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RETROPHARYNGEAL ABSCESS N.pptx
- 1. RETROPHARYNGEAL ABSCESS DR. NZEMEKE,ISIOMA R. RESIDENT DOCTOR DEPT OF ENT, LUTH NIGERIA.
- 2. OUTLINE • INTRODUCTION • RELEVANTANATOMY • EPIDEMIOLOGY • CLASSIFICATION • AETIOPATHOGENESIS • CLINICAL FEATURES • INVESTIGATIONS • DIFFERENTIAL DIAGNOSIS • TREATMENT • COMPLICATIONS • CONCLUSION • REFERENCES
- 3. INTRODUCTION • Retropharyngeal abscessia an infection of the retropharyngeal space • Retropharyngeal space is a potential space posterior to the pharynx and the cervical oesophagus • Often presents late, most times in airway obstruction • It is life threatening,adequate care and management is needed • Mortality and morbidity often follows delayed or missed diagnosis
- 4. EPIDEMIOLOGY • Incidence iscommoner in children than adults • mostly children 2-5years, following airway infection • Higher in males than females • No racial predilection • Incidence is declining -wide availability of antibiotics -improvement in medical care • OGB Nworgu et at (2005) UCH review 30patients within 10yrs – M:F - 1:1 – Age- 3mths-38yrs (23pxs ˂ 5yrs)
- 5. RELEVANT ANATOMY • Retropharyngealspace lies posterior to the pharynx and cervical oesophagus • It extends from the skull base to the level of vertebra T1 - T4, • Boundaries: alar fascia, buccopharyngeal fascia,parapharyngeal space, carotid shealth • Divided by a midline raphe
- 6. RELEVANT ANATOMY • Contents –lypmph; suprahyoid – fats • LYMPH NODES – medial nodes;atrophies – lateral nodes • node of Rouviere; superior most – drains the nasal cavity, paranasal sinuses, soft palate,auditory canal and middle ear
- 7. CLASSIFICATION 1. ACUTE – Commonerin children – Causes; • upper respiratory infection • trauma/foreign body impaction 2. CHRONIC – common with tuberculosis of the cervical spine – usually spreads from the prevertebral space – Insidous in onset – Mild symptoms or asymptomatic
- 8. AETIOPATHOGENESIS • Retropharyngeal abscessis polymicrobial; – implicatedcated in upper airway infections;rhinosinusitis,adenioditis,tonsilitis • Most common is group A beta-hemolytic Streptococcus. Others; – Staphylococcus auerus – Fusobacterium – Haemophilus • Also occurs – following direct trauma and subsequent innoculation into the retropharyngeal space – direct spread of infection from vertebral osteomyelitis or discitis, tuberculosis and fracture of the spine
- 9. AETIOPATHOGENESIS • Following infection; –Activation of interleukins – Release of inflammatory cells(neutrophils, macrophages,lymphocytes) • fever • pain • oedema • celluiltis – Phagocytosis, necrosis (liquefaction) – Abscess formation • In TB • spread to lymph nodes • spread from tubercular vertebral abscess • The risk increases in immunocompromised state ,manultrition, poor socioeconomic status
- 10. CLINICAL FEATURES Acute Symptoms –Fever – Nasal discharge – cough – vomiting – Sorethroat – odynophagia/refusal to feed – dysphagia – neck pain and swelling – dyspnoea – change in voice(muffled, hot potatoe voice)
- 11. CLINICAL FEATURES Signs – ill-lookingand toxic – pyrexia – dyspnoeic – drooling – torticollis – cervical lymphadenopathy • Inflammed and lateral bulging of the pharyngeal wall
- 12. CLINICAL FEATURES Chronic – painlesslump in the throat – dysphagia – Cough – weight loss – anorexia – chest pain – median bulging of the posterior pharyngeal wall
- 13. INVESTIGATIONS Specific • Plain softtissue lateral neck radiograph • contrast computed tomography scan of the neck • Magnetic resonance imaging • Acid fast bacillus test/Mantoux test/TB QuantiFEREON test • Culture and sensitivity
- 14. INVESTIGATION • Full bloodcount – Leucocytosis/Leucocytopaenia – Neutrophilia/neutropaenia – Eosinophilia – Lymphocytosis – Anaemia • Erythrocyte sedimentation rate ↑ • Serum glucose • Retroviral screening • Chest xray – mediastinitis – pneumonia
- 15. INVESTIGATION Plain soft tissuelateral neck radiograph – widening of the prevertebral soft tissue – >1/2 and 1/3rd of the corresponding vertebral body in adults and children respectively – straightening of the cervical spine and loss of the usual cervical lordosis. – pockets of gases • Caries and calcifications of the spine
- 16. INVESTIGATION Computed Tomograpy Scan – hypodensedlesion with peripheral/rim enhancement • differentiates abscess from cellulitis • extent of the abscess and complications
- 17. DIFFERENTIAL DIAGNOSIS • Croup –steeple’s sign on xray • Acute epiglottitis – thumbs up appearance on xray • Peritonsillar abscess • Parapharyngeal abscess • Odontal abscess
- 18. TREATMENT • Multidiscipline; ENTsurgeons, Anaesthestist, paediatricians, orthopaedics/spine surgeons, infectious disease control unit/microbiologist • Depends on stage at presentation • Principles/Aims of Treatment – airway management – drainage of abscess – antimicrobial therapy – prevent and manage complications
- 19. TREATMENT • Admit/resuscitation • Rehydrate •Antibiotics/Antituberculosis • Analgesics • Surgical airway management; – cricothyrotomy – Tracheostomy • Surgical drainage
- 20. TREATMENT Approaches – Transoral – Transcervical(anterioror posterior) • for large abscess • chronic abscess • significant inferior • abscess across fascia planes involving other deep neck spaces
- 21. TREATMENT Transoral Abscess drainage •preop blood workup • GXM blood • Obtain informed consent • Usually done under general anaesthesia via oroendotracheal tube or tracheostomy – care must be taken to avoid rupturing the abscess during intubation and should be done by the most ewxperienced anaesthestist
- 22. TREATMENT • Patient isplaced in supine position with the neck extended,shoulder roll applied, the head tilted downwards and stabilised • Draping • Mouth gag is applied • Pharynx is packed • Antibiotic administer
- 23. TREATMENT – Minimal decompressionwith needle and syringe – Vertical incision is made at the point of most fluctuancy – The abscess widely opened with a large clamp, the loculi broken and the contents suctioned completely. – Anaesthesia reversed – Endotracheal intubation may be left in place – Pus aspirate sent for MCS
- 24. TREATMENT Post op care 1.Maintain nil per os 2. Airway monitor and control 3. Antibiotics 4. Analgesics 5. Iv fuid 6. Treatment of underlying conditions and oral intake when stable
- 25. COMPLICATIONS • Extension ofinfection into mediastinum other neck spaces • Haemorrhage • Spontaneous rupture and aspiration • Laryngeal spasm • pneumonia • Septicemia • Reaccumulation of abscess
- 26. CONCLUSION • Retrophryngeal abscessis a life threatening conditions requiring urgent ENT care • prognosis is good if it is recognised and treated early • Prompt evaluation and care are important in limiting its fetal complications • It is also important to manage and possibly avoid the likely causes to minimise the risk of developing retropharyngeal abscess
- 27. REFERENCE • Scott-Brown’s Otorhinolaryngology,Head and Neck Surgery 7th edition • Textbook of Ear, Nose, Throat and Head Neck Surgery Clinical and Practical fourth Edition • Operative otorhinolaryngology • SURGICAL ANATOMY OF THE HEAD AND NECK • Introductory Head and Neck Imaging; Eugene Yu MD FRCPC University of Toronto Canada, Lalitha Shankar MD FRCPC University of Toronto Canada
- 28.