Parapharyngeal space infections
Parapharyngeal space infections occur in the deep neck, e.g., submandibular or retropharyngeal areas. Differential diagnosis includes parotitis, actinomycosis, peritonsillar abscess, and lymphadenitis. Sources include dental, foreign body, tonsillitis, malignancy, and surgical complication.
CASES/YEAR
300 (US); 6,000 (Global)
OTHER NAMES
Deep neck infections; Submandibular (sublingual) infection; Lateral pharyngeal (parapharyngeal) infection; Retropharyngeal space infection; Parapharyngeal abscess; Ludwig's angina; Postanginal septicemia (Lemierre's disease);
INCUBATION
Estimated: 1-10 days;
INITIAL SYMPTOMS
Sore throat or dental infection;
COMMENTS
Parapharyngeal space infections usually originate in the tonsils or pharynx and sometimes from dental or lymph node sources. The parapharyngeal space is divided into anterior and posterior compartments by the styloid process. The posterior compartment contains the carotid arteries, internal jugular veins, and numerous nerves. Abscesses in the posterior compartment can cause septic thrombophlebitis or erosions of the carotid artery. [Merck Manual, p. 842] Differential diagnosis includes parotitis, actinomycosis, peritonsillar abscess, and lymphadenitis. Dental sources are most common; others sources are foreign body, tonsillitis, malignancy, and surgical complication. [ABX Guide: Cervical fascial space infections] Findings in retropharyngeal abscess may include sore throat, dysphagia, neck pain, drooling, stridor, and dyspnea. Complications include airway obstruction, aspiration pneumonia, pleural effusion, pericardial effusion, and mediastinitis. [Cohen, p. 314-5]
DIAGNOSTIC
Clinical diagnosis confirmed by contrast-enhanced CT; [Merck Manual, p. 842] CT scan with contrast or MRI can clearly define space; Gram stain & culture (sometimes cytology) after needle aspiration or surgery; [ABX Guide: Cervical fascial space infection]
SIGNS & SYMPTOMS
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>fever
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E dysphagia
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E pharyngitis
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H leukocytosis
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H lymphadenopathy
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N stiff neck
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R chest pain
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R dyspnea
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X pleural effusions
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*arthritis
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*brain abscess or lesion
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*cranial neuropathy
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*endocarditis
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*mediastinitis
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*osteomyelitis
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*pneumonia
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*sepsis
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*shock
ENTRY
Inhalation, Skin or Mucous Membranes (Includes Conjunctiva)
TREATMENT
Principles of treatment are: 1.) Define location with CT; 2.) ENT/Oral Surgery consult for drainage; 3.) Must get Gram stain and culture; 4.) Airway protection; and 5.) Initial antibiotics against anaerobes and streptococci; [ABX Guide: Deep Neck Infections]
REFERENCES FOR CASES/YEAR
1. (US) 1/20 X global cases/yr;
2. (Global) There were only 29 cases of parapharyngeal space infection or deep neck abscess hospitalized in a tertiary university hospital in Israel between 1988 and 2004 (15 years). 22 were posterior (relatively benign) and 7 were anterior (surgical drainage required and complications common). Assuming that all cases would have been referred to this tertiary hospital, then the incidence rate would be 29/15 or about 2 cases per year in a population of 8 million or about 0.25 cases/million/year; 131 patients were seen by the ENT physicians at Tan Tock Seng Hospital in Singapore for deep neck abscesses between 2004 and 2009 (5 years). The parapharyngeal space was involved in 31 of the cases. Singapore has a population of 5 million. Assuming that all cases would have been referred to this hospital, the incidence rate would be 29/5 = 5.8 cases/year and 5.8/5 million or about 1 case per million/year. Use this higher number.