Deep Neck Space Infections: Parapharyngeal, Retropharyngeal and Peritonsillar Abscesses

Infections can form virtually anywhere in the body and the throat is no exception.  Surprisingly, the throat and surrounding areas is a rather complicated piece of anatomy.  There are several different areas or spaces that can become involved with infection in and around the throat.  And if an infection progresses, it can turn into an abscess.  An abscess is a collection of purulence (or “pus”)—a result of an infection left untreated.  It’s the body’s attempt to confine or wall-off the infection, preventing further spread, but in doing so it creates a great deal of pain and the person with the abscess feels absolutely crappy.  As per the previous post on peritonsillar abscesses, “peritonsillar” refers to an infection developing around or behind the tonsil, but there are two other areas where abscesses can occur.

Those other two also are classified as deep neck abscess because of their location in the neck.  There are other areas of the neck that can be involved but for the purposes of this discussion I kept the classification to the three more common ones that arise from the oropharynx (i.e., the ‘throat”) and which present to the E.R.  The details and differences are better explained in chart form below.  This information may be more pertinent to medical students and residents but should be helpful for all you lay people as well.  I’ll go out on a limb and not insult anyone’s intelligence and so below are the gory details:

Type of abscess	Peritonsillar	Retropharyngeal	Parapharyngeal
Location	Around or next to the tonsil (between the tonsil and tonsillar fossa—the “pocket” that holds the tonsil). Peri- = around, surrounding	On the back wall of the throat (pharynx) or behind the throat in the retropharyngeal space. Retro- = behind, back	To the side of the throat, deep to the tonsillar fossa in an area called the parapharyngeal space. Para- = alongside, by the side of
Symptoms (i.e., what you might feel or experience as a result of this problem)	-Sore throat on one side, usually severe pain -difficulty swallowing: often cannot swallow one’s own saliva -Trismus: difficulty opening mouth -neck pain: due to enlarged and inflamed lymph node(s) on the same side -referred ear pain often (on same side as abscess -Difficulty breathing in more severe cases	-Generalized sore throat, can be more noticeable on one side -difficulty swallowing: neck as severe usually as peritonsillar abscess -Trismus -neck pain -Neck stiffness, sometimes neck bent towards one side -Usually no referred ear pain -Difficulty breathing in more severe cases	-Sore throat on one side -Trismus -difficulty swallowing usually not as severe as peritonsillar abscess -neck pain -neck stiffness: to lesser degree than a retropharyngeal  abscess -referred ear pain might be present -Difficulty breathing in more severe cases
Findings on Physical Examination (i.e., what the doctor sees when she/he checks you out).	-patient often has a muffled (“hot potato”) voice. -Drooling, difficulty swallowing saliva. -tonsil pushed towards or across the midline -uvula deviated away from the involved side	-voice may be muffled or normal -tonsils appear normal and symmetric in appearance -Drooling can occur -no uvula deviation -nonspecific neck tenderness -neck is stiff, restricted movement, can be bent towards one side (torticollis)	-voice may be muffled or normal -tonsil might be deviated but not nearly as significant as a peritonsillar abscess -Usually does not have drooling -uvula usually midline -Tenderness and swelling on the side of the neck -Neck sometimes is stiff
CT Imaging: Axial Cross Sections (ie, imaging cutting slices through your neck, and looking up at those slices).	-CT of neck: oftentimes not needed unless the diagnosis is unclear.	-CT of neck often is needed for diagnoses, extend of abscess and aids in surgery.	-CT of neck often is needed for diagnosis and aids in surgery if needed
Treatment	Medical: antibiotics, steroids, orally or i.v. Surgical: -needle aspiration (i.e., poke the abscess with a needle to drain it), -Incision and drainage through the mouth   (the 2 can be done at bedside) or -Tonsillectomy and drainage of the abscess under general anesthesia.	Medical: antibiotics, steroids, both i.v. Surgical: -Drainage through the mouth (requires general anesthesia).  -For more advanced cases, incision and drainage through a neck incision.	Medical: antibiotics, steroids, both i.v. Surgical: -Usually incision and drainage through a neck incision.  Sometimes if it is more medial, drainage through an oral (mouth approach).
Complications if left untreated.	-Sepsis and septic shock (infection invades blood stream and spreads throughout the body) -If ruptures, can spill down trachea and into lungs (causing aspiration pneumonia -Airway obstruction (i.e., breathing is obstructed, you may suffocate) -can lead to deep neck infection via spread to para- or retropharyngeal spaces -Death	-Sepsis and septic shock -Airway obstruction -Ruptureà lungs àpneumonia -Spread downward into mediastinum (mid part of chest) -Death	-Sepsis and septic shock -Airway obstruction -Ruptureàlungs àpneumonia -Spread downward into mediastinum (mid part of chest) -carotid artery or jugular vein involvement (i.e., the major blood vessels to and from the head) with rupture or thrombosis (clot) -Death

©Randall S. Fong, M.D.

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