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Suppurations of the Pharynx | symtoms, signs, treatment

I. Peritonsillar Abscess (Quinsy)

Definition: Collection of pus between fibrous capsule of the tonsil, usually at its upper pole &
the superior constrictor muscle.

Etiology: 
  • Usually as a complication of acute tonsillitis
  • Organisms: usually mixed aerobic & anaerobic infection.
Incidence: Usually young adult
Pathology: Starts by infection in the depth of one of the crypts (usually crypta magna).

Symptoms: 
(as tonsillitis but more severe)
General: Fever, headache, malaise (if pus >> hectic fever).
Local: 
  • Sore throat, severe & unilateral.
  • Severe dysphagia & odynophagia.
  • Unilateral neck pain & referred otalgia. 
  • Foetor oris 
  • Drooling
Signs:
General: Fever, tachycardia, toxic facies.
Peritonsillar-Abscess-quinsy
Local
  • Trismus, torticollis – muffled voice
  • Asymmetrical edema and congestion of soft palate.
  • Swelling above & lateral to tonsil
  • Tonsil is displaced downwards & medially.
  • Uvula is edematous & pushed to other side.
  • Large , firm , tender jugulodigastric LN.
Treatment:
A) During stage of peritonsillar cellulitis
  1. Parentral antibiotics
  2. Antipyretics , analgesics , bed rest , adequate fluids,& mouth wash
B) During stage of peritonsillar abscess
  1. Indicated by: Hectic fever,throbbing pain, pitting edema on probing, and aspiration of pus.
  2. Treated by: Incision & drainage Parentral antibiotics
Site of incision:
  • Most bulging point
  • Mid point of a line from base of uvula to last upper molar tooth.
  • 1/2 cm lat. to point of crossing of a vertical line along anterior pillar with a horizontal line
  • along base of uvula.
Technique: use a guarded knife, Hilton method to open loculation usually under G.A

C) Tonsillectomy should be done 4-6 weeks later

Differential Diagnosis:
  • Neoplasm (carcinoma,lymphoma). - Acute leukaemia. – Aneurysm of ICA
  • Abscess related to upper molar tooth. -Parapharyngeal swelling.
Complications:
  • Laryngeal edema & stridor. 
  • Pyaemia & septicaemia 
  • Para pharyngeal abscess

II. Parapharyngeal Abscess

Definition: Collection of pus in para pharyngeal space.
Etiology:
  • Peritonsillar abscess 
  • Tonsillitis 
  • Petrositis & mastoiditis
Symptoms: 
like quinsy + unilateral neck swelling
Signs: Fever, tachycardia, torticollis

Becks triad: 

  1. Swelling in lateral Pharyngeal wall pushing a normal tonsil medially.
  2. Tender firm external swelling on lateral side of the neck.
  3. Trismus.
Investigations: C T of pharynx & neck.
Parapharyngeal-Abscess
Treatment: 
As quinsy:
Hospitalization + incision & drainage by external incision along anterior border of sternomastoid.

Differential Diagnosis: All para pharyngeal swellings (salivary gland tumors neurogenic tumors, carotid aneurysm)

Complications:
  • Laryngeal oedema & stridor.
  • Mediastinitis.
  • Thrombosis of IJV.
  • Erosion of carotid artery.

III. Retropharyngeal Abscess (R.P.A):

Collection of pus between buccopharyngeal fascia of the posterior pharyngeal wall & the
prevertebral fascia.

A) Acute R.P.A :

Etiology: Suppuration of retropharyngeal L.N (gland of Henle) following URT infection.
Incidence: Usually child, as gland atrophies later.
Pathology: Abscess occurs to one side of midline.
Symptoms:
  • Fever, headache, malaise.
  • Severe dysphagia.
  • Stridor due to laryngeal edema

Signs:
  • Fever, tachycardia, torticollis with flexed neck.
  • Swelling in the posterior pharyngeal wall to one side of midline with hyperaemia &
  • congestion
  • Large tender cervical lymph node.
Investigations:
  • Xray :widening of prevertebral space
  • CT
Treatment:
  1. Incision & drainage: trans oral route. Head down Trendelenberg position
  2. Tracheostomy if stridor.
  3. Parentral antibiotics.

B) Chronic R.P.A ( cold abscess , Pott’s disease )

Etiology: T.B of cervical spine.
Incidence: In adult , uncommon.
Pathology: Cold abscess.

Symptoms: General: TB toxemia night fever, night sweat loss of weight, loss of appetite.
Local: Sore throat & odynophagia.

Signs: 
General: Neurological signs, associated pulmonary T.B
Local: Bulge of midline of posterior pharyngeal wall and tenderness over cervical spine.

Investigation:
  • Xray: destroyed vertebral bodies, chest X ray.
  • Sputum analysis, tuberculin test, needle biopsy.
  • CT scan
Treatment:
  1. Anti tuberculous treatment.
  2. Incision & drainage along posterior border of sternomastoid.
  3. Orthopedic treatment.

IV. Ludwig’s angina

Definition: Suppuration in submandibular space.
Etiology: Dental causes in 90%, infection of lower tooth, or extraction of septic tooth.
Incidence: More in diabetics.

Symptoms:
  • General: Fever, headache, malaise.
  • Local: Severe pain with dysphagia, muffled voice , difficult respiration .

Signs:

General: Fever, tachycardia.
Local:
  • Massive indurated tender neck swelling below the mandible
  • Swollen floor of mouth with the tongue pushed upwards
Treatment: 
  1. Hospitalization, care of air way, toxaemia.
  2. Parenteral antibiotics, antipyretics, analgesics.
  3. Secure airway: tracheostomy.
  4. Drainage: a free incision decompression.

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