Parapharyngeal abscess of face and neck: Anesthetic management

Velmurugan Deisingh, Karthik. G*

Department of Anesthesiology, Kauvery Hospital, Chennai

Background

Parapharyngeal abscess is a deep neck space infection that can land up in life-threatening airway obstruction. Anesthetizing a patient with this condition is a definite challenge. In this case, we chose the option of securing the airway by awake nasal fiberoptic intubation with spontaneous ventilation.

Case Presentation

A 58-year-old female presented with history of pain and swelling in left side of face for 4 days, difficulty in opening the mouth, difficulty in swallowing and fever.

Within 2 h of arrival to the emergency department, patient had tachycardia, and increasing breathlessness along with swelling of face and neck.

Immediately MRI neck was done showing inflammatory changes, with air pockets and large pharyngeal collections involving deep spaces of neck, peritonsillar region, left parotid and left carotid

They were causing mass effect displacing the pharynx on the right, obstructing the oropharynx.

Fig. 1. Preop mouth opening.

Fig. 2. CT Neck showing Left parapharyngeal abscess.

ENT surgeon along with Orofacial-maxillary surgeon immediately planned for an emergency exploration, drainage of abscess and tracheostomy. Preoperative assessment of airway was done and mouth opening was found to be less than 2 finger breadth with minimal restriction in neck extension. So, the patient was explained about the need of awake fiberoptic bronchoscope intubation technique and also its risks.

Immediately patient was shifted to operating room with difficult airway trolley and tracheostomy back up ready along with ENT surgeon and Orofacial- maxillary surgeon nearby. As the patient was not able to lie flat as dyspnea worsens, we made the patient lie at a 45-degree angle. The patient was quite cooperative for the preoperative preparations such as administration of Oxymetazoline nasal drops with adrenaline and upper airway blocks using Inj. 4% lignocaine and 2% lignocaine with adrenaline were administered. Premedications such as Inj. glycopyrrolate 0.2 mg and Fentanyl 50 mcg i.v were given.

Fig. 3. Upper airway block with 4% LOX with adrenaline.

Adequate preoxygenation was done prior to the procedure. While passing the 3.8 mm fiberoptic bronchoscope through right nostril, there was difficulty in negotiating till the vocal cords due to secretions and pharyngeal abscess obscuring the vision. After crossing the vocal cords, on entering the trachea, carina was visualized and we immediately railroaded 6.5 mm flexometallic endotracheal tube over the FOB till the carina. We connected the circuit , there was no Etco2 trace and we were not able to ventilate. Then ETT was pulled out 1.5 to 2 cm, and connected the circuit. This time we could successfully ventilate the patient, capnography visualized and ETT was secured properly. Immediately tracheostomy was performed.

On exploration of the oral cavity, the palate was edematous, swollen tongue and peritonsillar space, indicated no space for orotracheal intubation. Large amount of thick purulent secretions in paratonsillar, parapharyngeal, retropharyngeal, infratemporal, parotid space, submandibular and other deep neck spaces were drained along with removal of necrosed tissues.

After the surgery, the patient was shifted to intensive care unit for elective post operative ventilation.

Fig. 4. Oral cavity showing congested large Edematous palate with swollen tongue

Discussion

Parapharyngeal abscesses are rare but they cause potential morbidity and mortality if immediate and timely intervention is not done properly. The main complications were compression of trachea and pharynx, aspiration pneumonia, carotid artery and jugular venous compression, mediastinitis and empyema. The primary anesthetic concerns are anticipated difficult airway secondary to airway obstruction by the abscess. In these scenarios, awake Fiberoptic bronchoscope intubation technique plays a very crucial role in securing the airway. Thus, it is mandatory to have all the necessary equipment for difficult airway management checked and ready including tracheostomy back up.

Fig. 5. Post OP mouth opening.

Conclusion

Fiberoptic bronchoscope is a diagnostic and therapeutic technique of great value. It can be of immense help for tracheal intubations in patients with extremely limited mouth opening. Proper preoperative assessment, teamwork, difficult airway equipment including tracheostomy kit with presence of ENT surgeon for performing emergency surgical airway if needed, adequate oxygenation all contribute to successful management of patient with parapharyngeal abscess.

Dr. Velmurugan Deisingh

Consultant Anaesthesiologist and Head of the Department

Parapharyngeal abscess of face and neck: Anesthetic management