Parapharyngeal abscess: diagnosis, complications and management in adults

Impact of the COVID-19 era on clinical presentation, management and microbiology in paediatric peritonsillar abscess: A case-control study

OBJECTIVES

Peritonsillar abscess (PTA) is the most common soft-tissue infection of the head and neck. This potential complication of tonsillitis has demonstrated unique microbial trends during the COVID-19 pandemic. This era has resulted in a major shift in the hygiene and social habits of the general population, which has resulted in changes in the presentation, management and microbiology of several infectious diseases. To date, the impact of COVID 19 on PTA microbiology and clinical presentation in the paediatric population has yet to be investigated.

DESIGN

Retrospective chart review comparing all cases of paediatric (age 0-18) PTA in an academic tertiary centre during the COVID-19 pandemic (03/2020-02/2022) and compared them to two control groups: pre-COVID (03/2018-02/2020) and post-COVID (03/2022-03/2023). All patients were treated with either needle aspiration, incision and drainage or both means in addition to intravenous antibiotics.

SETTING

A large Ear Nose and Throat department in a tertiary referral center.

PARTICIPANTS

Consecutive children aged 18 years or under, admitted with a diagnosis of Peritonsillar abscess.

MAIN OUTCOME MEASURES

We analyzed the clinical and microbiologcal features of all cases of pediatric peritonsillar abscess during the COVID-19 era (03/2020-02/2022) and compared them to a pre and post control cases.

RESULTS

A total of 96 PTA cases were included (35 pre-COVID, 35 COVID and 26 post-COVID). The means of procedural treatment shifted in favour of incision and drainage versus needle aspiration during the COVID era. The length of hospitalisation increased during the COVID era (3.6 days vs. 2.1 and 3.1 pre and post-COVID respectively, p < .001). No other notable differences in the clinical and demographic features were found between the three eras. The COVID-19 era saw an increase in Fusobacterium (37.1% vs. 8.6% and 24% pre and post-COVID, respectively; p = .008) and Streptococcus Anginosus (31.4% vs. 5.7% and 7.7% pre and post-COVID, respectively; p = .007) species isolation.

CONCLUSIONS

The COVID-19 pandemic did not seem to impact the clinical presentation of paediatric PTA yet resulted in a change in microbiological pathogens. The choice of I&D as a means to shorten hospital stay during the pandemic may have led to an actual increase in hospital stay, suggesting that NA may be the preferred management approach.

[Disproving the myth of "abscess weather" predisposing to peritonsillitis and peritonsillar abscess]

BACKGROUND

Peritonsillar abscess (PTA) is often seen as a complication of acute tonsillitis and is defined as pus retention between the tonsillar capsule and the peritonsillar tissue. The etiology and pathogenesis have not yet been fully elucidated. A connection between certain weather conditions and temperature fluctuations and the occurrence of abscesses in the head and neck region has been discussed for years. The question here is whether higher temperature fluctuations are predisposing for the formation of abscesses.

MATERIALS AND METHODS

A retrospective evaluation of all patients hospitalized with peritonsillitis or PTA in the Department of Otorhinolaryngology of the Klinikum Rechts der Isar of the Technical University of Munich during a period of 10 years (2012-2021) was performed. Each patient was individually correlated with daily temperature data from the statistical meteorological office of the City of Munich.

RESULTS

A total of 1450 patients were included, 270 patients (18.62%) with peritonsillitis and 1180 patients (81.38%) with PTA. A correlation between the occurrence of peritonsillitis or PTA and major temperature fluctuations could be excluded in this large patient population. Moreover, a similar frequency of peritonsillitis and PTA was seen throughout the year.

CONCLUSION

The myth of a temperature dependence of the development of peritonsillitis or PTA and a so-called abscess weather could be negated in this study.

Parapharyngeal Abscess: Antibiotic-only or Open Surgical Drainage?

Objective:Many problems of parapharyngeal abscess (PPA), such as etiology, predisposing factors, and therapeutic methods, are still controversial. We aim to investigate the characteristics of PPA to better understand the therapeutic effects of the disease. Methods: We retrospectively collated the medical record reviews of 49 PPA patients who were treated as PPA inpatients when a patient was hospitalized and diagnosed with PPA, and empiric antibiotics were used. Only if the drug treatment was ineffective, the abscess was large, or the disease continued to progress, and surgical treatment was adopted. Results: In total, 49 patients who met the research criteria were identified. Streptococcus was the most common organism in PPA patients. The morbidity of diabetes in PPA patients was higher than the prevalence of diabetes in the overall population. Interestingly, the length of hospital stay was shorter in the antibiotic-only group than in the surgery group (P < 0.05). Furthermore, the duration from onset to treatment in the antibiotic-only group was shorter than in the surgery group. Conclusion: Our treatment protocol is effective. Antibiotic-only method is also recommended for the PPA which was effective for the empiric antibiotics and localized. Early diagnosis and treatment of PPA could ultimately reduce the severity of PPA.

The assessment and management of deep neck space infections in adults: A systematic review and qualitative evidence synthesis

OBJECTIVES

To summarise current practices in the diagnosis and management of deep neck space infections (DNSIs). To inform future studies in developing a framework in the management of DNSIs.

DESIGN

This review was registered on PROSPERO (CRD42021226449) and reported in line with PRISMA guidelines. All studies from 2000 that reported the investigation or management of DNSI were included. The search was limited to English language only. Databases searched included AMED, Embase, Medline and HMIC. Quantitative analysis was undertaken with descriptive statistics and frequency synthesis with two independent reviewers. A qualitative narrative synthesis was conducted using a thematic analysis approach.

SETTING

Secondary or tertiary care centres that undertook management of DNSIs.

PARTICIPANTS

All adult patients with a DNSI.

MAIN OUTCOME MEASURES

The role of imaging, radiologically guided aspiration and surgical drainage in DNSIs.

RESULTS

Sixty studies were reviewed. Thirty-one studies reported on imaging modality, 51 studies reported treatment modality. Aside from a single randomised controlled trial, all other studies were observational (n = 25) or case series (n = 36). Computer tomography (CT) was used to diagnose DNSI in 78% of patients. The mean percentage of management with open surgical drainage was 81% and 29.4% for radiologically guided aspiration, respectively. Qualitative analysis identified seven major themes on DNSI.

CONCLUSIONS

There are limited methodologically rigorous studies investigating DNSIs. CT imaging was the most used imaging modality. Surgical drainage was commonest treatment choice. Areas of further research on epidemiology, reporting guidelines and management are required.

Treatments and outcomes of adult parapharyngeal and retropharyngeal abscess: 1882 cases from a Japanese nationwide database

PURPOSE

Although parapharyngeal and retropharyngeal abscesses are potentially fatal deep neck abscesses, there is limited evidence for the treatment courses for adult patients with these abscesses. We aimed to describe the practice patterns and clinical outcomes of adult patients undergoing an emergency surgery for parapharyngeal or retropharyngeal abscesses using a nationwide database.

MATERIALS AND METHODS

We identified patients aged ≥18 years who underwent emergency surgery for parapharyngeal (para group, n = 1148) or retropharyngeal (retro group, n = 734) abscesses from July 2010 to March 2020, using a nationwide inpatient database. We performed between-group comparisons of the baseline characteristics, treatment course, and outcomes.

RESULTS

Compared with the retro group, the para group was more likely to be older (median, 66 vs. 60 years; P < 0.001) and have several comorbidities, such as diabetes (21 % vs 16 %; P = 0.010) and epiglottitis (33 % vs. 26 %; P = 0.002), except for peritonsillar abscess (14 % vs. 22 %; P < 0.001) and tonsillitis (2.1 % vs. 13 %; P < 0.001). Regarding intravenous drugs administered within 2 days of admission, approximately half of the patients received steroids, non-antipseudomonal penicillins, and lincomycins. The para group received more comprehensive treatments, such as tracheostomy, intensive care unit admissions, and swallowing rehabilitation, within total hospitalization than the retro group. Moreover, it demonstrated higher in-hospital mortality (2.7 % vs. 1.1 %; P = 0.017) and morbidity (16 % vs. 9.7 %; P < 0.001), and longer length of hospitalization than the retro group.

CONCLUSION

The current nationwide study provided an overview of the characteristics, treatments, and outcomes for patients who underwent an emergency surgery for parapharyngeal or retropharyngeal abscess.

Critical infections in the head and neck: A pictorial review of acute presentations and complications

Non-traumatic head and neck emergencies include several disease processes such as infectious, inflammatory, and malignant. Infections are among the most common pathological processes that affect the head and neck, and are particularly important due to their acute, severe, and potentially life-threatening nature. Radiologists need to be well acquainted with these entities because any delay or misdiagnosis can lead to significant morbidity and mortality. Having a general understanding of such diseases is crucial, their prevalence, clinical presentation, common causative pathogens, route of spread, potential complications, and multimodality radiological appearance. Furthermore, understanding the relevant anatomy of the region, including the various fascial planes and spaces, is essential for radiologists for accurate image interpretation and assessment of potential complications. Our aim is to review the most common severe infections affecting the head and neck as well as other rare but potentially life-threatening infections. We will also describe their imaging features while focusing on the anatomy of the regions involved and describing their potential complications and treatment options.

Clinical evaluation of antibiotic regimens in patients with surgically verified parapharyngeal abscess: a prospective observational study

PURPOSE

We aimed to evaluate the effectiveness of different antibiotic regimens for the treatment of parapharyngeal abscess (PPA) and characterize patients, who suffered potentially preventable complications (defined as death, abscess recurrence, spread of infection, or altered antibiotic treatment because of insufficient progress).

METHODS

Sixty adult patients with surgically verified PPA were prospectively enrolled at five Danish Ear-nose-throat departments.

RESULTS

Surgical treatment included internal incision (100%), external incision (13%), and tonsillectomy (88%). Patients were treated with penicillin G ± metronidazole (n = 39), cefuroxime ± metronidazole (n = 16), or other antibiotics (n = 5). Compared to penicillin-treated patients, cefuroxime-treated patients were hospitalized for longer (4.5 vs 3.0 days, p = 0.007), were more frequently admitted to intensive care (56 vs 15%, p = 0.006), underwent external incision more frequently (31 vs 5%, p = 0.018), and suffered more complications (50 vs 18%, p = 0.022), including re-operation because of abscess recurrence (44 vs 3%, p < 0.001). Nine patients suffered potentially preventable complications. These patients displayed significantly higher C-reactive protein levels, received antibiotics prior to admission more frequently, underwent external incision more commonly, and were admitted to intensive care more frequently compared to other patients.

CONCLUSION

The majority of patients with PPA were effectively managed by abscess incision, tonsillectomy, and penicillin G ± metronidazole. Cefuroxime-treated patients were more severely ill at time of admission and had worse outcome compared to penicillin-treated patients. We recommend penicillin G + metronidazole as standard treatment for patients with PPA, but in cases with more risk factors for potentially preventable complications, we recommend aggressive surgical and broadened antibiotic therapy, e.g. piperacillin-tazobactam.

Microbiology of parapharyngeal abscesses in adults: in search of the significant pathogens

We aimed to describe the microbiology of parapharyngeal abscess (PPA) and point out the likely pathogens using the following principles to suggest pathogenic significance: (1) frequent recovery, (2) abundant growth, (3) growth in relative abundance to other microorganisms, (4) percentage of the isolates recovered in both absolute and relative abundance, (5) more frequent recovery in PPA pus compared with tonsillar surface and tissue. Comprehensive bacterial cultures were performed on specimens obtained from adult patients (n = 60) with surgically verified PPA, who were prospectively enrolled at five Danish ear-nose-throat departments. The prevalent isolates (in PPA pus) were unspecified anaerobes (73%), non-hemolytic streptococci (67%), Streptococcus anginosus group (SAG) (40%), Corynebacterium spp. (25%), Neisseria spp. (23%), Fusobacterium spp. (22%), Fusobacterium necrophorum (17%), Prevotella spp. (12%), and Streptococcus pyogenes (10%). The bacteria most frequently isolated in heavy (maximum) growth were unspecified anaerobes (60%), SAG (40%), F. necrophorum (23%), and Prevotella spp. (17%). The predominant microorganisms (those found in highest relative abundance) were unspecified anaerobes (53%), SAG (28%), non-hemolytic streptococci (25%), F. necrophorum (15%), S. pyogenes (10%), and Prevotella spp. (10%). Four potential pathogens were found in both heavy growth and highest relative abundance in at least 50% of cases: F. necrophorum, Prevotella spp., SAG, and S. pyogenes. SAG, Prevotella spp., F. necrophorum, S. pyogenes, and Bacteroides spp. were recovered with the same or higher frequency from PPA pus compared with tonsillar tissue and surface. Our findings suggest that SAG, F. necrophorum, Prevotella, and S. pyogenes are significant pathogens in PPA development.

Experiential learning in simulated parapharyngeal abscess in breathing cadavers

Purpose

Education in airway management is a fundamental component of anesthesiology training programs. There has been a shift towards the use of simulation models of higher fidelity for education in airway management. The goal of this study was to create a novel cadaveric model of a simulated parapharyngeal abscess with features of a difficult airway such as distorted anatomy and narrow airway passages presenting as stridor. The model was further assessed for its suitability for enhanced experiential learning in the management of difficult airways.

Methods

Cadaver heads were modified surgically to simulate parapharyngeal abscess. Airtight torso of the cadaver was connected to an Oxylog ventilator to simulate respiratory movements—the opening and closing of air channels with breaths in a patient with parapharyngeal abscess. Advanced airway workshop facilitators conducted directed one-to-one learning, and provided feedback to participants. A paper-based feedback was obtained from 72 participants on their confidence level, and the realism, attractiveness, beneficial, and difficulty levels of the simulated cadaveric models.

Results

The modified cadavers were reliable in simulating difficult airways. The majority of participants (91%) reported an increase in confidence level for management of the difficult airway after the experience with the modified cadavers and found the models realistic (93%), attractive (92%), beneficial (93%), and difficult (85%).

Conclusions

Surgical modifications of cadavers to simulate difficult airways such as parapharyngeal abscess with edema and stridor can be incorporated into advanced airway management courses to enhance experiential learning in airway management by awake fibreoptic intubation, and promote patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00540-021-02904-0.

Patients with comorbid rheumatoid arthritis are predisposed to peritonsillar abscess: real-world evidence

PURPOSE

The peritonsillar abscess (PTA)-rheumatoid arthritis (RA) association remains unclear. Here, the effects of RA on PTA incidence and prognosis are elucidated.

METHODS

We compared PTA incidence and prognosis of 30,706 RFCIP-registered patients with RA (RA cohort) with matched individuals without RA from another database of 1 million randomly selected people representing Taiwan's population (non-RA cohort).

RESULTS

The RA cohort had significantly higher PTA incidence [incidence rate ratio (IRR) (95% CI) 1.73 (1.10-2.71), P = 0.017) and cumulative incidence (P = 0.016, Kaplan-Meier curves). Cox regression analyses demonstrated RA cohort to have an estimated 1.72-fold increased PTA risk (95% CI 1.09-2.69, P = 0.019). PTA was more likely within the first 5 years of RA diagnosis (for < 1, 1-5, and ≥ 5 postdiagnosis years, IRRs: 2.67, 2.31, and 1.10, respectively, and P = 0.063, 0.021, and 0.794, respectively; average onset duration: 4.3 ± 3.3 years after RA diagnosis). PTA increased length of hospital stay significantly and risk of complication with deep neck infection nonsignificantly [6.5 ± 4.5 vs 4.6 ± 2.8 days (P = 0.045) and 18.52% vs 7.81% (P = 0.155), respectively]. Moreover, RA-cohort patients not receiving RA therapy exhibited 5.06-fold higher PTA risk than those receiving RA-related therapy (95% CI 1.75-14.62, P = 0.003).

CONCLUSIONS

In patients with RA, PTA incidence is the highest within 5 years of RA diagnosis, and RA therapy is essential for reducing PTA risk.

LEVEL OF EVIDENCE

4.

Severe parapharyngeal abscess that developed significant complications: management during the COVID-19 pandemic

A 50-year-old Caucasian man presented to the emergency department during the early stages of the COVID-19 pandemic with a rapidly progressive facial swelling, fever, malaise and myalgia. The patient had recently travelled to a COVID-19-prevalent European country and was therefore treated as COVID-19 suspect. The day before, the patient sustained a burn to his left forearm after falling unconscious next to a radiator. A CT neck and thorax showed a parapharyngeal abscess, which was surgically drained, and the patient was discharged following an intensive care admission. He then developed mediastinitis 3 weeks post-discharge which required readmission and transfer to a cardiothoracic unit for surgical drainage. This report discusses the evolution of a deep neck space infection into a mediastinitis, a rare and life-threatening complication, despite early surgical drainage. This report also highlights the difficulties faced with managing patients during the COVID-19 pandemic.

Complications of peritonsillar abscess

Background

The vast majority of patients with peritonsillar abscess (PTA) recover uneventfully on abscess drainage and antibiotic therapy. However, occasionally patient´s condition deteriorates as the infection spread in the upper airway mucosa, through cervical tissues, or hematogenously. The bacterial etiology of PTA is unclarified and the preferred antimicrobial regimen remains controversial. The current narrative review was carried out with an aim to (1) describe the spectrum of complications previously recognized in patients with peritonsillar abscess (PTA), (2) describe the bacterial findings in PTA-associated complications, and (3) describe the time relation between PTA and complications.

Methods

Systematic searches in the Medline and EMBASE databases were conducted and data on cases with PTA and one or more complications were elicited.

Results

Seventeen different complications of PTA were reported. The most frequently described complications were descending mediastinitis (n = 113), para- and retropharyngeal abscess (n = 96), necrotizing fasciitis (n = 38), and Lemierre´s syndrome (n = 35). Males constituted 70% of cases and 49% of patients were > 40 years of age. The overall mortality rate was 10%. The most prevalent bacteria were viridans group streptococci (n = 41, 25%), beta-hemolytic streptococci (n = 32, 20%), F. necrophorum (n = 21, 13%), S. aureus (n = 18, 11%), Prevotella species (n = 17, 10%), and Bacteroides species (n = 14, 9%). Simultaneous diagnosis of PTA and complication was more common (59%) than development of complication after PTA treatment (36%) or recognition of complication prior to PTA (6%).

Conclusion

Clinicians involved in the management of PTA patients should be aware of the wide range of complications, which may arise in association with PTA development. Especially males and patients  > 40 years of age seem to be at an increased risk of complicated disease. In addition to Group A streptococci and F. necrophorum, the current findings suggest that viridans group streptococci, S. aureus, Prevotella, and Bacteroides may also play occasional roles in the development of PTA as well as spread of infection. Complications occasionally develop in PTA patients, who are treated with antibiotics and surgical drainage.

A Retrospective Cohort Study of Risk Factors for Descending Necrotizing Mediastinitis Caused by Multispace Infection in the Maxillofacial Region

PURPOSE

Descending necrotizing mediastinitis (DNM) has been the most common life-threatening complication of multispace infection (MSI) in the maxillofacial region owing to the lack of a timely diagnosis and treatment. We assessed the clinical characteristics and diagnosis of odontogenic MSI and evaluated the risk factors for DNM caused by MSI.

PATIENTS AND METHODS

We performed a retrospective cohort study of inpatients with MSI in the maxillofacial region from January 2012 to October 2016. The patients were classified into a non-DNM group and a secondary DNM group. The information collected included gender, age, systemic comorbidities, source of maxillofacial infection, computed tomography imaging data, and laboratory test results. Univariate analysis (t test and χ² test, or the Fisher exact test) and logistic regression analysis were applied.

RESULTS

A total of 296 patients were included. The mortality was 6.3%. On univariate analysis, the following factors were statistically significant: gender (P = .001); age (P = .003); source of infection (P = .004); number of affected spaces (P < .001); involvement of the parotid space (P < .001), submandibular space (P < .001), subgingival space (P < .001), pterygomandibular space (P < .001), parapharyngeal space (P < .001), and retropharyngeal space (P < .001); and percentage of neutrophils (P < .001). On multivariate analysis, the parapharyngeal space (P = .008), source of infection (P = .037), and number of affected spaces (P < .001) were statistically significant.

CONCLUSIONS

Glandular infection, parapharyngeal space involvement, and the presence of multiple affected spaces were risk factors for DNM. Clinicians should vigilantly watch for these factors during clinical treatment and effective measures taken to prevent the occurrence of DNM as soon as possible.

A Perspective of Clinical Behaviour and Management of Deep Neck Space Infections (DNSI): The Clinical Conundrum

The diagnosis and management of deep neck space infections remain a challenging task for otolaryngologists. A retrospective observational analysis of 137 cases of deep neck infections at a tertiary care centre was reviewed. We present 137 treated cases of DNSIs in a retrospective 5 years clinical study conducted in the department of otolaryngology at a tertiary care center from January 2012 to December 2016. Demographic information, Socio-economic data, etiopathogenesis, clinical presentation, spaces involved, diagnosis, and treatment strategies, associated morbidities, course and complications were analysed and compared with past experiences. Odontogenic and salivary gland infections causes were the most common source of DNIs. Major complication observed was skin defect. In this study, submandibular space infection was found to be the most common space involved in DNSI. Pain (100%) was the most common clinical complaint followed by neck swelling (65.69%). Staphylococcus aureus (38 cases) was the most common micro-organism isolated. Surgical intervention was the main modality of treatment and there was one mortality. DNSIs are fairly common challenging and potentially lethal entities which can lead to severe complications in a very short time, should there be delay in its prompt diagnosis and management. Computerized Tomography Scan (CT scan) with contrast is the investigation of choice in diagnosing DNSIs. Assessment of airway control must take precedence.

The usefulness of abscess tonsillectomy followed by intraoral drainage for parapharyngeal abscess concomitant with peritonsillar abscess in the elderly

Parapharyngeal abscess (PPA) may cause life-threatening complications and peritonsillar abscess (PTA) and tonsillitis frequently precede PPA. The optimal management of PPA caused by PTA has been the subject of debate with respect to the surgical approach. We present three cases of PPA concomitant with PTA in elderly patients. In two cases, the abscesses in parapharyngeal space were drained by abscess tonsillectomy followed by intraoral incision of the tonsillar bed. On the other hand, the third case did not undergo abscess tonsillectomy because of his refusal of surgery and needed extraoral drainage after the aggravation of PPA. Based on the experience of those three cases, it was suggested that abscess tonsillectomy followed by intraoral incision of the tonsillar bed might be a useful surgical approach for the drainage of PPA concomitant with PTA, especially in elderly patients.

Transcanal incision and drainage of a parapharyngeal abscess in a pediatric patient: A novel technique

The disease of parapharyngeal abscess is well known to the otolaryngologist and is commonly managed via transoral, transcervical, or combined incision and drainage. We report a novel approach to an abscess that was drained through the external auditory canal (EAC). An otherwise healthy 2-year-old female presented with a 4-day history of fevers, decreased oral intake, neck stiffness, and voice changes. CT neck with contrast revealed a deep abscess in the left neck extending from the peritonsillar space into the parapharyngeal space in close proximity to the anterior aspect of the EAC. Because the EAC was the closest surface to the abscess collection, we elected to attempt drainage through this route. Successful incision and drainage was performed via transcanal approach. She received intravenous antibiotics and steroids post-operatively and surgical packing was removed. She was discharged home on post-operative day 5 afebrile and tolerating a regular diet and continued to do well at most recent outpatient follow-up.

Deep neck infections: A single-center analysis of 63 cases

BACKGROUND AND PURPOSE

With the use of antibiotic therapy, the incidence of deep neck infections has decreased in recent decades. The aim of this investigation was to review the clinical course and the management of deep neck infections in our department, compare them to the experiences of the common literature and identify predisposing factors for lethal complications.

MATERIAL AND METHODS

In this single-center analysis, 63 patients with deep neck infections were treated surgically. The following clinical data were analyzed and compared: age, gender, laboratory data, spatial manifestation, therapeutic modalities, comorbidities, length of hospitalization and complications.

RESULTS

There was a predominance of male patients (58.7%) and a mean age of 57.9 years. The most common symptoms at diagnosis were sore throat (96.8%) and neck swelling (92.0%). Cardio/pulmonary diseases and diabetes mellitus were the most common comorbidities. There was a significantly longer hospital stay for patients with diabetes mellitus. The most common manifestation was a parapharyngeal abscess in 24 patients (38.1%), followed by peri-/retrotonsillar infections in 19 patients (30.2%). In 29 patients, a multiple space infection was observed, with a significantly longer duration of hospitalization and a higher rate of complications. The main life-threatening complication was the development of airway obstruction in 20 patients (31.7%), who all received a tracheostomy. The duration of hospitalization for patients with complications was significantly longer.

CONCLUSION

Close attention must be paid to the management of patients with deep neck infections, especially patients with diabetes mellitus and cardio/pulmonary diseases or patients with multiple space infections.

Rare mycotic aneurysms of internal jugular vein and innominate vein secondary to untreated parapharyngeal abscess: A case report

We report a 31 year old woman presented with three months history of large untreated parapharyngeal abscess and bleeding from the mouth. On evaluation chest CT scan identified the abscess extending down to the superior mediastinum and multiple small lung abscesses. Echocardiography showed tricuspid valve insufficiency. Patient was brought to the operating room (OR) and intra-operatively it was found that she had multiple large mycotic pseudoaneurysms of the internal jugular vein and right brachiocephalic veins. All these pseudoaneurysms were repaired with pericardial patches under cardiopulmonary bypass. Patient did well in the short postoperative follow up and was then referred to plastic surgery and ENT for further surgical interventions.

Parapharyngeal abscess is frequently associated with concomitant peritonsillar abscess

To characterize patients with parapharyngeal abscess admitted to a Danish tertiary care centre and evaluate our management. This is a retrospective chart review. All records of patients with parapharyngeal abscess admitted to the Ear-Nose-Throat Department at Aarhus University Hospital, Denmark, from January 2001 through December 2011 were reviewed. In total, 63 patients (41 males), aged 4-89 years (median, 45 years) were included in the study. The mean annual incidence of parapharyngeal abscess was 0.9 cases/100,000 population. Thirty-three (52%) patients had concomitant peritonsillar abscess. In two patients the parapharyngeal abscess was accompanied by necrotizing fasciitis. The most frequent surgical approach used was intrapharyngeal incision in combination with tonsillectomy. The most commonly used antibiotic regimen was benzylpenicillin plus metronidazole. Seven (13%) patients returned to the operating theatre due to post-tonsillectomy haemorrhage or insufficient abscess drainage. Tonsillectomy and internal incision of the abscess in combination with a narrow-spectrum intravenous penicillin and metronidazole is a safe and efficient approach for managing parapharyngeal abscesses. This approach, however, carries a relatively high complication rate, requiring close surveillance in the early post-operative period. This is especially true for parapharyngeal abscess patients without peritonsillar abscess. In our series, these patients were more ill, more likely to experience complications, require intensive care, intubation, and tracheotomy, than parapharyngeal abscess patients with concurrent peritonsillar abscess. The frequent co-existence of parapharyngeal abscess and peritonsillar abscess favours careful consideration of addition of tonsillectomy to intrapharyngeal incision.

Just a sore throat? Uncommon causes of significant respiratory disease

We present two uncommon underlying causes of a sore throat which, if missed or delayed in diagnosis, can lead to disastrous consequences. Our first case is of Lemierre's syndrome diagnosed in a 21-year-old man presenting with a 5-day history of sore throat, fever, right-sided pleuritic chest pain and bilateral pulmonary nodules on CT imaging. Fusobacterium necrophorum cultured from peripheral blood and an occluded left internal jugular vein on ultrasound lead to an eventual diagnosis. Our second case presents a 29-year-old woman with a 5-day history of sore throat, fever and right-sided pleuritic chest pain. A left-sided quinsy was diagnosed and aspirated and the patient was discharged home. She represented shortly with worsening pleuritic pain and was found to have a right-sided pleural effusion with descending mediastinitis originating from the tonsillar abscess. Delayed diagnosis resulted in open thoracotomy, decortication and prolonged intravenous antibiotics.

An 18FDG-PET/CT finding of a mediastinal abscess

A 66-year-old man with left pyriform fossa squamous cell carcinoma (T2N0) was treated with chemoradiation. Nine months later, an emergency tracheostomy was performed for respiratory distress. Contrast-enhanced neck and thorax CT demonstrated a right pyriform mass. FDG-PET/CT showed linear increased uptake extending superiorly from the tracheostomy to the right Eustachian tube and inferiorly to the posterior mediastinum. Postmortem examination confirmed a 7 × 2.2 cm abscess extending from the right parapharyngeal, peritracheal, and prevertebral structures to the mediastinum.

[Peritonsillar infections: prospective study of 100 consecutive cases]

INTRODUCTION

Peritonsillar infection is the most frequent complication of acute tonsillitis. Peritonsillar infections are collections of purulent material, usually located between the tonsillar capsule and the superior constrictor of the pharynx. Peritonsillar infection can be divided into abscess and cellulitis.

MATERIAL AND METHODS

We prospectively analysed the clinical data from 100 patients with peritonsillar infection from 2008 to 2010. The diagnosis of abscess or peritonsillar cellulitis was primarily based on obtaining pus through fine-needle aspiration.

RESULTS

Seventy-seven per cent of patients had no history of recurrent tonsillitis and 55% were receiving antibiotic treatment. Sixty-two cases were peritonsillar abscess and the rest were cellulitis. Trismus, uvular deviation and anterior pillar bulging were statistically associated with peritonsillar abscess (P<.005). All patients were admitted to hospital and treated with puncture-drainage, intravenous antibiotics (amoxicillin/clavulanate in 83% of cases) and a single dose of steroids. All patients were discharged on oral antibiotic therapy. The mean length of hospital stay was 3 days and the recurrence rate was 5%.

CONCLUSIONS

Due to the absence of clinical practice guidelines, there are different therapeutic protocols. According to our experience, puncture-aspiration and administration of intravenous antibiotics is a safe, effective way to treat these patients. To determine the efficacy and safety of outpatient management, controlled studies would be needed.

Changing trends of peritonsillar abscess

OBJECTIVE

This retrospective, cohort study aims to assess the changing characteristics of peritonsillar abscess (PTA).

METHOD

Data were obtained from PTA patient records admitted to a secondary hospital over a 10-year period.

RESULTS

A total of 427 patients, aged 31.6 +/- 15.2 years (range, 3-91), were treated for PTA, reflecting an incidence of 0.9/10 000/y. Forty-seven (11%) patients had more than one episode. There was no sex, seasonal, or side predominance. Thirteen (3%) patients developed complications. One hundred four (24.4%) patients were 40 years or older, had a longer hospital stay, and were prone to complications. One hundred two (23.8%) patients did not have an anteceding pharyngotonsillitis. Smoking was more common among patients with PTA as compared with the general population and was associated with more complications. A total of 283 (66.2%) patients developed PTA in spite of prior antibiotic therapy; 51.1% of smokers that received prior antibiotics had a higher incidence of Streptococcus viridans isolates.

CONCLUSION

Peritonsillar abscess may have changed its characteristics: affecting more older patients having a worse and longer course and PTA evolvement without anteceding tonsillitis or in spite of a prior adequate antibiotic therapy. Smoking may be a predisposing factor.

Immediate tonsillectomy: indications for use as first-line surgical management of peritonsillar abscess (quinsy) and parapharyngeal abscess

Objectives:

This study was designed to evaluate the efficacy and morbidity of immediate tonsillectomy used to treat peritonsillar abscess (quinsy) and parapharyngeal abscess.

Subjects and method:

This four-year, retrospective study was based on 31 patients hospitalised in a university hospital ENT and head and neck surgery department for peritonsillar and/or parapharyngeal abscess. All patients underwent immediate, bilateral tonsillectomy. The length of hospital stay, duration of antibiotic therapy, microbiological findings, complications, and the time to complete recovery and oropharyngeal healing were recorded.

Results:

The patients' mean post-tonsillectomy hospital stay was 2.84 days (median: 3 days). No post-operative haemorrhage was observed. All patients were considered to be cured at the day 10 follow-up visit, and complete oropharyngeal healing was observed at the day 21 visit. The duration of antibiotic therapy ranged from 10 to 15 days (mean: 11.5 days; median: 10 days).

Discussion and conclusion:

Immediate tonsillectomy appears to be a safe and effective surgical technique for the management of peritonsillar and parapharyngeal abscess; in particular, it markedly reduces patients' hospital stay (when performed early in the course of the disease) and duration of antibiotic therapy. Immediate tonsillectomy has become the first-line treatment for parapharyngeal abscess and several types of peritonsillar abscess in our department.

[Ascending pancreatitis with mediastinal and parapharyngeal involvement]

A male patient who had suffered from alcohol dependence for several years was transferred to the Magdeburg University Hospital with signs of sepsis. The main cause for this was a previously unsuccessfully treated acute episode of chronic pancreatitis. Diagnostic imaging showed a distended ascending abscess extending above the larynx. During interdisciplinary emergency surgery, the neck, mediastinum and abdomen were drained and the pancreatic abscess removed. Under drainage, antibiotic therapy and parenteral nutrition the patient made a full recovery.

Parapharyngeal abscess: diagnosis and treatment

To study the circumstances of diagnosis, predisposing factors, bacteriology and therapeutic management of parapharyngeal abscesses. This retrospective study over a period of 7 years concerned 16 patients hospitalized in an ENT and Head and Neck surgery department for parapharyngeal abscess. All patients were treated by intravenous antibiotics and steroids for 5-7 days. The length of hospital stay was 6-15 days. Parapharyngeal abscesses associated with peritonsillar and retropharyngeal abscess were all initially aspirated transorally for evacuation and bacteriologic examination. Five patients underwent surgical drainage (two via cervical incision, three by immediate tonsillectomy techniques and one by intra-oral drainage). Two patients presented jugular vein thrombosis. No life-threatening complication was observed. Patients were considered to be cured when cervical CT scan performed on D21-45 was normal. Parapharyngeal abscess is the second most common deep neck abscess after peritonsillar abscess. The diagnosis is both clinical and radiologic. CT scan is the best imaging examination for diagnosis and follow-up of parapharyngeal abscess. Non-complicated parapharyngeal abscesses require first-line medical management (intravenous antibiotics (amoxicillin and clavulanic acid) combined with steroids) and follow-up CT scan.

[Abscess of the parapharyngeal space]

The abscess of parapharyngeal space is very dangerous health condition graving numerous complications such as: jugular vein thrombosis, mediastinitis, arterial bleeding. This state originates most frequent during the acute pharyngitis, and especially acute tonsillitis. The aim of our study was to review the clinical sings, computed tomography scans and outcome of parapharyngeal space infection. 3 patients treatment in our Department were underwent surgical drainage and aggressive antibiotic therapy. One patient was treated solely with intravenous antibiotic therapy. The average time of hospitalization was 16 days. No one complication was observed.

Unusual radiographic appearance of drug-induced pharyngeal angioedema and differential considerations

A 59-year-old woman treated chronically with enalapril, an angiotensin-converting enzyme inhibitor (ACE-I) presented with difficult swallowing and speaking. Although her symptoms were clinically consistent with an adverse angioedema reaction to the ACE-I, initial imaging was not entirely consistent with our conceptual understanding of angioedema. This case report will discuss the myriad possible imaging presentations of this disease, as well as the differential diagnosis for this atypical manifestation of ACE-I-induced angioedema.

Use of intraoperative ultrasound for localizing difficult parapharyngeal space abscesses in children

While treatment of parapharyngeal and deep-space neck abscesses has progressed rapidly due to improvements in diagnostic imaging and medical therapy, surgical drainage remains the mainstay of treatment for larger and medically unresponsive abscesses. In many cases the intricate and delicate anatomy in children represents a challenging situation for the surgeon, particularly if he or she is not experienced in the care of the pediatric population. We present a novel idea used in the surgical management of parapharyngeal space abscesses in three children less that 6 years of age, in whom intraoperative ultrasound was used as an additional tool to locate and successfully drain the abscess.

From a sore throat to the intensive care unit: the Lemierre syndrome

Lemierre syndrome is characterized by an acute oropharyngeal infection, suppurative thrombophlebitis of the internal jugular vein and metastatic infections. The infection is usually caused by Fusobacterium necrophorum. We report on a 19-year-old male patient who was admitted with a five-day history of fever, sore throat and progressive dyspnea. Computed tomography of the neck and chest revealed a parapharyngeal abscess, jugular vein thrombosis, descending necrotizing mediastinitis and multiple areas of bilateral consolidation and cavitations within the lungs. Fusobacterium necrophorum was identified in the blood culture. Early combined abscess drainage with neck and chest incisions, together with broad spectrum intravenous antibiotic treatment and medical management in an intensive care unit resulted in a good clinical outcome.