Discussion
We have found only one study (PubMed search) reporting four PMA
cases.6 However, in our series PMAs represented 14,3%
of DNIs, suggesting that this entity is not uncommon, and in “real
world” practice may be underdiagnosed or misdiagnosed as parapharyngeal
abscesses. PMA is supposed to be mainly associated with pharyngeal
mucosa’s infections; while infections of the teeth, major salivary
glands, or other foci lateral to pharyngeal constrictor can hardly
result in PMA.6 Our results support this, since none
of our cases had odontogenic or salivary source of infection.
Symptoms of PMAs are similar to those of DNIs. Dysphagia was consistent
symptom in all patients, with odynophagia and sore throat lagging
behind. Skoulakis et al6, did not report trismus and
neck swelling in their cases. In our series, mild trismus noticed in
20,75% of patients; but this finding was significantly lower than other
DNIs. Neck swelling, secondary to neck lymphadenitis, even though
significantly lower than other DNIs, was recorded in 24,53%. The rest
of PMA symptoms were not significant different from other DNIs. Fever
was noted in half of our patients, whilst mean WBC and CRP values were
raised.
Lateral pharyngeal wall edema was a constant physical examination
finding in all cases, while in some of them edemas in other
oropharyngeal parts coexisted. In 43(40,6%) patients with abscess
extension to hypopharyngeal part of PMA, edema was extended to pyriform
sinus; while in those where pus reached the most inferior part of PMS,
arytenoid or aryepiglottic fold edema coexisted. No other findings from
laryngeal endoscopy were recorded, while follow up of the 5 cases with
epiglottic edema and the 2 cases with the true vocal cord edema revealed
the presence of epiglottic retention cysts and Reinke edema
respectively. Tenderness during palpation of larynx (bilateral movement)
was also a constant finding in all patients. Similar findings were
reported by Skoulakis, et al.6
CT-scan with contrast (figure 1) is the “gold standard” to set PMA
diagnosis6. Abscess protrusion into pharyngeal lumen
may give the impression of parapharyngeal abscess; however, PMS is
located to the lateral pharyngeal wall among pharyngeal mucosa and
pharyngeal constrictors, extends under the hyoid bone and passes medial
to it; in contrast other spaces pass lateral to (e.g. carotid space) or
end to the hyoid bone (e.g. parapharyngeal space). MRI may also be used,
while ultrasonography cannot identify PMS adequately.6
Streptococcus pyogenes and Staphylococcus aureus were the
commonest bacteria species in our series. Microbiology of PMA seems to
be similar to other DNIs and related to pharyngeal
microflora.3,6 However, we had only a small number of
positive cultures, so on these grounds safe and generalized conclusions
cannot be made. Empirical therapy with IV-ampicillin/sulbactam combined
with metronidazole or clindamycin seemed to be effective in our
practice.
Skoulakis et al, suggested that “the abscess, as a rule, is
drained spontaneously ”6. In our series spontaneous
drainage was noted in 49,1% of patients, and the mean time until
spontaneous drainage was 1.8±0.8 days from admission. In all instances
spontaneous opening was small and the flow of pus was slow allowing the
patient to swallow it; we believe this was the main reason why no
compilation related to tracheobronchial pus aspiration was noted in any
of these patients. PMS lying just deep to pharyngeal mucosa while dense
connective tissue is present only in its deeper border, hence hindering
infection spread towards deeper spaces and facilitating pus drainage
intraluminal in case of PMA by virtue of least resistance. Furthermore,
pharyngeal constrictor’s pressure on the abscess during the pharyngeal
peristaltic wave facilitates spontaneous drainage through the
“vulnerable” mucosa. Transoral drainage under local anesthesia or
aspiration may also be performed in order to shorten hospital-stay.
In our series, no major adverse event was noted and no further surgical
intervention was needed. Superficial PMS location in pharyngeal lumen
and dense deep border together with spontaneous drainage may be the
reasons why abscesses constrained in PMS fare better than other DNIs.
Even though our data withdrawn from a prospectively collected database,
retrospective nature of our study is the main limitation. On the other
hand, we believe that the relatively large number of cases minimizes
bias and present meaningful results.
In conclusion, our study suggests that PMAs, are not so rare as they are
considered to be; however, there is a lack of literature on this space
abscesses. PMAs have much in common with other DNIs but they are less
dangerous than their deep-seated counterparts, since its superficial
location renders them amenable to spontaneous drainage, aspiration,
incision and drainage intraorally obviating spread to deeper structures.
Conflict of interest: None to declare.
Data availability statement: The data that support the findings
of this study are available on request from the corresponding author.
The data are not publicly available due to privacy or ethical
restrictions.