Transcript الشريحة 1
Infection of pharyngeal spaces
• The retropharyngeal space lies behind the pharynx and esophagus, just anterior to the prevertebral fascia. It extends superiorly to the base of the skull and inferiorly to the bifurcation of the trachea.
• Patients generally present with trismus, drooling, dyspnea, dysphagia, and a mass, often fluctuant, on one side of the posterior pharyngeal wall.
• Lateral radiographs of the neck are also helpful in diagnosis. It is important, however, to have proper positioning of the patient at the time of X-ray; otherwise the results may be misleading. The patient should have the neck extended in a true lateral position for the X-ray.
• The parapharyngeal space is cone shaped. Superiorly it starts at the base of the skull and inferiorly its margin ends at the hyoid bone. The superior constrictor muscle is the medial boundary, and the parotid gland, the mandible, and the pterygoid muscle are its lateral margins , the prevertebral fascia is present posteriorly.
• A parapharyngeal space abscess can develop when infection or pus from the tonsillar region goes through the superior constrictor muscle. The abscess then forms between the superior constrictor muscle and deep cervical fascia.
• Patients can present with toxemia and pain in the throat and neck, with tender swelling of the neck in the region of the angle of the mandible. Examination may reveal tonsillitis and/or medial displacement of the tonsil.
Parapharyngeal Abscess Retro-pharyngeal Abscess (Acute & Chronic)
Parapharyngeal Abscess
Def What is parapharyngeal space?
Collection of pus in the PARA-PHARYNGEAL Space A connective tissue space which:
-Lies on the lateral side of the nasopharnx and oropharynx -Extends from skull base to hyoid bone -
Contains
: -
Internal carotid artery
-
Internal jagular vein
-
Last 4 cranial nerves
-
Cervical sympathetic trunk
-
Deep cervical lynph nodes
-
Etiology:
Acute Tonsillitis or after tonsillectomy Infection of last lower molar tooth Infection of the parotid salivary gland The infection passes through the Superior constrictor muscle Symptoms Same as in Quinsy
Signs:
General; fever Pharyngeal: Cervical
Investigations:
CT & MRI
-
The lateral pharyngeal wall & tonsil is pushed medially -Trismus due to spasm of ptrygoid muscles A unilateral diffuse tender swelling :
-
Below & behind the angle of the mandible
-
Deep to the anterior border of the sternomastoid
-
The neck is tilted to the diseases side
Complications
-
Spread to Skull base
meningitis carotid sheath
thrombosis of IJV and rupture of carotid artery Mediastinum
Mediastinitis Larynx
laryngeal edema Rupture aspiration
into the pharynx
Bronchopneumonia
Treatment
Medical
: massive antibiotic therapy and,
Surgical drainage A vertical incision at the anterior border of the sternomastoid muscle
Acute Retropharyngeal Abscess
• • • • •
It is a connective tissue space between : the buccopharyngeal fascia & pre-vertebral fascia
Collection of pus in the retropharyngeal space
The two fasciae are attached to each side by median raphe.
It extends from the skull base to the posterior mediastinum It contains retropharyngeal lymph node one on each side The Retropharyngeal LN atrophy at the age of 5 BuccoPharyngeal Fascia The Retropharyngeal space Prevertebral fascia
• Age: below the age of 5 ( The Retropharyngeal LN atrophy at the age of 5 ) • Site : at one side of the midline ( The two fasciae are attached to each other at the midline by median raphe.) • Etiology • Upper Rrspiratory Tract Infection with suppuration of Retropharyngeal LN • After Adenoidectomy operation • Impacted FB
Symptoms
In A child below 5 years
General
: FHAM • • •
Pharyngeal
:
Severe sore throat Dysphagia Difficult breathing
Abscess
Signs
General
: fever
Pharyngeal Swelling of the posterior Pharyngeal wall to one side of the midline Cervical:
Neck inclination due to muscle spasm
Normal Patient Lateral view of the Neck
• -
Look for
The vertebral column
( for any destruction e.g in Pott ’ s disease)
The pre-vertebral space
(3/4 the width of the body of the vertebra )
The airway
•
Investigations
: plain X ray & CT scan
Complications:
-
Spread to mediastinum
mediastinitis
-
Rupture………….
Widening of prevertebral space Normal vertebral bodies
Treatment Medica l: massive antibiotic therapy and, Surgical drainage Tracheostomy if indicated Incision in the posterior pharyngeal wall with the patient in the Trendlenberg position Why?
In this position the head is lower than the chest to avoid aspiration of pus
Chronic Retropharyngeal Abscess Pre-vertebral Abscess
Formation of a cold abscess in the
pre-vertebral space What is the pre-vertebral space?
A space between: - The cervical vertebrae - The pre-vertebral fascia
-
Etiology:
Pott
’
s Disease i.e tuberculosis of cervical vertebrae
the abscess rupture through the prevertebral fascia
abscess reaches the the Retropharyngeal space prevertebral fascia
Symptoms In an adult General
: Tuberculous Toxaemia
Pharyngeal
: Mild sore throat
Cervical
: limited painful neck movement -
Night sweets -Night fever -Loss of weight -Loss of appetite
Signs:
General
: Tuberculous toxaemia
Pharyngeal
:
Cervical
: Tenderness over cervical spines - Pallor - Low grade fever - Loss of weight
The swelling lies in the midline of the posterior pharyngeal wall
Investigations Plain X ray & CT scan
Widening of the Prevertebral space Destruction of the cervical vertebrae
Treatment
:
Medical:
therapy Antituberculous
Surgical
Drainage
Orthopedic Management Through a vertical incision along the posterior border of the sternomastoid muscle
Hypopharyngeal Pouch
Hypopharyngeal pouch
Synonyms
Hypopharyngeal diverticulum Zenker ’s diverticulum Pharyngo-oesophageal pouch Retropharyngeal pouch Killian ’s diverticulum
Introduction
• Hypopharyngeal pouch is an acquired pulsion diverticulum caused by posterior protrusion of mucosa through pre-existing weakness in muscle layers of pharynx or esophagus. • In contrast, congenital diverticulum like Meckel's diverticulum is covered by all
Weak spots b/w muscles
Weak spots b/w muscles
Posterior: 1. Between Thyropharyngeus & Crico pharyngeus: Killian's dehiscence (commonest)
Origin of Zenker ’s diverticulum
History
• First described in 1769 by Ludlow • Friedrich Zenker & von Ziemssen first described its picture in their book in 1877
Etiology
1. Tonic spasm of cricopharyngeal sphincter: C.N.S. injury Gastro-esophageal reflux 2. Lack of inhibition of cricopharyngeal sphincter 3. Neuromuscular in-coordination between Thyro-pharyngeus & Cricopharyngeus 4. Second swallow against closed cricopharynx These lead to increased intra-luminal pressure in
Clinical Features
1. Entrapment of food in pouch: sensation of food sticking in throat & later dysphagia 2. Regurgitation of entrapped food: leads to foul taste bad odor nocturnal coughing choking 3. Hoarseness: due to spillage laryngitis or sac pressure on recurrent laryngeal nerve 4. Weight loss: due to malnutrition 5. Compressible neck swelling on left side:
Complications
1. Lung aspiration of sac contents 2. Bleeding from sac mucosa 3. Absolute oesophageal obstruction 4. Fistula formation into: trachea major blood vessel 5. Squamous cell carcinoma within Zenker diverticulum (0.3% cases)
Investigations
• Chest X-ray: may show sac + air - fluid level • Barium swallow • Barium swallow with video-fluoroscopy • Rigid Oesophagoscopy • Flexible Endoscopic Evaluation of
Barium swallow
Barium swallow with Video fluoroscopy
Rigid Oesophagoscopy
Cricopharyngeal myotomy
Styalgia (Eagle Syndrome)
Introduction
• Normal length of styloid process is 2.0
–2.5 cm • Length >30 mm in radiography is considered an elongated styloid process • 5-10% pt with elongated styloid have pain • Increased angulation of styloid process both anteriorly & medially, can also cause pain
Classical Variety
• Occurs several years after tonsillectomy • Pharyngeal foreign body sensation • Dysphagia • Dull pharyngeal pain on swallowing, rotation of neck or protrusion of tongue • Referred otalgia • Due to scar tissue in tonsillar fossa engulfing branches of glossopharyngeal
Normal Styloid Process
Elongated Styloid Process
Theories for pain
• Irritation of glossopharyngeal nerve • Irritation of sympathetic nerve plexus around internal carotid artery • Inflammation of stylo-hyoid ligament • Stretching of overlying pharyngeal mucosa
Diagnosis
1. Digital palpation of styloid process in tonsillar fossa elicits similar pain 2. Relief of pain with injection of 2% Xylocaine solution into tonsillar fossa 3. X-ray neck lateral view 4. Ortho-pan-tomogram (O.P.G.) 5. Coronal C.T. scan skull 6. 3-D reconstruction of C.T. scan skull
X-ray neck lateral view
Coronal C.T. scan
Coronal 3-D C.T. scan
Medical Treatment
1. Oral analgesics 2. Injection of steroid + 2% Lignocaine into tonsillar fossa 3. Carbamazepine: 100 – 200 mg T.I.D. 4. Operative intervention reserved for: • •
failed medical management for 3 months severe & rapidly progressive complaints
Styloid Process Excision
Intra-oral route
• via tonsil fossa • no external scarring • poor visibility due to difficult access • high risk of damage to internal carotid artery • iatrogenic glossopharyngeal nerve injury
Tonsillectomy & fossa incision
Styloidectomy
Styloidectomy
• Tonsillectomy done. Styloid process palpated.
• Incision made in tonsillar fossa just over the tip.
• Styloid attachments elevated till its base with periosteal elevator.
• Styloid process broken near its base with bone nibbler, avoiding injury to