A sequel of phlegmonous pharyngitis. Symptoms; masked by its depth;
pharyngeal wheezing or roaring with little local swelling; difficult
swallowing; resisting tissues tend to chronicity. Results; pharyngeal
fistula, burrowing along œsophagus, rupture into chest or
blood-vessels, lymphadenitis, compression of vagus, or jugulars,
permanent infected cavity with small orifice. Diagnosis from pus in
guttural pouches. Treatment; external opening; antisepsis.
This is a natural result of phlegmonous pharyngitis, but it is possessed
of so great importance alike in its chronicity and its results that it
seems to deserve a special article. Like its initial morbid condition it
is especially common in the soliped, and like that may be traceable to
strangles, influenza, and local traumatism.
The _symptoms_ are at first those of phlegmonous pharyngitis, and, if
the local swelling, induration and tenderness are less marked than in
other cases, it is due to the location of the inflammatory lesion deeply
between the pharynx and the atlas and occiput. Indeed the moderate
aspect of the external swelling, conjoined with the noisy wheezing or
violent roaring, may be taken as important diagnostic indications. The
supra-pharyngeal region is so closely confined on its lateral aspects,
by the union of the fascia of the sternomaxillaris and mastoido-humeral
muscles, that the swelling is confined in the early stages just as the
pus is later. As this resistant fascia prevents any relief by lateral
expansion, the engorged tissues press downward on the softer and less
resistant upper wall of the pharynx and seriously impair both
respiration and deglutition. Similarly when pus has formed, these
lateral fibrous barriers, reënforced by organized lymph, stand in the
way of the advance of the pus toward the skin, and lead it to dissect
its way downward toward the pharynx. Even here the thickening of the
tissues by the organized products of the lymph will often interpose a
serious bar, and the pus remains pent up indefinitely, a source of
wheezing, roaring and impaired deglutition, and a constant threat of
secondary abscess or septic infection. Even the dense fibroid tissues
may soften and degenerate and the pus may make its way spontaneously to
the pharynx, or less frequently through the skin of the parotid, or
intermaxillary region, or into the œsophagus or larynx. A fistula of the
pharynx opening externally and allowing the escape of alimentary matters
has been often noticed. These are especially liable to follow puncture
of the abscess.
Among the less common sequelæ are fistula of the œsophagus; purulent
pneumonia in connection with the purulent dissection of the œsophagean
walls and rupture into the chest (Fichet, Schneider); ulceration of the
blood vessels in the cow (Jonge); adenitis and lymphangitis of the neck,
and the thoracic glands, followed by pericarditis and pleurisy (Cadeac);
multiple embolic abscesses of internal organs (Dieckerhoff); compression
and degeneration of the vagus nerve, with consequent respiratory and
digestive troubles (Baudon); and compression and obstruction of the
jugulars with passive congestion of the brain and vertigo. (Delamotte,
Debrade). Even when the abscess opens into the pharynx the orifice is
usually small, the pus escapes imperfectly, and food materials enter and
the fistula may thus persist for a length of time. The same imperfect
discharge is liable to take place with an external orifice and the pent
up pus becomes inspissated, caseated and even calcified.
_Diagnosis._ Supra-pharyngeal abscess is to be distinguished from pus in
the guttural pouches, by the lack of coincidence of the discharge with
the dependence of the head in grazing, eating roots or drinking from a
bucket; by the absence of the intermission when the head is elevated;
and by the fact that the discharge is less frequently limited to the one
nostril. The hearing too is less likely to be affected.
_Treatment._ As soon as the presence of pus can be recognized it should
be evacuated. This is often attempted through the roof of the pharynx,
but with such an opening there is always danger from the entrance and
decomposition of alimentary matters. If fluctuation can be felt
externally, it is better to be opened through the skin. The integument
may be incised with a lancet, and the tissues further penetrated by
manipulations with the finger nail, a grooved sound or the point of
closed scissors. In this way the vessels and nerves are pushed aside and
the dangers of hemorrhage, fistula and paralysis avoided. The cavity
must be irrigated with an antiseptic solution (carbolic acid 3:100; or
acetate of aluminum 1:20).