Deep neck space infections can be particularly troubling in the absence of an early diagnosis. A parapharyngeal abscess, roughly defined as an infection of the parapharyngeal space, is seen after dissemination of other more common deep neck space infections (for example peritonsillar, tonsillar, or retropharyngeal abscesses, as well as tonsillitis) [1] [2] [3], or previous upper respiratory tract infections [4], but it may be the primary source of infection as well [5]. The clinical presentation is diverse and most frequent symptoms are fever, the stiffness of the neck accompanied by a swelling or a bulging mass, lymphadenopathy, and trismus (spasm of the jaw that results in impaired temporomandibular joint activity) [3] [4] [5]. Additional findings include torticollis, a range of respiratory complaints (stridor, voice changes, and sleep apnea), drooling, and odynophagia [3] [4] [5]. Most studies address that children in their first decade of life are the principal population in whom parapharyngeal abscesses are recognized [3] [4] [5], but the condition may be seen in patients of all ages. Because of the close proximity to the bronchial tree, complications such as aspiration pneumonia, mediastinitis and rheumatic fever/glomerulonephritis in the setting of streptococcal infection have been reported [4].

• Fever

  We present the first reported case of parapharyngeal abscess in a child with periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome, an uncommon syndrome of recurrent, self-limiting fever in children. [ncbi.nlm.nih.gov]

  Symptoms and Signs Most patients have fever, sore throat, odynophagia, and swelling in the neck down to the hyoid bone. [msdmanuals.com]

  Symptoms include fever, limited neck movement, voice changes, stridor, proximal lymphadenopathy with swelling of the neck, and breathing difficulties. [symptoma.com]

  Symptoms include fever, sore throat, painful swallowing, and swelling in the neck. [en.wikipedia.org]

• Swelling

  Posterior space abscesses cause swelling that is more prominent in the posterior pharyngeal wall. Trismus is minimal. [msdmanuals.com]

  Symptoms include fever, sore throat, painful swallowing, and swelling in the neck. [en.wikipedia.org]

  Abstract A 7-month-old boy presented to the emergency department with reduced oral intake, neck swelling and fever. Clinical examination revealed a 3 cm left parotid and left level I neck swelling with left medialised tonsil but no trismus. [ncbi.nlm.nih.gov]

• High Fever

  Other structures within the carotid sheath may be involved, causing rigors, high fever, bacteremia, neurologic deficit, or a massive haemorrhage caused by carotid artery rupture. [en.wikipedia.org]

  Posterior abscesses may involve structures within the carotid sheath, possibly causing rigors, high fever, bacteremia, neurologic deficits, and massive hemorrhage caused by carotid artery rupture. [msdmanuals.com]

  The main signs and symptoms are trismus, induration or swelling in the area around the angle of the mandible, high fever and swelling of the lateral pharyngeal wall, so that the protruding towards medial. [purba-java-indo.blogspot.com]

• Malaise

  RPA is a relatively uncommon illness, and therefore may not receive early diagnosis in children presenting with stiff neck, malaise, difficulty swallowing, or other symptoms listed below. [icd.codes]

  Drooling, malaise, decreased oral intake, irritability, neck mass, and respiratory distress or stridor, decreased appetite, jaw stiffness or neck stiffness, or muffled voice can also be seen. [radiologykey.com]

  […] most common), Streptococcus anginosus, viridans streptococci, Staphylococcus aureus, and Haemophilus species, often in a polymicrobial environment Acute bacterial tonsillitis (see acute tonsillitis ) Clinical features Features of tonsillitis : fever, malaise [amboss.com]

  […] the mouth Trismus: difficulty in opening the mouth Respiratory problems, such as stridor (abnormal breathing sound that is very high-pitched) High-grade fever Airways obstruction Cough Agitation Neck pain, stiff neck, presence of swelling in the neck Malaise [dovemed.com]

  It is usually seen in an infant or young child with high fever, agitation, neck pain, malaise, fever, dysphagia, drooling, cough, respiratory distress, and stridor. [ 3 ] There is a stiff neck with the head tilted to one side. [patient.info]

• Chronic Infection

  Infection can occur from: Pharynx: acute and chronic infection of tonsil and adenoids Teeth: dental infection occurs from lower last molar tooth Ear: Bezold's abscess and petrositis Other space: infection of parotid retropharyngeal space External trauma [en.wikipedia.org]

  Aetiology: Infection of parapharyngeal space can occur from: 1. Pharynx. Acute and chronic infections of tonsil and adenoid, bursting of peritonsillar abscess. 2. Teeth. Dental infection usually comes from the lower last molar tooth. 3. Ear. [earnosethroatclinic.blogspot.com]

  Parapharyngeal abscess ETIOLOGY:-  Acute/Chronic infections of tonsils and adenoid, bursting of the peritonsillar abscess.  Dental infection usually from the lower last molar.  From Bezold abscess or Petrositis.  Infections of parotid, retropharyngeal [slideshare.net]

  In conclusion, TB is the commonest chronic infection in Nigeria. Cervical spine TB is rare, more so when it co-exist with retropharyngeal abscess. [atmph.org]

  Okeowo's Companion to Ear, Nose and Throat Diseases in the Tropics. 2004, Lagos, Nigeria: University of Lagos Press, 3: 109-114. 1 Google Scholar Cowan DL, Hibbert J: Acute and chronic infections of the pharynx and tonsils. [jmedicalcasereports.biomedcentral.com]

• Stridor

  The physical examination revealed cervical lymphadenopathy in 30 children (77%), limitation of neck movements in 25 (64%), torticollis in 21 (54%), drooling in three (8%), and stridor in two (5%). [ncbi.nlm.nih.gov]

  Symptoms include fever, limited neck movement, voice changes, stridor, proximal lymphadenopathy with swelling of the neck, and breathing difficulties. [symptoma.com]

  Retropharyngeal abscess and stridor in infants. [explainmedicine.com]

  Stridor is a late sign of airway compromise. Why is this important? DNSI may need surgical drainage under general anaesthetic and admission to critical care. If left, DNSI will cause airway obstruction. [entsho.com]

• Odynophagia

  Symptoms and Signs Most patients have fever, sore throat, odynophagia, and swelling in the neck down to the hyoid bone. [msdmanuals.com]

  Fever, odynophagia, sore throat, torticollis (due to spasm of prevertebral muscles) and signs of toxaemia are common to both compartments. Complications 1. Acute oedema of larynx with respiratory obstruction. 2. [earnosethroatclinic.blogspot.com]

  Symptoms and Signs of Parapharyngeal Abscess Most patients have fever, sore throat, odynophagia, and swelling in the neck down to the hyoid bone. [merckmanuals.com]

  Diagnosing parapharyngeal abscess and mediastinitis can be challenging, but should be suspected and ruled out in cases of post-operative odynophagia, fever, and/or neck swelling and thoracic pain. [ncbi.nlm.nih.gov]

• Overeating

  There has been much recent debate in the literature over the merits of various treatment strategies, including tonsillectomy. [ncbi.nlm.nih.gov]

  A review of 30 cases of retropharyngeal abscess over an 11-year period in Nigeria found the median age to be 21 months, and 77% of patients were younger than 5 years. [emedicine.medscape.com]

  The incision is made with 11 blade knife over the most prominent portion of the swelling. The I&D is done under local anaesthesia. [drtbalu.co.in]

• Dysphagia

  Erythema, odynophagia, and dysphagia often accompany such infections. Trismus is most commonly associated with anterior compartment abscesses. Parapharyngeal space abscess. [abcradiology.blogspot.com]

  Progression of the signs and symptoms is key as it pertains to inflammation and obstruction of the upper airways and/or gastrointestinal tract and there may be dysphagia, dyspnea, stridor, neck stiffness, drooling, trismus and/or chest pain. [radiopaedia.org]

  May differ between adults and children Most common: Sore throat Neck pain/stiffness Odynophagia Dysphagia Fever Additional presenting symptoms: Stridor, dyspnea Muffled voic... [5minuteconsult.com]

  Presentation Acute retropharyngeal abscess presents with severe sore throat, dysphagia, trismus, stridor, dribbling of saliva, and a high fever. It may rapidly progress to airway obstruction. [patient.info]

  Clinical features include fever, sore throat, dysphagia, a “ hot-potato ” voice, and trismus ( lockjaw ). [amboss.com]

• Dysphagia

  Erythema, odynophagia, and dysphagia often accompany such infections. Trismus is most commonly associated with anterior compartment abscesses. Parapharyngeal space abscess. [abcradiology.blogspot.com]

  Progression of the signs and symptoms is key as it pertains to inflammation and obstruction of the upper airways and/or gastrointestinal tract and there may be dysphagia, dyspnea, stridor, neck stiffness, drooling, trismus and/or chest pain. [radiopaedia.org]

  May differ between adults and children Most common: Sore throat Neck pain/stiffness Odynophagia Dysphagia Fever Additional presenting symptoms: Stridor, dyspnea Muffled voic... [5minuteconsult.com]

  Presentation Acute retropharyngeal abscess presents with severe sore throat, dysphagia, trismus, stridor, dribbling of saliva, and a high fever. It may rapidly progress to airway obstruction. [patient.info]

  Clinical features include fever, sore throat, dysphagia, a “ hot-potato ” voice, and trismus ( lockjaw ). [amboss.com]

• Trismus

  If the trismus is marked, preoperative tracheostomy becomes mandatory. Abscess is drained by a horizontal incision, made 2-3 cm below the angle of mandible. [earnosethroatclinic.blogspot.com]

  Trismus is minimal. Posterior abscesses may involve structures within the carotid sheath, possibly causing rigors, high fever, bacteremia, neurologic deficits, and massive hemorrhage caused by carotid artery rupture. [msdmanuals.com]

  Examination found trismus, through which a lateral pharyngeal bulge could be observed. [ncbi.nlm.nih.gov]

• Dental Abscess

  Assessment and recognition History may indicate a preceding upper respiratory tract infection, ingested foreign body, peritonsillar abscess or dental abscess. [entsho.com]

  Nonparotid swelling that may stimulate parotitis include lymphoma, lymphangitis, cervical adenitis, external otitis, dental abscess, actinomyces not evolving the parotid, and cysts. [anaerobicinfections.blogspot.com]

• Aphthous Stomatitis

  Case report and review of the literature to date concerning periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome. [ncbi.nlm.nih.gov]

• Torticollis

  The combination of a parapharyngeal abscess and torticollis in an adult, due to a spastic contraction of the sterno-cleido-mastoid muscle is an extremely rare condition. [ncbi.nlm.nih.gov]

• Neck Pain

  Clinical findings at presentation were: fever (93%), cervical lymphadenopathy (93%), neck pain (90%), torticollis (74%), odynophagia (64%), trismus (32%), drooling (22%) and stridor (6%). [ncbi.nlm.nih.gov]

  Neck pain and stiffness Compression of the adjacent group of neck muscles and soft tissues by the abscess causing inflammatory response.[2] References MARTINS RH, CASTILHO EC, WEBER ST, SEMENZATI GDE O, CAMPOS LM. [explainmedicine.com]

  A 19-year-old female patient presented to our Medicine Outpatient Department (OPD) at All India Institute of Medical Sciences (AIIMS) with odynophagia and neck pain for two months, without any other constitutional symptoms. [lungindia.com]

• Muscle Spasm

  There may be anteroposterior, rotary, or transverse displacement of C1 on C2, or C2 on C3, caused by intense muscle spasm or direct inflammatory ligamentous involvement. Contrast-enhanced CT will demonstrate the location and extent of the disease. [mirc.luriechildrens.org]

  Trismus Anterior parapharyngeal abscesses can cause spasm of jaw muscles resulting difficulty in opening of the mouth. Stridor Commonly seen in infants.[1] occurs due to the narrowing of the airway lumen. [explainmedicine.com]

• Neck Swelling

  Abstract A 7-month-old boy presented to the emergency department with reduced oral intake, neck swelling and fever. Clinical examination revealed a 3 cm left parotid and left level I neck swelling with left medialised tonsil but no trismus. [ncbi.nlm.nih.gov]

  Patients often present with fever, sore throat and neck swelling. Erythema, odynophagia, and dysphagia often accompany such infections. Trismus is most commonly associated with anterior compartment abscesses. Parapharyngeal space abscess. [abcradiology.blogspot.com]

• Neck Mass

  Physical findings include fever, cervical adenopathy, decreased range of neck motion, neck mass, posterior pharyngeal mass, and respiratory distress. [radiologykey.com]

  Healy GB (1989) Inflammatory neck masses in children: a comparison of computed tomography, ultrasound, and magnatic resonance imaging. Arch Otolaryngol Head Neck Surg 115:1027–1028 Google Scholar 11. [doi.org]

  Katya Rozovasky et al performed Ultrasound in 210 patients with neck masses and found 99.5% accuracy in diagnosis. Additional CT was done in 25 patients that helped to detect airway obstruction in 4 patients. [apicareonline.com]

• Neck Stiffness

  An otherwise healthy 2-year-old female presented with a 4-day history of fevers, decreased oral intake, neck stiffness, and voice changes. [ncbi.nlm.nih.gov]

  Progression of the signs and symptoms is key as it pertains to inflammation and obstruction of the upper airways and/or gastrointestinal tract and there may be dysphagia, dyspnea, stridor, neck stiffness, drooling, trismus and/or chest pain. [radiopaedia.org]

  Drooling, malaise, decreased oral intake, irritability, neck mass, and respiratory distress or stridor, decreased appetite, jaw stiffness or neck stiffness, or muffled voice can also be seen. [radiologykey.com]

  Patient Presentation A 21-month-old male came to an outside emergency department with fever, difficulty swallowing, and neck stiffness. [pediatriceducation.org]

The diagnosis of a deep neck space infection must be suspected in the presence of a bulging mass in the neck accompanied by voice changes, fever, and respiratory difficulties. A thoroughly obtained patient history that will note the course and progression of symptoms, and a detailed physical examination during which inspection and palpation of the neck, pulmonary auscultation, and a complete ear, nose, and throat (ENT) exam are conducted, are the first steps that will allow sufficient evidence to be raised towards a parapharyngeal abscess. Once a presumptive diagnosis is made, a microbiological investigation is recommended as the next step in the workup. Bronchoalveolar aspirates, blood cultures, or needle aspiration have all been described as potential methods to obtain a viable sample for identification of the underlying cause [1] [6]. Klebsiella pneumoniae, streptococcal, and staphylococcal species are primary pathogens involved in the development of deep neck space infections, but it is not uncommon for a polymicrobial infection to be present [4] [6]. Imaging studies are equally important in the assessment of a parapharyngeal abscess. Ultrasonography of the neck and chest X-rays (if the involvement of pulmonary system is suspected) are viable first-line methods, but computed tomography (CT) is the gold-standard due to its ability to confirm the exact location of the abscess and determine its spread into adjacent tissues [5] [7].

• Neutrophilia

  Instigate the following procedures and investigations: IV access + FBC (neutrophilia), CRP, U&Es, blood cultures (usually negative) Keep NBM until senior review and initiate IV fluids Initiate broad spectrum IV antibiotics and analgesia Humified oxygen [entsho.com]

• Leukocytosis

  Neutrophil leukocytosis remained elevated (14x10 9 /L) and a moderate increase of thrombocytopenia was detected. [ncbi.nlm.nih.gov]

  There was significant leukocytosis (28.1) with increased neutrophils (25.8). [omicsonline.org]

  Complete blood cell count (CBC) with differential usually reveals leukocytosis with increased percentage of neutrophils and bands. [clinicaladvisor.com]

  Acute bacterial parotitis usually is unilateral, the gland becomes swollen and tender, and patients frequently have toxemia with marked fever and leukocytosis. [anaerobicinfections.blogspot.com]

Treatment with etanercept plus methotrexate was started. Three months later, methotrexate was discontinued. [ncbi.nlm.nih.gov]

Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. [doi.org]

It is important to establish early diagnosis, and complications to be aware of getting a good prognosis. [thieme-connect.com]

[…] spread from other deep head and neck spaces (e.g. parotid, retropharyngeal or submandibular spaces ) secondary to penetrating trauma of the neck iatrogenic e.g. injection of local anesthetic for tonsillectomy or mandibular nerve block Treatment and prognosis [radiopaedia.org]

[…] throat, blockage of the airways, swallowing difficulties, respiratory problems, and stiff neck with neck pain Early diagnosis and management of Retropharyngeal Abscess is necessary to prevent severe complications from developing in the child or adult The prognosis [dovemed.com]

Septic thrombosis of the jugular vein or haemorrhage secondary to erosion into the carotid artery, Prognosis [ 10 ] Prognosis is generally good if the condition is diagnosed early, is managed promptly and effectively and if no complications occur. [patient.info]

Outlook (Prognosis) It is important to get medical help right away. This condition can lead to blockage of the airway. This is life threatening. With prompt treatment, a full recovery is expected. [ufhealth.org]

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. [icd10coded.com]

Parapharyngeal abscess with an etiology of Pott's disease is rare. Modern imaging is highly contributive to diagnosis and follow-up of lesion regression under treatment. [ncbi.nlm.nih.gov]

It is important to know that there are differences in etiological factors and clinical behaviors between the adult case and pediatric one. [jstage.jst.go.jp]

Overview Peritonsillar abscess Epidemiology Most common deep neck infection Most common in adolescents and young adults Etiology Pathogens: Streptococcus pyogenes (most common), Streptococcus anginosus, viridans streptococci, Staphylococcus aureus, and [amboss.com]

References: [1] [3] [12] [6] [13] [14] [15] Retropharyngeal abscess Epidemiology Generally the most dangerous deep neck infection Most common in children < 5 years of age ♂ > ♀ Overall incidence in the U.S. has increased. [amboss.com]

Clindamycin should only be used if the MRSA isolate is susceptible to clindamycin, or local epidemiology supports its empiric use (clindamycin resistance < 10%). [clinicaladvisor.com]

Chronic retropharyngeal abscess is rare but is usually due to tuberculosis of the spine. [ 2 ] Epidemiology Uncommon and occurs much less commonly today than in the past because of the widespread use of antibiotics for suppurative upper respiratory infections [patient.info]

Grisaru-Soen G, Komisar O, Aizenstein O, Soudack M, Schwartz D, et al. (2010) Retropharyngeal and parapharyngeal abscess in children--epidemiology, clinical features and treatment. Int J Pediatr Otorhinolaryngol 74: 1016-1020. [omicsonline.org]

We discuss the possible pathophysiology of neck abscess as a presenting feature of nasopharyngeal carcinoma, and the relationship between the parapharyngeal abscess and endogenous bacterial endophthalmitis. [ncbi.nlm.nih.gov]

Pathophysiology The pathophysiology of this disease is unknown. The condition is usually the endpoint of a disease that starts with acute follicular tonsillitis, progresses to peritonsillitis, and ends with formation of an abscess. [tonsilitisunderstood.blogspot.com]

The exact pathophysiology through which KD leads to PPA is unknown. [journals.lww.com]

We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. [ncbi.nlm.nih.gov]

This process is a reaction of protection by the tissue to prevent the spread / extension of infection to other parts of the body. Parapharyngeal abscess is a collection of pus that forms in the parapharyngeal space. [purba-java-indo.blogspot.com]

[…] respiratory infection can prevent this problem. [ufhealth.org]

[…] inflammation, or infected tonsils/adenoids RPA can cause severe sore throat, blockage of the airways, swallowing difficulties, respiratory problems, and stiff neck with neck pain Early diagnosis and management of Retropharyngeal Abscess is necessary to prevent [dovemed.com]

As it may prevent additional discomfort to the patient caused by unnecessary surgical or pharmaceutical interventions.[6] References LON SA, LATEEF M, SAJAD M. Acute epiglottitis: A review of 50 patients. [explainmedicine.com]

1. Page C, Biet A, Zaatar R, Strunski V. Parapharyngeal abscess: diagnosis and treatment. Eur Arch Otorhinolaryngol. 2008;265(6):681-686.
2. Galioto NJ. Peritonsillar Abscess. Am Fam Physician. 2017;95(8):501-506.
3. Marques PM, Spratley JE, Leal LM, Cardoso E, Santos M. Parapharyngeal abscess in children: five year retrospective study. Braz J Otorhinolaryngol. 2009;75(6):826-830.
4. Gharib B, Mohammadpour M1, Sharifzadeh M, et al. A 15-Month-Old Boy With Respiratory Distress and Parapharyngeal Abscess: A Case Report. Acta Med Iran. 2016;54(12):812-816.
5. Brito TP, Hazboun IM, Fernandes FL, et al. Deep neck abscesses: study of 101 cases. Braz J Otorhinolaryngol. 2016;pii:S1808-8694(16)30082-9.
6. Lee YQ, Kanagalingam J. Bacteriology of deep neck abscesses: a retrospective review of 96 consecutive cases. Singapore Med J. 2011;52(5):351-355.
7. Capps EF, Kinsella JJ, Gupta M, Bhatki AM, Opatowsky MJ. Emergency imaging assessment of acute, nontraumatic conditions of the head and neck. Radiographics. 2010;30(5):1335-1352.