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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 14  |  Issue : 4  |  Page : 202-204

A case report on anesthesia management for a patient with deep neck space infection (retropharyngeal and parapharyngeal abscess)


1 Department of Anesthesiology, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India
2 Department of Periodontology, Himachal Dental College, Sundernagar, Himachal Pradesh, India

Date of Submission10-Mar-2022
Date of Acceptance26-Jun-2022
Date of Web Publication15-Nov-2022

Correspondence Address:
Aastha Jindal
Department of Anesthesiology, Pacific Institute of Medical Sciences, Udaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijds.ijds_29_22

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  Abstract 


A 44-year-old woman complained of neck swelling, discomfort, and swallowing difficulties. She was admitted to the hospital on an emergency basis for incision and drainage. Deep neck space infection was diagnosed using a neck X-ray, ultrasonography, and contrast enhanced computed tomography. The successful anesthetic management of this patient at the Pacific Institute of Medical Sciences in Udaipur is presented here.

Keywords: Airway management, anaesthetic management, tracheostomy


How to cite this article:
Jindal A, Kumar A, Shekhawat KK, Sharma P. A case report on anesthesia management for a patient with deep neck space infection (retropharyngeal and parapharyngeal abscess). Indian J Dent Sci 2022;14:202-4

How to cite this URL:
Jindal A, Kumar A, Shekhawat KK, Sharma P. A case report on anesthesia management for a patient with deep neck space infection (retropharyngeal and parapharyngeal abscess). Indian J Dent Sci [serial online] 2022 [cited 2022 Dec 9];14:202-4. Available from: http://www.ijds.in/text.asp?2022/14/4/202/361198




  Introduction Top


Airway management in deep neck space infection is considered as an anesthetic challenge due to possibility of inpromptu rupture of abscess accompanied by aspiration. We hereby present a case of deep neck space infection which was drained fortuitously under general anesthesia.


  Case Report Top


Clinical presentation

A 44-year-old female was admitted with chief complaints of tooth ache for 15 days, neck swelling, painful and inconvenient swallowing for 10 days [Figure 1]. The patient developed pain in tooth which was associated with difficulty in swallowing. She had no previous history of any comorbidity, no history of any previous surgery, no allergy to any drug and no history of being on any medication.
Figure 1: Picture showing bulging over the posterior pharyngeal wall on oral examination using tongue depressor

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Neck X-ray, ultrasonography (USG), and contrast enhanced computed tomography (CECT) scan were used to diagnose deep neck space infection.

Widened prevertebral soft-tissue shadow was seen on radiograph [Figure 2]. USG neck was suggestive of abscess with Sialadenitis and adjacent inflammatory changes [Figure 3]. CECT neck with upper thorax showed multiple peripherally enhancing loculated fluid density collection with internal air foci involving the bilateral parapharyngeal, pharyngeal mucosal, retropharyngeal, sublingual, visceral, posterior cervical spaces, supra and infraclavicular region with inferior extension into the mediastinum and along the right side of pericardial space. There was involvement of the bilateral submandibular gland and compression over oesophagus due to the retropharyngeal collection.
Figure 2: X-ray neck lateral view showing widened prevertebral space

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Figure 3: USG reports. USG: Ultrasonography

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These findings were suggestive of extensive necrotizing fasciitis with multiple abscess formation (with air pockets) involving the neck spaces, the submandibular gland, and mediastinum. Glottic and subglottic larynx appeared normal. Bilateral major neck vessels were customary. Clear trachea and main bronchi were found. Hilar or mediastinal lymphadenopathy was absent. Mediastinal vessels and tubular structures were normal. Minimal left pleural effusion was seen. Few atelectatic bands were seen in right middle lobe and left lung.

Diagnostic investigations revealed:

  • Hb-11.2 g%
  • HCT-34.5%
  • PT-13.9
  • INR-1.20
  • Sodium-135.5 mEq/L
  • Potassium-2.5 mEq/L.


Treatment plan

The patient was initially given intravenous (IV) Clindamycin 600 mg twice daily (BD) and IV Rantac 2cc twice daily (BD). Emergency intraoral drainage was done. Preanesthetic assessment was performed on the patient. She was afebrile. Edema was present over face along with swelling present on the submandibular region. Pulse rate of patient was 92 beats/min and blood pressure was 128/82 mm Hg. Mouth opening of patient was limited to 2 fingers. She had restricted neck movement as well as due to severe pain. Mallampati score was III. Loose teeth were absent. Spine was conventional.

The respiratory system evaluation revealed that the trachea was central. Mutually equal air entry was observed. Systemic examination was also customary.

Consent was taken prior to surgery for emergency tracheostomy after explaining the risks and anticipated difficult intubation to patient's relatives. They were also explained the need for keeping the patient intubated during the postoperative period. All equipment for difficult airway management, including that for emergency tracheostomy, was maintained on hand in anticipation of the expected difficult mask ventilation and intubation. IV line was secured in the operating room with 20 G cannula attached to Ringer's Lactate solution. Heart rate, oxygen saturation, respiratory rate, and electrocardiogram were all monitored. To avoid aspiration of contents, patient was kept in head low position. Injection Midazolam 1 mg, injection Glycopyrrolate 0.2 mg, and injection Ondansetron 4 mg was used to premedicate the patient. Patient was also given injection Dexamethasone 8 mg and injection Hydrocortisone 200 mg. Three minutes of preoxygenation was performed.

Anesthesia was induced by injection Propofol 100 mg followed by injection succinylcholine 100 mg injection Propofol 100 mg was used to induce anesthesia, which was followed by injection succinylcholine 100 mg. A direct laryngoscopy revealed an abscess on the posterior pharyngeal wall as well as an oedematous epiglottis. Bougie was originally introduced with careful visualization of the vocal cords in the first try. The tube was threaded over the Bougie, but intubation was unsuccessful. Then, with the help of stillette, the intubation was successful on the second attempt. To intubate the patient, a micro-laryngeal tube size 5.0 (portex, cuffed) was employed. After establishing bilateral air entry, the tube was repaired. Throat packing was used to prevent abscess contents from being aspirated. Sevoflurane and oxygen were used to maintain anesthesia.

Injection Atracurium 0.5 mg/kg was given. The patient was put on volume-controlled ventilation with tidal volume set at 450 ml and respiratory rate at 12 breaths/min. Intraoral drainage of the abscess was done. The patient was shifted to the intensive care unit on the ventilator, for observation after the removal of oropharyngeal packing. Patient was kept under sedation with midazolam and atracurium.

Next day, infusion of midazolam and atracurium was stopped. The patient was weaned off the ventilator gradually. Leak test was performed. Patient was put on pressure-controlled ventilation. Then, patient was extubated after she was showing full efforts of respiration. Patient was maintaining oxygen saturation of 95% on room air postextubation. Heart rate was 82 beats/min and BP was 140/84 mmHg.

When the patient was cognizant, alert, breathing normally, maintaining oxygen saturation on room air, and hemodynamically stable, he was transferred to the ward.


  Discussion Top


Retropharyngeal abscess is pus collection in the retropharyngeal space which runs from base of the skull superiorly to the mediastinum inferiorly up to T1 level. The posterior pharyngeal wall borders it on the front, while the alar fascia borders it on the back. The parapharyngeal space continues it laterally.[1]

The formation of a retropharyngeal abscess can occur as a result of bacterial infection of the retropharyngeal space following dental or tonsillar diseases. If left untreated, the posterior pharyngeal wall might move forward into the oropharynx, causing dyspnea and airway obstruction. Swallowing difficulties, trismus, and a fluctuant posterior pharyngeal mass are examples of ancillary clinical symptoms.[2]

The location and size of the abscess collection determine how to secure the airway. The most secure method of airway protection is a tracheostomy.[3] Patients with severe neck infections, particularly those with Ludwig's angina, are at risk of dying due to airway management errors. Airway management is difficult, but in these individuals, a safe approach of airway control has yet to be identified.[4]

It is difficult to secure the airway using direct laryngoscopy, awake blind nasal intubation, awake fiberoptic intubation, or an elective tracheostomy because of the deformed airway anatomy, insufficient mouth opening, tissue edema, and immobility.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rao MS, Linga Raju Y, Vishwanathan P. Anaesthetic management of difficult airway due to retropharyngeal abscess. Indian J Anaesth 2010;54:246-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Miller's anesthesia, 8th edition. Anesthesiology 2016;124:2529.  Back to cited text no. 2
    
3.
Mulimani SM. Anesthetic management of tuberculous retropharyngeal abscess in adult. J Anaesthesiol Clin Pharmacol 2012;28:128-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: A case series and review of the literature. Anesth Analg 2005;100:585-9.  Back to cited text no. 4
    
5.
Cho SY, Woo JH, Kim YJ, Chun EH, Han JI, Kim DY, et al. Airway management in patients with deep neck infections: A retrospective analysis. Medicine (Baltimore) 2016;95:e4125.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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