A Case Report On the Potential for Spatial Spread of Parapharyngeal Abscess in A Diabetic Patient

Significance Statement

Parapharyngeal abscesses can be life-threatening, although they are less common currently. Diabetes mellitus, the most common comorbidity, can cause unexpected dissemination as in our case. Widespread dissemination from deep neck spaces should be considered and patients should be followed closely. Imaging plays an important role in diagnosis and rapid treatment may prevent mortality and morbidity.

A 63-year-old female patient presented to our clinic with complaints of sore throat, fever, and trismus. The patient had a history of diabetes mellitus and hypertension for about 20 years. The sore throat had been present for 6 days without any known dental operation. Clinical examination revealed swelling of the left lateral wall of the oropharynx and deviation of the uvula. The left jugulodigastric lymph nodes were also enlarged and firm. Laboratory tests revealed leukocytosis (20.1 × 109/L), elevated sediment reactive protein (CRP) (207.1 mg/L), and elevated glucose (342 mg/dL). Contrast-enhanced computed tomography (CT) of the neck was performed with a prediagnosis of abscess. In the images, a 33 × 28 mm centrally hypodense, thick, contrasting, and irregularly circumscribed fluid loculation containing gas densities was observed in the left parapharyngeal area (Figure 1A). The fatty planes in the neighborhood of the lesion were contaminated and multiple lymph nodes, the largest of which was 15 × 12 mm in size, were observed in the left jugulodigastric chain. With the diagnosis of parapharyngeal abscess, drainage was performed by intra-oral approach. Broad-spectrum antibiotics were started and alpha hemolytic streptococcus was detected in microbiological examination. The patient was followed up for 3 days and no significant decrease in leucocytosis and CRP was observed. The patient’s complaints continued and a second operation was performed by trans-cervical approach and the abscess was drained again. After this operation, the patient’s laboratory values partially regressed (leukocyte; 15 × 109/L, CRP; 84 mg/L, glucose; 231 mg/dL) and she started to complain of left lower quadrant abdominal pain. Abdominal examination showed distension and abdominal ultrasound was unremarkable. A contrast-enhanced CT of the neck was repeated on the 10th day of hospitalization. The images demonstrated the extension of the parapharyngeal abscess into the masticator and parotid spaces. In addition, the abscess site reached the paraspinal muscles by crossing the carotid space posteriorly (Figure 1B and C). Contrast-enhanced magnetic resonance (MR) imaging was performed to evaluate the spinal abscess and to abscess extension. It was shown that the paraspinal abscess began in the cervical region, involved the trapezius muscle in the thoracic region, and extended to the subcutaneous tissue at the lumbar1-2 level. There was marked wall enhancement and gas intensity at the location of the abscess. Contrast enhancement due to intense inflammation was also present in the fat planes adjacent to the abscess (Figure 2). The surgeons drained the abscess from the lower part (thoracic 12-lumbar 1) and placed two drains. After this operation, the patient’s clinical condition improved, her values normalized, and she was discharged after 19 days.

Figure 1.

Axial section contrast-enhanced CT image (A) shows an abscess localization (asterisk) filling the parapharyngeal space with a thick and contrasted wall containing gas densities. Axial (B) and sagittal (C) contrast-enhanced CT images show the extension of the abscess into the paraspinal and the masticator spaces (arrows). CT, computed tomography.

Figure 2.

Contrast-enhanced sagittal section cervical (A) and thoracic (B) MR images show the extension of the peripherally contrasted abscess along the muscle planes (arrows). In the lumbar axial section (C), arrows show the continuity of the lesion on the left abdominal wall. CT, computed tomography; MR, magnetic resonance.

Abscesses of the deep neck spaces bounded by the leaves of the deep cervical fascia are currently less common but can cause significant mortality and morbidity. Peritonsillar, parapharyngeal, and retropharyngeal abscesses are the most common locations and are more common in males. The origin of the abscess is odontogenic in the majority of cases (50-70%) but may also be tonsillitis, foreign body, or parotitis. The condition may rapidly spread to other cavities, causing mediastinitis, airway obstruction, arterial erosion, venous thrombus, and sepsis. While young adults are the most common age group, it is more common in diabetic patients in the 5th to 6th decades of life. Imaging modalities, in particular CT with contrast, play an important role in the diagnosis. The size of the lesion, its extension areas, and potential complications can be assessed. Gas densities can be observed within the peripherally contrasted hypodense fluid localization.^1-3 MR imaging, which better visualizes soft tissues, can detect possible epidural extension. Complications and hospitalization are more common in diabetic patients, especially those with non-regulated blood glucose. To our knowledge, this case is the most widely disseminated deep neck abscess in the literature. Immediate agent-sensitive antibiotherapy and surgical drainage are the basis of treatment.^3-5