1. Infection of pharyngeal spaces

2. Retropharyngeal Space Infection
The retropharyngeal space lies behind the pharynx and esophagus, just anterior to the prevertebral fascia. It extends superiorly to the base of the skull and inferiorly to the bifurcation of the trachea.
Patients generally present with trismus, drooling, dyspnea, dysphagia, and a mass, often fluctuant, on one side of the posterior pharyngeal wall.
Lateral radiographs of the neck are also helpful in diagnosis. It is important, however, to have proper positioning of the patient at the time of X-ray; otherwise the results may be misleading. The patient should have the neck extended in a true lateral position for the X-ray.

3. Parapharyngeal Space Abscess
The parapharyngeal space is cone shaped. Superiorly it starts at the base of the skull and inferiorly its margin ends at the hyoid bone. The superior constrictor muscle is the medial boundary, and the parotid gland, the mandible, and the pterygoid muscle are its lateral margins , the prevertebral fascia is present posteriorly.
A parapharyngeal space abscess can develop when infection or pus from the tonsillar region goes through the superior constrictor muscle. The abscess then forms between the superior constrictor muscle and deep cervical fascia.
Patients can present with toxemia and pain in the throat and neck, with tender swelling of the neck in the region of the angle of the mandible. Examination may reveal tonsillitis and/or medial displacement of the tonsil.

4. Infection of Pharyngeal Spaces Parapharyngeal Abscess
Retro-pharyngeal Abscess
(Acute & Chronic)

5. Parapharyngeal Abscess
Collection of pus in the
PARA-PHARYNGEAL Space
Def
What is parapharyngeal space?
A connective tissue space which:
Lies on the lateral side of the nasopharnx and oropharynx
Extends from skull base to hyoid bone
Contains:
Internal carotid artery
Internal jagular vein
Last 4 cranial nerves
Cervical sympathetic trunk
Deep cervical lynph nodes

6. The infection passes through the Superior constrictor muscle
Etiology:
Acute Tonsillitis or after tonsillectomy
Infection of last lower molar tooth
Infection of the parotid salivary gland
The infection passes through the
Superior constrictor muscle
Symptoms
Same as in Quinsy

7. Signs: Investigations: General; fever Pharyngeal: Cervical CT & MRI
- The lateral pharyngeal wall & tonsil is
pushed medially
- Trismus due to spasm of ptrygoid muscles
A unilateral diffuse tender swelling :
Below & behind the angle of the mandible
Deep to the anterior border of the sternomastoid
The neck is tilted to the diseases side

8. - Skull base  meningitis
Complications
Spread to
- Skull base  meningitis
carotid sheaththrombosis of IJV and rupture of carotid artery
Mediastinum Mediastinitis
Larynx laryngeal edema
Rupture into the pharynx aspiration Bronchopneumonia

9. at the anterior border of the sternomastoid muscle
Treatment
Medical: massive antibiotic therapy and,
Surgical drainage
Sternomastoid
A vertical incision
at the anterior border of
the sternomastoid muscle

10. Acute Retropharyngeal Abscess
It is a connective tissue space between :
the buccopharyngeal fascia & pre-vertebral fascia
The two fasciae are attached to each side by median raphe.
It extends from the skull base to the posterior mediastinum
It contains retropharyngeal lymph node one on each side
The Retropharyngeal LN atrophy at the age of 5
Collection of pus in the retropharyngeal space
BuccoPharyngeal
Fascia
The Retropharyngeal space
Prevertebral fascia

11. Age: below the age of 5 (The Retropharyngeal LN atrophy at the age of 5)
Site: at one side of the midline (The two fasciae are attached to each other at the midline by median raphe.)
Etiology
Upper Rrspiratory Tract Infection with suppuration of Retropharyngeal LN
After Adenoidectomy operation
Impacted FB

12. Symptoms In A child below 5 years General: FHAM Pharyngeal:
Severe sore throat
Dysphagia
Difficult breathing
Abscess

13. Signs General: fever Pharyngeal Swelling of the posterior
Pharyngeal wall to one
side of the midline
Cervical: Neck inclination due to muscle spasm

14. Normal Patient Lateral view of the Neck
Look for
The vertebral column
( for any destruction e.g in Pott’s disease)
The pre-vertebral space (3/4 the width of the body of the vertebra)
The airway

15. Investigations: plain X ray & CT scan Complications:
Spread to mediastinummediastinitis
Rupture………….
Widening of
prevertebral space
Normal vertebral
bodies

16. Treatment Medical: massive antibiotic therapy Surgical drainage
and,
Surgical drainage
Tracheostomy if indicated
Incision in the posterior pharyngeal wall with the patient in the Trendlenberg position Why?
In this position the head is lower than the chest
to avoid aspiration of pus

17. Chronic Retropharyngeal Abscess Pre-vertebral Abscess
Formation of a cold abscess in the pre-vertebral space
What is the pre-vertebral space?
A space between:
The cervical vertebrae
The pre-vertebral fascia

18. Etiology: Pott’s Disease
i.e tuberculosis of cervical vertebrae  the abscess rupture through the prevertebral fascia  the abscess reaches the Retropharyngeal space
prevertebral fascia

19. Symptoms In an adult General: Tuberculous Toxaemia
Pharyngeal: Mild sore throat
Cervical: limited painful neck movement
-Night sweets
-Night fever
-Loss of weight
-Loss of appetite

20. The swelling lies in the midline of the posterior pharyngeal wall
Pallor
Low grade fever
Loss of weight
Signs:
General: Tuberculous toxaemia
Pharyngeal:
Cervical: Tenderness over cervical spines
The swelling lies in the midline of
the posterior pharyngeal wall

21. Investigations Plain X ray & CT scan Widening of the
Prevertebral space
Destruction of the
cervical vertebrae

22. Through a vertical incision along the posterior border of the
Treatment:
Medical: Antituberculous therapy
Surgical Drainage
Orthopedic Management
Through a vertical incision along
the posterior border of the
sternomastoid muscle

23. Hypopharyngeal Pouch

24. Hypopharyngeal pouch

25. Synonyms Hypopharyngeal diverticulum Zenker’s diverticulum
Pharyngo-oesophageal pouch
Retropharyngeal pouch
Killian’s diverticulum

26. Introduction
Hypopharyngeal pouch is an acquired pulsion diverticulum caused by posterior protrusion of mucosa through pre-existing weakness in muscle layers of pharynx or esophagus.
In contrast, congenital diverticulum like Meckel's diverticulum is covered by all muscle layers of visceral wall.

27. Weak spots b/w muscles

28. Weak spots b/w muscles Posterior: 1. Between Thyropharyngeus & Crico-
pharyngeus: Killian's dehiscence (commonest)

29. Origin of Zenker’s diverticulum

30. History First described in 1769 by Ludlow
Friedrich Zenker & von Ziemssen first described its picture in their book in 1877

31. Etiology

32. 1. Tonic spasm of cricopharyngeal sphincter:
 C.N.S. injury  Gastro-esophageal reflux
2. Lack of inhibition of cricopharyngeal sphincter
3. Neuromuscular in-coordination between Thyro-pharyngeus & Cricopharyngeus
4. Second swallow against closed cricopharynx
These lead to increased intra-luminal pressure in
hypopharynx & mucosa bulges out via weak areas.

33. Clinical Features

34. Entrapment of food in pouch: sensation of food sticking in throat & later dysphagia
Regurgitation of entrapped food: leads to  foul taste  bad odor  nocturnal coughing  choking
Hoarseness: due to spillage laryngitis or sac pressure on recurrent laryngeal nerve
Weight loss: due to malnutrition
Compressible neck swelling on left side: reduces with a gurgling sound (Boyce sign)

35. Complications Lung aspiration of sac contents Bleeding from sac mucosa
Absolute oesophageal obstruction
Fistula formation into:
 trachea  major blood vessel
Squamous cell carcinoma within Zenker diverticulum (0.3% cases)

36. Investigations Chest X-ray: may show sac + air - fluid level
Barium swallow
Barium swallow with video-fluoroscopy
Rigid Oesophagoscopy
Flexible Endoscopic Evaluation of Swallowing

37. Barium swallow

38. Barium swallow with Video-fluoroscopy

39. Rigid Oesophagoscopy

40. Cricopharyngeal myotomy

41. Styalgia (Eagle Syndrome)

42. Introduction Normal length of styloid process is 2.0–2.5 cm
Length >30 mm in radiography is considered an elongated styloid process
5-10% pt with elongated styloid have pain
Increased angulation of styloid process both anteriorly & medially, can also cause pain
Commonly seen in females over 40 years.

43. Classical Variety Occurs several years after tonsillectomy
Pharyngeal foreign body sensation
Dysphagia
Dull pharyngeal pain on swallowing, rotation of neck or protrusion of tongue
Referred otalgia
Due to scar tissue in tonsillar fossa engulfing branches of glossopharyngeal nerve

44. Normal Styloid Process

45. Elongated Styloid Process

46. Theories for pain Irritation of glossopharyngeal nerve
Irritation of sympathetic nerve plexus around internal carotid artery
Inflammation of stylo-hyoid ligament
Stretching of overlying pharyngeal mucosa

47. Diagnosis
Digital palpation of styloid process in tonsillar fossa elicits similar pain
Relief of pain with injection of 2% Xylocaine solution into tonsillar fossa
X-ray neck lateral view
Ortho-pan-tomogram (O.P.G.)
Coronal C.T. scan skull
3-D reconstruction of C.T. scan skull

48. X-ray neck lateral view

49. Coronal C.T. scan

50. Coronal 3-D C.T. scan

51. Medical Treatment Oral analgesics
Injection of steroid + 2% Lignocaine into tonsillar fossa
Carbamazepine: 100 – 200 mg T.I.D.
Operative intervention reserved for:
failed medical management for 3 months
severe & rapidly progressive complaints

52. Styloid Process Excision

53. Intra-oral route via tonsil fossa no external scarring
poor visibility due to difficult access
high risk of damage to internal carotid artery
iatrogenic glossopharyngeal nerve injury
high risk of deep neck space infection

54. Tonsillectomy & fossa incision

55. Styloidectomy

56. Styloidectomy Tonsillectomy done. Styloid process palpated.
Incision made in tonsillar fossa just over the tip.
Styloid attachments elevated till its base with periosteal elevator.
Styloid process broken near its base with bone nibbler, avoiding injury to glossopharyngeal nv.
Tonsillar fossa incision closed.

57. Thanks