess.
* Squeezing of pus from the crypts on pressure on the tonsils (sure sign).
Treatment : Tonsillectomy.
TONSILLECTOMY INDICATIONS/CI
Excision of the palatine tonsils.
Indications :
A- Inflammatory :
1- Repeated acute attacks (more than 3-4 times per year for at least 2 years or 7 times per one year).
2- One attack of quinsy.
3- Chronic non specific tonsillitis either atrophic or with marked enlargement interfering with swallowing or breathing (obstructive sleep apnea).
4- Chronic specific tonsillitis :
* Diphtheria carrier.
* Primary tuberulosis.
* Fungus infection.
B- Traumatic :
* Impacted foreign body tonsil which cannot be removed (unilateral tonsillectomy).
C- Neoplastic : (Unilateral tonsillectomy).
* Benign : Papilloma.
* Malignant : Carcinoma, very early (excional biopsy).
D- Adjacent septic focus :
* Recurrent otitis media.
* Persistent cervical adenitis especially if T.B is suspected (as the tonsils are the portal of entry of T.B bacilli).
E- Distant septic focus :
* Rheumatic fever.
* Nephritis.
F- Step in other surgical procedure :
As a part of UVPP (uvulo palatophryngoplasty) and 9th nerve neurectomy.
Contraindications :
Absolute :
* Bleeding disorders : e.g. haemophilia, purpura and leukaemia.
* Advanced heart, kidney and chest diseases.
Relative :
* Acute tonsillitis, to avoid haemorrhage.
* Upper respiratory infection to avoid postoperative anaesthetic complications.
* Epidemics of poliomyelitis for fear contracting polio.
* Anaemia, hypertension, diabetes to avoid complications of these diseases.
* Pregnancy to avoid abortion or premature labour.
* Menstruation to avoid bleeding.
Preoperative preparations :
1- History : to exclude any contraindications as bleeding tendency.
2- General examination : to evaluate the general condition of the patient and
exclude any contraindication for anaesthesia.
3- Investigations :
a- Blood examination : CBC, bleeding time, clotting time, prothrombin time, Hb % (do not do the operation if Hb % is less than 70%) and ESR.
b- Urine for sugar (Diabetes) and albumin (nephritis).
c- Chest x-rays.
d- ECG in adults and in suspected cardiac patients (penicillin for 4 days before the operation to avoid subacute bacterial endocarditis).
e- Fasting for at least 6 hours before surgery to avoid inhalation of vomitus during recovery from anaesthesia.
Tonsillectomy technique/Post-op care/complications
Technique :
A- Tonsillectomy by dissection the commonest technique :
B-other techniques (diathermy, laser and coblation)
* Advantage : Decreased blood loss (valuable in patients with bleeding tendency).
* Disadvantages : Increased cost and delayed healing.
Postoperative care :
1- Position of the patient :
- Post tonsillectomy position : The patient lies on one side, the lower limb near the bed is flexed till the chest while the other lower limb is extended, put a small pillow infront of the patient chest for support, the bed side upper limb is flexed while the other upper limb is extended over the pillow.
- This position allows early detection of bleeding, any vomitus can easily get out, avoids falling back of the tongue and allow observation of the colour (cyanosis).
2- Observation of :
- Colour : cyanosis (respiratory obstruction) and pallor (hemorrhage).
- Pulse : rapid (hemorrhage).
- Blood pressure : drop (hemorrhage).
- Vomiting and hemorrhage (reactionary).
- Frequent swallowing movement (hemorrhage).
3- Feeding :
- 2-3 hours after the operation to avoid vomiting.
- The 1st day : cold soft foods and fluids.
- 2nd day : semi solid food.
- 3rd day : normal diet, avoid hard and spicy foods.
4- Medications :
Antibiotic (for one week) and analgesics.
Complications :
1- Complications of general anaesthesia.
2- Hemorrhage : the commonest complications:
a- Primary hemorrhage : hemorrhage during operation :
Causes :
- Improper preparation of the patient.
- Bad dissection (not in the proper plane).
- Fibrosed tonsillar bed e.g. quinsy.
Treatment :
- Ligation of the bleeding vessels and diathermy.
- Suture the pillars with or without pack.
- If not controlled : blood transfusion and ligation of the ext. carotid artery.
b- Reactionary hemorrhage :
- Hemorrhage during the first 24 hours after the operation.
- Due to :
* Failure to ligate all bleeding vessels.
* Slipping of a ligature.
* Dislodging of a thrombus by coughing or straining.
* Rising of blood pressure during recovery from anaesthesia.
- The condition is diagnosed by spitting fresh blood, pulse is increasing, blood pressure is decreasing, frequent swallowing, vomiting of dark altered blood and shock (in severe cases).
Treatment :
Mild cases :
-Remove the blood clots from the tonsillar bed and apply pressure with a cotton swab soaked in a solution of hydrogen peroxide and ephedrine.
Severe cases :
- Ligate the bleeding vessels under general anaesthesia.
- Suturing of the pillars may be needed.
- If not controlled ligation of ext. carotid artery.
- Blood transfusion and anti-shock measures.
c- Secondary hemorrhage : Occurs between 3rd to 10th day after the operation due to infection of tonsillar bed.
Treatment :
- Antibiotic injection.
- Local gurgle with H2O2 or pressure with gauze soaked in H2O2.
- If bleeding continue : suturing of the pillars on a pack for 2 days.
3- Injury : Teeth, tongue, lips, palate (nasal regurge) and dislocation of jaw from mouth gag.
4- Infection :
* Local sepsis : causing dysphagia, bleeding and foetor oris.
* Near by :
- Otitis media.
- Cervical lymphadenitis.
- Parapharyngeal abscess.
* General : Bacteraemia causing flaring up of rheumatic activity, nephritis and endocarditis in susceptible patients (prophylactic penicillin should be give pre- and post-operation).
5- Incomplete removal.
6- Pulmonary complications :
a- Respiratory obstruction : due to
- Extubation spasm of the vocal cords (suction of blood or secretion on cords and give oxygen).
- Falling back of the tongue (pull the mandible forwards, put an air way)
- Inhalation of blood clots, vomitus tonsillar tissue or piece of gauze (bronchoscopic removal).
b- Aspiration pneumonia, lung abscess.
ACUTE PHARYNGITIS
Acute inflammation of the mucosal lining of the pharynx.
Types :
* Non-specific acute pharyngitis :
Acute simple pharyngitis.
* Specific acute pharyngitis :
a- Bacterial :
- Diphtheria.
- Vincent’s angina.
b- Fungal :
- Moniliasis (candidiasis or thrush).
c- Viral :
- Infectious mononucleosis (glandular fever).
- Acquired immuno-deficiency syndrome (AIDS).
ACUTE SIMPLE PHARYNGITIS :
Etiology :
* Causative organisms :
- Mostly primary viral infection. In association with common cold and influenza.
- May be followed by bacterial infection with Streptococcus haemolyticus (commonest) Streptococcus pneumoniae and Haemophilus influenzae.
* Mode of transmission : Droplet infection.
Symptoms :
* General symptoms : Rapid onset of fever, headache, anorexia and malaise.
* Pharyngeal symptoms : Rapid onset of severe sore throat and referred otalgia.
Signs :
* General signs : High fever and flushed face.
* Pharyngeal signs :
- Diffuse hyperaemia of the pharyngeal mucosa.
-The mucosa may be covered with a non-adherent yellowish true membrane.
* Cervical signs : Enlarged tender upper deep cervical lymph nodes.
Complications :
* Spread of infection : otitis media and laryngitis.
Treatment :
* Antibiotics therapy.
* Supportive and symptomatic measures : rest, ample fluid intake, analgesics, antipyretics and gargles.
DIPHTHERIA
- An acute membranous inflammation caused by Corynebacterium diphtheria.
- Usually affects the pharynx (faucial diphtheria). It may involve the larynx or the nose. Children are particularly affected, especially between 2-5 years.
- Age: Any age VS 2-5 years
- Onset: Rapid VS Gradual
- Pain: Severe VS Slight
- Face: Flushed VS Pale
- Fever: High 39-40 VS Moderate 37.5 to 38
- Pulse: Rapid proportionate with the rise oF temperature and full VS Very rapid disproportionate to the rise of temperature thready feeble (toxic myocarditis)
- Toxaemia: Moderate the patient is
irritable VS Severe the patient is flabby - Local examination: The membrane is not
extending beyond the tonsil can be easily separated VS Spreads beyond the tonsil e.g.to the palate, posterior pharyngeal wall, adherent and leaves bleeding surface on stripping - Lymph nodes: Moderate swelling VS The whole neck is swollen
- Blood: P.N.Ls and leukocytosis VS Slight lymphocytosis
- Swab: Haemolytic streptococci VS Positive for diphtheria bacilli
- Albumin in urine: Uncommon VS Common
VINCET’S ANGINA
Acute ulcerative inflammation of the pharynx affecting tonsils, fauces and gums.
Etiology :
* Causative organisms : Gram –ve fusiform bacilli and borrelia vincenti (spirochaeta denticola).
* Predisposing factors : prolonged use of antibiotics, bad oral hygiene (carious teeth).
Symptoms :
* General : absent or very mild fever.
* Local : sore throat (pain is marked), fetor oris and unilateral tender cervical lymph node.
Signs :
* Unilateral ulcer on tonsil covered by grayish yellow membrane, non-adherent, easily removed leaving an excavating ulcer with irregular edge.
Investigations : Throat swab : film shows organisms.
Treatment :
* Hydrogen peroxide mouth wash.
* Penicillin or Erthromycin and Metronidazole.
MONILIASIS (Thrush)
Fungus infection of the pharynx by Candida albicans.
Predisposing factors :
* Debilitating conditions.
* Prolonged use of broad spectrum antibiotics or corticosteroids.
* Immune deficiency states e.g. AIDS, diabetes, malignancies and chronic debilitating diseases.
Symptoms :
No fever, sore throat and severe dysphagia.
Signs : White patches of thin membrane which can be easily removed, appear over
the mucosa of the pharynx and cheek.
Treatment :
* Stop the used drugs.
* Vitamins.
* Nystatin or amphotericin suspension paint or gentian violet 1% paint.
CHRONIC PHARYNGITIS
Non specific :
Aetiology :
* Recurrent attacks of acute pharyngitis.
* Nasal obstruction (mouth breathing) and sinusitis.
* Teeth and gums infections.
* Excessive use of tobacco.
* Reflux oesophagitis.
Symptoms :
* Irritation in the throat (sore throat).
* Hawking (frequent clearing the pharynx).
Signs :
The pharyngeal mucosa may show one of the following clinical types :
* Catarrhal : red congested mucosa with enlarged uvula.
* Hypertrophic : small nodules of lymphoid tissue are scattered over the pharyngeal wall, giving a granular appearance.
* Atrophic : dry and glazed mucosa with some viscid mucous on the surface (usually accompanied by atrophic rhinitis).
Treatment :
* Treat the predisposing factors.
* Local applications e.g. gurgle, lozenge, spray.
Chronic Specific :
A- Syphilis :
* Very rare now.
Primary :
- Chancre : Painless nodule affect the tonsils.
- Cervical adenitis.
Secondary :
- Mucous patch : grayish rounded area over the tonsils, tongue and cheek.
- Skin rash.
- Generalized lymphadenopathy.
Tertiary :
- Gumma : hard mass on the palate, post. Pharyngeal wall. It ulcerates giving ulcer with deep punched out edge, indurated base and necrotic yellowish floor (wash-leather appearance).
- It infiltrates the palate causing perforation.
- It cause adhesions between the palate and posterior pharyngeal wall.
B- Tuberculosis (T.B) :
* Primary or secondary to pulmonary T.B.
* It gives small tubercle on the tonsil and palate which ulcerate giving painful ulcer with undermined edge and pale granulations in the floor.
C- Scleroma :
* Associated with rhinoscleroma.
* Glazed atrophic mucosa with crustation but without ulceration.
* It cause adhesions between the palate and posterior pharyngeal wall.
PHARYNGEAL MANIFESTATIONS OF BLOOD DISEASES
I- Infectious mononucleosis :
Acute pharyngitis caused by Epstein Barr virus.
Symptoms :
* Sore throat and dysphagia.
* Fever, headache and malaise (Febrile type).
Signs :
* Generalized lymphadenopathy and splenomegaly (glandular type).
* Pharyngeal ulcers surrounded by congested area and covered by whitish membrane (anginose type).
Investigations :
* Blood picture : monocytosis and lymphocytosis with atypical lymphocytes.
* Serological test : positive paul Bunnell’s test i.e patients serum can agglutinate sheep RBCs (due to presence of abnormal antibodies).
Treatment :
* Antibiotics therapy to avoid secondary bacterial infection. (Avoid ampicillin because it may cause a skin rash).
* Supportive and symptomatic measures as rest, ample fluid intake, analgesics, antipyretics and gargles (as warm tea with lemon).
* Systemic steroids in severe cases.
-
II- Agranulocytosis :
A grave condition characterized by marked reduction in the neutrophil polymorphs, due to bone marrow depression.
Etiology :
* Primary : idiopathic.
* Secondary to :
- Drugs containing the benzene ring e.g. sulphonamides, cytotoxic drugs or chloramphenicol.
- Irradiation.
-Terminal stage in renal and hepatic failure or malignancy.
Clinical picture :
* Sore throat of sudden onset.
* Necrotic ulceration (without red inflammatory reaction around) in the oral and pharyngeal mucosa which later become extensive and form gangrenous stomatitis.
* Malaise with prostration which may be terminal.
Diagnosis :
* Blood picture shows leucopenia down to 2000 cells/ml and neutrophils down to 400 cells/ml.
* Sternal puncture.
Treatment :
* Stop the causative drug.
* Blood transfusion and vitamin B12.
* Systemic antibiotics for secondary infection.
* Bone marrow transplantation.
-
III- Acute leukaemia :
Neoplastic disease of the bone marrow leading to marked increase in the number of immature blast white blood cells.
Clinical picture :
* Hypertrophied bleeding gums.
* Generalized lymphadenopathy and splenomegaly.
* Sternal tenderness.
* Sore throat with extensive necrotic ulcers and pseudo-membrane on the pharyngeal mucosa.
Investigations :
* Blood picture : marked leukocytosis (with many immature blast cells), anaemia and thrombocytopenia.
* Bone marrow aspirate (sternal puncture) : diagnostic.
Treatment :
* Hospitalization, isolation and systemic antibiotics to prevent secondary infection.
* Repeated fresh blood transfusion.
* Chemotherapy and bone marrow transplantation.
ULCERS OF THE OROPHARYNX
I- Local causes :
1- Traumatic :
* Mechanical e.g. ill fitting denture, cheek biting and jagged teeth (ulcers have punched out serrated edges, soft base, red granulations in the floor, heals in few days).
* Thermal : too hot foods or drinks.
* Chemical : corrosives, tobacco (hyperkeratosis).
* Radiotherapy : dryness of the oral mucosa (xerostomia).
2- Infective :
Bacterial :
* Acute specific :
- Diphtheria : dirty white grayish pseudomembrane.
- Vincent angina : deep ulcer.
* Chronic specific :
- T.B : undermined edge, superficial with pale granulation tissue.
- Syphilis : deep punched out, wash leather slough and indurated base.
* Fungal : Moniliasis.
* Viral :
- Herpes simplex : herpetic stomatitis with vesicles on the buccal mucosa which rupture giving painful shallow ulcers with red edematous margin.
- Herpes zoster : vesicular eruption on palate, tonsils and posterior pharyngeal wall with shallow ulcers, usually accompanied by herpes zoster otitis.
- Infectious mononucleosis.
- AIDS : caused by HIV, persistent oral thrush, moniliasis, herpetic ulcers and cervical lymphadenopathy.
3- Malignant ulcer :
* Ulcer with everted edge, indurated base and necrotic floor.
-
II- Miscellaneous causes :
1- Blood diseases : acute leukaemia and a granulocytosis.
2- Dyspeptic ulcers : small punched out painful ulcer on the lips, cheek, and the tongue. Usually related to gastrointestinal disorders.
3- Behcet’s syndrome :
* Iritis with oropharyngeal and genital ulcers.
* Aetiology : unknown.
* Treatment : steroids (local and systemic).
4- Vitamin deficiency :
* Vit. B deficiency: it gives painful red swollen glazed tongue.
* Vit. C deficiency (scurvy): gives swollen easily bleeding gums.
5- Skin diseases :
* Pemphigus : the oral lesion is in the form bullae that rupture to form painful ulcers.
* Lichen planus : the oral lesion is in the form erythematous lesions which form a painful ulcers.
* Both diseases are treated by steroids.
6- Drugs : Hypersensitivity lead to vesicles which rupture give ulcers.
7- Cancrum oris : occurs in immunocompromised patient, ulceration of the gum, buccal mucosa with sloughing bone exposure and gangrene.
8- Recurrent aphthous stomatitis :
Commonest cause of oral and pharyngeal ulceration.
Etiology :
Unknown. May be vitamin deficiency, immunological disturbance or stress.
Clinical picture :
* General manifestations : Good general condition.
* Pharyngeal manifestations : Recurrent single or multiple small painful oral and pharyngeal ulcers which are surrounded with marked hyperaemia. They heal spontaneously within 1-2 weeks.
Treatment : Local corticosteroids.
Peritonsillar abscess (Quinzy)
Collection of pus in peritonsillar space i.e. between tonsil capsule and its bed (superior constrictor muscle).
Pathogenesis :
* Repeated attacks of acute tonsillitis leads to fibrosis and obstruction of the opening of the crypts especially crypta magna.
* In acute tonsillitis pus accumulates within the obstructed crypts which rupture in the peritonsillar space.
Clinical picture :
* Usually in adult (rare in children).
* Usually unilateral in fibrotic tonsils, it may occur over tonsillar remnants.
Symptoms :
Symptoms of acute tonsillitis becomes more severe.
* Fever (up to 41C), anorexia and malaise.
* Pain becomes unilateral, throbbing and radiates to the ear.
* Dysphagia becomes more severe up to the degree of drooling saliva.
* Speech becomes thickened (muffled).
* Trismus due to reflex spasm of the medial pterygoid muscle.
* Torticollis due to reflex spasm of the sternomastoid muscle.
* Foetor oris.
Signs :
* The soft palate is oedematous above and lateral to the tonsil (pitting oedema on probing).
* The tonsil is pushed downwards and medially.
* The uvula is oedematous and pushed to the other side.
* The cervical glands are enlarged and tender.
Differential diagnosis :
* Tumours of the tonsil :
- No acute symptoms.
- No pus on aspiration.
- Biopsy is diagnostic.
* Aneurysm of the int. carotid artery :
- Pulsations are seen.
- Blood on aspiration.
* Parapharyngeal swelling (Bec’s triad).
* Unilateral hypertrophied tonsil (no acute symptom and uvula is central).
Complications :
* Rupture with aspiration of pus → bronchopneumonia.
* Spread of infection to :
- Parapharyngeal space (parapharyngeal abscess).
- The larynx (laryngeal obstruction).
- Septicemia.
Treatment :
* Medical treatment :
Before pus formation i.e in the stage of peri-tonsillar cellulites by massive antibiotic therapy.
* Surgical treatment :
1. Drainage of the abscess.
After pus formation i.e in the stage of peri-tonsillar abscess: as indicated by throbbing pain, fever become hectic, pitting edema and aspiration brings pus.
- How ?
o Anaesthesia commonly surface with the patient sitting.
o The incision is performed with a guarded scalpel or better a quinsy knife in one of these points :
a- Most pointing point.
b- Crypta magna.
c- Midway between the last upper molar tooth and base of the uvula.
d- 1/2 cm lateral to the meeting point of two lines : a vertical line along the anterior pillar and a horizontal line along the base of the uvula.
o The drainage is performed by a quinsy forceps; using Hilton’s method i.e the forceps is introduced closed → opened in the abscess → withdrawn out open.
2. Tonsillectomy:After 4-6 weeks to avoid recurrence of quinsy.
Parapharyngeal abscess
Suppuration in the parapharyngeal space.
Causes :
* Quinzy, acute tonsillitis and after tonsillectomy.
* Infection of last molar teeth.
* Petrositis (petrous apex is the roof of this space).
* Suppuration in cervical lymph node.
* Sharp foreign body.
Clinical picture :
* As quinsy : fever, anorexia, headache, malaise, pain, dysphagia, trismus and torticollis.
* Bec’s triad (diagnostic) :
- External neck swelling below and behind the angle of the mandible deep to the anterior border of sternomastoid.
- Internal swelling in the lateral wall of the pharynx (pushing the tonsil medially).
- Trismus : due to spasm of medial pterygoid muscle.
Investigations : CT is diagnostic.
Complications :
The infection may spread to :
* Base of the skull causing meningitis.
* Mediastinum causing mediastinitis.
* Internal jugular vein causing thrombophilibitis.
* The larynx causing laryngeal oedema.
Treatment :
* Systemic antibiotics, analgesic and antibiotic.
* Incision along the anterior border of the sternomastoid muscle and drainage of the abscess.
Retropharyngeal abscess
An abscess in the retropharyngeal space which may be acute or chronic.
I- Acute retropharyngeal abscess :
An abscess in one side of the midline of the pharynx between the buccopharyngeal and the prevertebral fasciae (Space of Gilette).
Etiology :
* Suppuration of the retropharyngeal glands of Henle in children under the age of 5 years (later the glands atrophy).
* The glands are usually infected from due to infection in nose, pharynx and tonsils.
Symptoms :
* Fever, malaise and anorexia.
* Stridor and croupy cough.
* Dysphagia difficult suckling and drooling of saliva.
* Torticollis.
Signs :
* Swelling in one side of the midline of the pharynx.
* Enlarged tender cervical glands.
Investigations :
* Plain x-ray lateral view neck shows widening of the prevertebral space in cervical region.
* CT is diagnostic.
Complications :
* Laryngeal edema and respiratory obstruction.
* Rupture leads to inhalation, suffocation and pulmonary complications.
Treatment :
* Antibiotics.
* Longitudinal incision is done from the mouth. Avoid inhalation of pus by cuffed endotracheal tube and using an electric sucker.
* Tracheostomy if needed.
-
II- Chronic retropharyngeal abscess :
Etiology :
* T.B caries of the cervical vertebrae (Pott’s disease). The cold abscess lies centrally behind prevertebral fascia – seen in older children and young adults usually secondary to pulmonary T.B.
* T.B. infection of the retropharyngeal lymph nodes due to spread of infection from deep cervical lymph nodes. The abscess here lies laterally in the retropharyngeal space i.e infront the prevertebral fascia.
Clinical picture :
* General: T.B toxaemia i.e loss of weight, night fever, sweating and cough with expectoration and may be haemoptysis.
* Local :
- Sore throat and mild dysphagia.
- Swelling in the midline of the pharynx (laterally if due to T.B lymphadenitis).
- Tender cervical spine.
- Enlarged cervical lymph nodes.
Investigations :
* X-ray lateral view neck : widening of prevertebral space with destroyed vertebrae.
* CT is diagnostic.
* Investigations for T.B : as chest x-ray and sputum analysis.
Treatment :
* External surgical drainage : incision from outside along posterior border of sternomastoid (not through mouth for fear of T.B enteritis).
* Anti-T.B drugs.
The differences between acute and chronic retropharyngeal abscess.
- Organism: Pyogenic (strept.) VS Tubercle bacillus
- Cause: Breakdown of the R.P lymph gland of Henle VS Caries of the cervical spine
- Site: Between buccoparyngeal fascia and pre-vertebral facia VS Behind the prevertebral fascia
- Oral/Exam: Abscess to one side of the middle line VS Abscess central
- Clinical picture:
Ill child, toxic, dysphagia, great dyspnea and croupy cough, nasal obstruction VS Adult, tuberculous, mild dysphagia thick voice noticed, tender cervical spine, torticollis - X-ray: Spine is free VS Caries in vertebrae
- Treatment
- Drainage from the mouth
- No anesthesia in children
- If general anesthesia, avoid inhalation of pus by low head position and electric suction or aspiration before incision
VS - Anti-tuberculous drugs
- Aspiration and injection of streptomycin
- Drainage from behind the sternomastoid muscle
