Furunculosis of the nasal vestibule: causes, diagnosis, complications, 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.

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.

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.