Bilateral peritonsillar and parapharyneal abscesses with cervial necrotizing fasciitis
Cervical necrotizing fascittis is a life-threatening, progressive, polymicrobial soft tissue infection of the neck characterized by gas formation and extensive tissue necrosis. Rarely, peritonsillar abscess can lead to cervical necrotizing fasciitis which is usually of dental origin. This is the first reported case of necrotizing fasciitis arising from bilateral peritonsillar and parapharyngeal abscesses. The cultured organisms included Streptococcus Milleri and mixed anaerobes.
Peritonsillar abscess (quinsy) is a common condition. The treatment generally involves analgesia, rehydration, intravenous antibiotics and either incision and drainage or needle aspiration of pus under local anaesthesia (Prior et al 1995). Complications of peritonsillar abscess include parapharyngeal (lateral pharyngeal space) or retro pharyngeal infection, airway obstruction, mediastinitis, thrombosis and rupture of major vessels and general sepsis (Greinwald et al 1995). Necrotizing fasciitis (NF) is an uncommon soft tissue infection characterized by gas formation and necrosis of superficial and deep fascia. This may extend to skin and muscle (Tovi et al 1991). Peritonsillar abscess has been previously reported as a cause of NF (Wenig et al 1984). We report a case of bilateral quinsies spreading to involve both parapharyngeal spaces, with anterior triangle and supraclavicular collections and an associated necrotizing soft tissue infection. The wound cultures grew Streptococcus Milleri and mixed anaerobes.
A 47 year old lady had a left quinsy diagnosed after a 4 day history of sore throat. She was admitted to a private district hospital where she was treated with intravenous antibiotics for three days. Drainage of the peritonsillar abscess was not performed at this time.
When the patient became increasingly unwell with developing neck swelling and trismus, she was transferred to a local hospital with intensive care facilities for further management. CT scanning showed diffuse parenchymal oedema with gas bubbles scattered throughout the neck tissues. It was erroneously reported as having no abscess collection (Figure 1). She was then transferred to the Alfred Hospital, a tertiary institution for further management and consideration of hyperbaric oxygen therapy on the basis of uncontrolled anaerobic infection.
Examination revealed a toxic, febrile lady with gross, bilateral, tender, brawny swelling of her neck. This extended up onto her face with swelling and erythema midway down her chest. There was no crepitus and, surprisingly, no airway obstruction. She had marked trismus with bilateral peritonsillar swelling as well as palatal and sublingual oedema. Fibreoptic naso-endoscopy of her hypopharynx and larynx was normal.
Aspiration of the left peritonsillar space revealed dark, foul smelling pus. She was immediately taken to the operating theatre and underwent awake fibreoptic nasotracheal intubation. An open tracheostomy was performed through oedematous necrotic soft tissue. The peritonsillar space was widely incised intra-orally on the left side, and, after finger dissection of the parapharyngeal space, 30 ml of pus was evacuated. The right peritonsillar area was aspirated but no pus was found. The left neck was explored externally via an incision along the anterior border of sternomastoid muscle. A copious amount of brown pus was drained deep to the platysma and 2 penrose drains were inserted. The patient was commenced on intravenous cefotaxime, gentamicin and metronidazole.
On review the following day, the left neck had improved slightly (Figure 2), but the right neck appeared more swollen. With her airway now secure, a repeat CT scan demonstrated multiple right sided collections (Figure 3). At surgery that day, a right peritonsillar abscess was drained intra-orally and the right sided neck collections and parapharyngeal abscess drained externally via an oblique incision.
Aspiration of the submandibular space did not reveal pus, consistent with Ludwig’s angina. Her left sided neck incision was reopened and, again, foul smelling pus and debris was encountered. Finger dissection through necrotic soft tissue connected both external oblique lateral neck incisions with the tracheostomy site and these were again all drained with penrose tubing. The patient also had a left sided pleural effusion. Whilst there were no radiological features of mediastinitis, there was concern that an empyema could have developed. An intercostal chest tube was inserted and revealed only a transudate. The catheter was removed a few days later.
She continued to improve, but on day 4 developed spiking temperatures, bilateral erythema, and fluctuance above her clavicles. In a third procedure, she had bilateral supraclavicular abscesses drained. Her other neck incisions were again reopened, debrided, irrigated with betadine, and closed loosely over multiple penrose drains (Figure 4).
The patient continued to improve on intravenous antibiotics, dressing changes, fluid management and nutritional support. Imipenam was added to the antibiotic regimen of cefotaxime, gentamicin and metronidazole. There was never any requirement for ventilatory or haemodynamic support.
Hyperbaric oxygen therapy was commenced twice daily. The wound cultures grew Streptococcus Milleri and mixed anaerobes. The drain tubes were systematically shortened then removed, and her tracheostomy decannulated. Her neck wounds required secondary skin approximation and suture. She was finally discharged on oral amoxycillin/clavulinic acid on day 22 having made an excellent recovery (Figure 5). She subsequently underwent scar revision with Z plasty correction a year later, with a much improved cosmetic result.
Peritonsillar abscess or quinsy is a common condition. The Causative organisms include mixed aerobes and anaerobes, usually Streptococcus, Staphylococcus, Bacteroides, Fusobacterium and Peptostreptococcus (Greinwald et al 1995). In the present case, the wound cultures grew Streptococcus Milleri, currently renamed Streptococcus anginosus, widely recognised as a potentially serious pyogenic pathogen, seven cases of otolaryngological interest having previously been reported in Aust. J Otolaryngol. by Bell-Allen and Kemp (1993).
Progression to a parapharyngeal or lateral pharyngeal space infection is an uncommon entity in the antibiotic era (Beck 1952). Surgical drainage is required when complications supervene such as subcutaneous emphysema, airway obstruction, skin necrosis overlying areas of cellulitis, haemorrhage following vessel erosion, internal jugular vein thrombosis with severe sepsis, or evidence of abscess formation clinically or on CT scanning (Shumrick and Sheft 1991).
The intra-oral approach to the parapharyngeal space should be confined to the drainage of smaller collections from progressive peritonsillar abscesses only because of the inadequate exposure if major haemorrhage ensues. The external approach involves a transverse submandibular incision, or an oblique/vertical incision which gives better exposure to the carotid sheath and allows extension inferiorly to explore the lower neck.
In 1871, Joseph Jones, a former Confederate surgeon, reported on a necrotizing soft tissue infection of the extremities in members of the army during the civil war, describing it as hospital gangrene. Meleney (1924) described a Streptococcal infection causing subcutaneous necrosis. In 1952, Wilson (1952) proposed the term Necrotizing Fasciitis (NF) for these infections involving necrosis of subcutaneous and superficial fascial tissues and stressed the importance of early diagnosis and aggressive surgical treatment. Albertsen and Thomsen (1970) described these as non-clostridial gas forming infections, with anaerobic bacteria being important pathogens.
NF is characterized by a fulminant infectious process, affecting the deep and superficial fascia whilst tending to spare the overlying skin and the underlying muscle (Svensson et al 1985). It begins as an ill-defined inflammatory process with non-fluctuant swelling and progressively involves the neck, face and chest (Krepsi et al 1981). The overlying skin is tender to palpation but may become anaesthetic due to cutaneous nerve involvement. A probe or finger can be passed along the fascial plane without resistance. Crepitus or the presence of subcutaneous gas on radiography has been reported in nearly 50% of cases of NF involving the head and neck (Skorina and Kaufman 1995). Vesiculation and purple discolouration followed by demarcated areas of frank skin necrosis may develop.
The differential diagnosis of NF includes erysipelas, pyoderma ganrenosum, clostridial gas gangrene and radiation induced necrosis (Greinwald et al 1995).
The most common cause of cranio-cervical NF is dental infection and trauma. Other causes include boils, pharyngitis, intravenous catheters, human bites, bums, abrasions, radiotherapy, blunt facial trauma, mandibular fractures, surgery, perichondritis and peritonsillar abscess (Tovi et al 1991, Spankus et al 1984). Predisposing systemic diseases include diabetes, arteriosclerosis, obesity, alcoholism, intravenous drug abuse, chronic renal failure, neoplasia and poor nutritional and immunocompromised states (Greinwald et al 1995).
The majority of cases of NF document a polymicrobial infection. The most common organism is Streptococcus followed by Staphylococcus and gram negative rods. Anaerobic bacteria which include Bacteroides species, Peptostreptococcus, Eubacterium, Proprionibacterium and Fusobacterium are also found in approximately one third of cases (Guiliano et al 1977).
The treatment of NF is based on early diagnosis, broad spectrum antibiotics, plus surgical drainage and debridement. A common finding on entering the superficial fascial layer is a foul smelling discharge which may vary from pus to a brown grey watery liquid referred to as “dishwater-like” pus (Skorina and Kaufman 1995). Necrotic debris should be excised back to bleeding tissue. Hyperbaric oxygen therapy has become increasingly popular (Zanetti 1988, Thom 1984). Mortality is usually due to overwhelming sepsis, multisystem organ failure, and mediastinitis (Spankus et al 1984).
NF starting from neck or dental infections more often leads to mediastinitis than from skin or mucosal sites. Greinwald et al (1995) cited a 30% mortality in patients with peritonsillar abscess and secondary NF. While the combined clinical entity of quinsy and NF has been described, to our knowledge there has not previously been a case reported of NF associated with bilateral peritonsillar abscesses combined with bilateral parapharyngeal and supraclavicular abscesses. In our case, the patient was transferred from another institution, not having had the quinsy initially drained. Rather than spontaneously discharging into the mouth, it clearly progressed into the parapharyngeal space and then tracked into the soft tissues of the neck. Delay in definitive drainage and recognition of the evolving left neck infection most likely led to direct spread to the contralateral side.
Whilst the ultimate outcome was good, the patient suffered considerable morbidity and cosmetic disfigurement from the multiple neck incision sites. This rare case highlights the serious complications that can evolve from undertreating the common peritonsillar abscess, and the potential of Streptococcus Milleri (Streptococcus anginosus) to cause severe and possibly life-threatening suppurative infections (Bell-Allen and Kemp 1993).
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Mackenzie, writing on this subject in his well known work on diseases of the throat says, speaking of the treatment of these cases, “the common, but fatal practice, is at once to use of probang and to force the obstruction object onwards. A foreign body, comparatively harmless in the pharynx, is thus often driven into the larynx, or even into the bronchi, or may become impacted in the oesophagus.” Although the use of the laryngoscope is now more familiar to the general practitioner than when the above was written twelve years ago, yet the practice which is condemned is still far from uncomon. The parasol probang, or the coincatcher, will often prove very useful in dislodging a foreign body from the oesophagus, but before using either instrument we ought always to explore with the laryngoscope the pharynx and larynx, where the foreign body may be in view; and within reach of the forceps. In young chilre, failing to get a good view with the laryngoscope, we ought to resort to digital examination, which as the parts are within more easy reach than in the adult, will often prove successful.
It will make it more easy to search for foriegn bodies if we have a knowledge of the most usual sites in which they are liable to lodge. The experienced detective generall knows where to find his man; so with the surgeon and his foreign body.
P.P. Burstin F.R.A.C.S.
M. Gordon F.R.A.C.S.
Department of Otolaryngology Head and Neck Surgery Alfred Hospital
Prahran, Victoria, 3181
Mr. Perry Burstin
Department of Otolaryngology
Royal Victorian Eye and Ear Hospital
32 Gisbome Street
Victoria 3002 Australia
Tel: # 61-3-9929-8666
Copyright Australian Society of Otolaryngology Head & Neck Surgery Ltd. Jul 1999
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