The parapharyngeal space, also known as the lateral pharyngeal or pharyngomaxillary space, is a pyramidal-shaped space with its apex at the hyoid bone and base at the base of the skull. Laterally, it is bound by the internal pterygoid muscle and the parotid gland with the superior pharyngeal constrictor muscle acting as the medial border. The posterior aspect of this space is in close proximity with the carotid sheath and cranial nerves IX through XII. Presenting symptoms of parapharyngeal space abscesses may include fever, dysphagia, odynophagia, drooling, and ipsilateral otalgia. Unilateral neck and jaw angle facial swelling in association with rigidity and limited neck motion is common. Potentially disastrous complications include cranial neuropathies, jugular vein septic thrombophlebitis, and erosion into the carotid artery. The origin of parapharyngeal abscesses may be from bacterial pharyngitis, sinuses, dentition, or lymphatic spread.
Management and Disposition
Preparations for definitive airway management via endotracheal intubation or surgery are vital. Early recognition and anticipation of other potentially disastrous complications should be considered and managed appropriately. Broad-spectrum parenteral antibiotic coverage for mixed aerobic and anaerobic infections (penicillin or clindamycin with metronidazole; consider adding vancomycin in high-risk groups) should be initiated. Radiologic modalities used to assess parapharyngeal and other deep-space neck infections include contrast-enhanced CT, ultrasound, plain radiography, and MRI. Emergent otolaryngologic or oral surgical consultation is warranted for definitive intraoperative incision and drainage of the abscess.
Suspected oropharyngeal abscesses in association with cranial nerves IX through XII involvement are pathognomonic of parapharyngeal abscesses.
Early preparation and well-planned advanced airway management are critical in the management of parapharyngeal abscesses.
Parapharyngeal Space Abscess. Unilateral facial, jaw angle, and neck swelling is seen in this patient. Nuchal rigidity may also be present. (Photo contributor: Sara-Jo Gahm, MD.)