Volume 2, Issue 1 , Pages 14-16, March 2007
Drainage of parapharyngeal abscess with modified needle
Article Outline
Summary
We report a parapharyngeal abscess in an infant that was drained transorally with a modified angled needle. Although transoral drainage of parapharyngeal abscesses has been described, there are no reports – to our knowledge – on the use of a modified angled needle. Our approach was effective and resulted in a rapid resolution of the symptoms. Management and different approaches for management of parapharyngeal abscess are briefly discussed.
Keywords: Parapharyngeal abscess, Pediatric, Transoral, Modified needle
1. Introduction
The initial diagnosis of a parapharyngeal abscess, especially in infants, is quite challenging as the disease often develops gradually. Optimal management of parapharyngeal abscesses has been the subject of debate with no global agreement on issues such as optimum approach or choice of antibiotic therapy. Many authors recommend initial medical treatment in the cellulitic stage, whilst reserving surgical intervention for established abscesses or for patients who fail to improve within 48
h of antimicrobial therapy, stressing that airway obstruction is the most important issue in treating such abscesses [1]. The aim of this paper is to describe successful transoral drainage of a parapharyngeal abscess in an infant with a modified angled needle.
2. Case report
A 7-month-old boy presented with a 2-day history of lethargy, irritability and reluctance to eat. Examination was unremarkable apart from a mild tonsillar erythema. His immunization history was up to date. During the night of his admission, the child spiked a temperature of 38.5 and his blood results showed marked leukocytosis with neutrophilia (WBC 34.5, Neutrophils 23.8, CRP 82). The following day oropharyngeal examination showed unilateral congestion and medial displacement of the tonsil. By this time, he was already started on intravenous cefuroxime. As meningitis had to be excluded, a lumbar puncture (LP) in addition to a CT scan of the neck was performed. LP was normal but the CT showed a 3cm×2cm swelling around the parapharyngeal area immediately medial to the internal carotid artery (Fig. 1). By the third day, the inflammatory parameters were not coming down significantly (WBC 26.8, CRP 76) despite intravenous antibiotics and the patient started developing torticollis. There was no airway compromise. It was therefore decided to drain the abscess under GA. After careful evaluation of the CT scan, intra-oral route was used to drain the abscess. Instead of a straight needle, a modified angled needle (routinely used in our department for peritonsillar abscesses) was used (Fig. 2). The angled tip was used to pierce through the point of maximum fluctuance of the swelling with immediate release of copius amounts of pus and subsequent rapid resolution of symptoms within 24h. The child was discharged 2 days postoperatively and remains well.
Fig. 1.
Axial CT neck showing a 3
cm×2cm swelling (big arrow) around the parapharyngeal area immediately medial to the internal carotid artery (small arrow).
Fig. 2.
A modified angled needle.
3. Discussion
The parapharyngeal space is a potential deep cervical space that is pyramidal in shape. Its base is at the skull base and its apex is at the hyoid. It is medially bounded by the buccopharyngeal fascia and the constrictor muscles of the pharynx. Laterally, it is bounded by the ascending ramus of the mandible and the pterygoid muscles. Posteriorly, it abuts the carotid sheath, which in turn lies anterior to the prevertebral fascia. Anteriorly, it ends at the pterygomandibular raphe [2].
Parapharyngeal abscess usually presents with local symptoms such as sore throat, dysphagia, dysphonia, trismus and drooling. Systemic symptoms of the disease include fever, malaise and leukocytosis [3]. The suspicion for parapharyngeal abscess becomes high if sore throat does not resolve even with antibiotics. Neck swelling, induration and limitation of neck movement however almost always indicate parapharyngeal space involvement.
Oropharyngeal infection, dental sepsis and local trauma are often implicated as causes of the disease [4]. It was hypothesized that an infected tonsil can spread infection to the parapharyngeal space through a weakness in the capsule and through preformed holes in the superior constrictor muscle [5]. Early identification of the infection cannot be over emphasized, as this would avoid the risk of rapid upper airway obstruction due to the swelling in the pharyngeal wall, and avoid the spread of infection to the mediastinum along the cervical facia of the longitudinal neck spaces [6].
Laboratory studies are unnecessary if the diagnosis is straightforward. A FBC may show leukocytosis with a predominance of neutrophils. Ultrasound, CT and MRI have all been used to confirm the diagnosis.
Non-surgical treatment depends upon hydration, analgesia and antibiotics. Surgical treatment can be via either external or intra-oral approach [7].
It is worthwhile to mention that in many pediatric cases, the parapharyngeal abscess coexists with the retropharyngeal abscess and both abscesses may communicate. This makes the intra-oral approach (which is more favourable in the retropharyngeal abscess) ideal to drain both abscesses [7], [3], [8].
Potential risks/concerns associated with needle aspiration over a more conventional incision and drainage are: incomplete evacuation of abscess and possible vascular injury by a sharp needle inserted blindly. An alternative technique for management of similar lesions would be to make a small incision in the mucosa with a blade and then to introduce a curved blunt clamp into the abscess cavity and spread as it is gently advanced. This avoids potential needle injury to vascular structures and the resulting opening into the abscess cavity allows for irrigation and will stay open for 24–48h to allow for further drainage.
4. Conclusion
The use of a modified angled needle for transoral drainage of parapharyngeal abscess has not been described. It proved easy to use with excellent results.
References
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PII: S1871-4048(06)00094-3
doi:10.1016/j.pedex.2006.10.003
© 2006 Published by Elsevier Inc.
Volume 2, Issue 1 , Pages 14-16, March 2007
