Eur Arch Otorhinolaryngol (2005) 262 : 345–350
DOI 10.1007/s00405-004-0800-6
MISCELLANEOUS
A. Alaani · H. Griffiths · S. S. Minhas · J. Olliff ·
A. B. Drake Lee
Parapharyngeal abscess:
diagnosis, complications and management in adults
Received: 12 November 2003 / Accepted: 30 March 2004 / Published online: 2 July 2004
© Springer-Verlag 2004
Abstract Parapharyngeal abscess may cause life-threat-
ening complications. Peritonsillar abscess and tonsillitis
may result in parapharyngeal abscess. Since the introduc-
tion of antibiotics, the incidence of parapharyngeal ab-
scess secondary to tonsillitis and peritonsillar abscess has
decreased dramatically. We present five cases of parapha-
ryngeal abscess resulting from tonsillitis and peritonsillar
infection extending to the parapharyngeal space in adult
patients. Two were complicated by mediastinitis despite
early treatment by wide spectrum antibiotics. We believe
that early diagnosis and aggressive antibiotic treatment
with early surgical drainage in cases associated with pus
collection are the key points in preventing serious and fa-
tal complications. We emphasize the diagnostic role of
computerized tomography (CT) scan and the importance
of early and proper drainage of these abscesses.
Keywords Parapharyngeal abscess · Quinsy ·
Peritonsillar abscess · Tonsillitis · Mediastinitis
Introduction
Parapharyngeal abscess is a serious medical condition that
may lead to potentially fatal complications including me-
diastinitis [7], mycotic aneurysm formation with possible
subsequent rupture of the internal carotid artery [16], in-
ternal jugular vein thrombosis with septic pulmonary em-
bolism [2] and upper airway obstruction. Dental abscess
and tonsillitis are the most common causes of deep neck
space infections leading to peritonsillar, parapharyngeal
and retropharyngeal abscesses [3, 11]. They commonly
A. Alaani (✉) · H. Griffiths · S. S. Minhas · A. B. Drake Lee
Department of ENT, Queen Elizabeth Hospital,
Edgbaston, Birmingham, B15 2TH, UK
Tel.: +44-7903004251, Fax: +44-1216272299,
e-mail: alaani1@hotmail.com
J. Olliff
Department of Radiology, Queen Elizabeth Hospital,
Edgbaston, Birmingham, UK
occur in young adults [15] and particularly in debilitated
and immunosuppressed patients.
We present five cases of parapharyngeal abscess in
adult immune-competent patients with a history of peri-
tonsillar abscess in two patients and a history of sore
throat only in the other. These patients were referred to
our department over a period of 6 months.
Case reports
The five cases are summarized in Table 1.
Case 1
A 75-year-old man presented with sore throat and left-sided upper
neck swelling of 4-day duration with odynophagia, dysphagia and
pyrexia. There was no history of diabetes or immune suppression.
Clinical examination revealed tonsillitis with a tender mass in the
left parotid area. Trismus was present with medial displacement of
the left lateral pharyngeal wall and peritonsillar tissues on oral ex-
amination without palpable cervical lymphadenopathy. The patient
was tired, feverish and tachycardic. Aspiration of the bulging lat-
eral pharyngeal wall revealed 1 ml of pus, which was sent for bac-
teriology. An urgent head and neck CT scan demonstrated a fluid
collection in the parapharyngeal space (Fig. 1). The patient was
commenced on broad-spectrum intravenous antibiotics (cefo-
taxime, benzyl penicillin and metronidazole). Internal drainage via
pharyngeal incision of the abscess with left-sided tonsillectomy
was performed. The appearance of the tonsil was suspicious, and
the specimen was sent for histopathological examination, which
showed only acute inflammatory changes with no malignancy.
A copious amount of pus was drained. Peptostreptococcus sensi-
tive to metronidazole was cultured from the infected material. Oral
feeding was resumed 24 h after the drainage. The blood culture
showed no bacterial growth. The patient was discharged home af-
ter 10 days of intravenous antibiotic treatment. Clinical examina-
tion 1 month later revealed no significant abnormality.
Case 2
A 29-year-old man presented with a history of sore throat,
odynophagia, dysphagia and pyrexia of 3-day duration. Clinical
examination showed tonsillitis with no cervical lymphadenopathy.
He had fever, tachycardia and was generally unwell. There was no
neck or lateral pharyngeal wall swelling on admission. A CT scan
346
Table 1 Summary of case reports
Patients Age Sex Medias Diabetes WBC HIV test Bacteriological culture Antibiotics Surgical
tinitis 1,000s/ml treatment

Case 1 75 Male No No 8.1 Not done Peptostreptococcus Benzyl penicillin, Yes

cefotaxime,
metronidazole
Case 2 29 Male Yes No 10.5 Negative Streptococcus species, Benzyl penicillin, Yes
Peptostreptococcus, cefotaxime,metro
Bacteroid Melaningoenius nidazole
Case 3 41 Male Yes No 7.2 Not done Bacteroid fragilis, Benzyl penicillin, Yes
Streptococcuss Milleri metronidazole
Case 4 52 Male No No 11.3 Not done B-Haemolytic Benzyl penicillin, No
streptococcus metronidazole,
flucloxacilline
Case 5 47 Female No No 18.2 Not done Mixed anaerobics Cefotaxime, No
metronidazole

Fig. 1 Axial CT scan demonstrates a collection of fluid and gas in Fig. 2 Axial contrast-enhanced CT scan demonstrates a rim-
the left parapharyngeal space. Some further loculated gas is seen enhancing collection posterolateral to the right oropharynx with
lying anterior to the deep lobe of the parotid gland and medial to a further collection extending across the midline in the retro-
the superficial lobe pharyngeal space

was not requested at admission because the possibility of parapha-
ryngeal abscess was not suspected initially. The patient was admit-
ted for intravenous benzylpenicillin. The next day the patient re-
mained unwell and febrile with rigors. Clinical examination re-
vealed a tender swollen neck, trismus, tonsillitis with left periton-
sillar cellulitis and bulging of the left pharyngeal wall. Cefotaxime
and metronidazole were added to his antibiotic regime. An urgent
CT scan of the neck and chest demonstrated multiple neck ab-
scesses in the parapharyngeal and retropharyngeal region (Fig. 2).
A decision was taken to drain the neck abscesses via a collar inci-
sion. At operation, pus and necrotic strap muscles were found and
sent for microbiological examination. Postoperatively, the patient
was admitted to the intensive therapy unit (ITU), intubated and
ventilated under heavy sedation. Microbiology culture of the pus
showed growth of Peptostreptococcus and Bacteroid melanino-
genicus. There was no bacterial growth on blood culture. The pa-
tient continued to have a swinging pyrexia and poor oxygen satu-
ration. Pus continued to drain through the operative site. A second
CT scan revealed fluid collections and extensive gas in the neck
(Fig. 3A) and mediastinum extending to the level of the aortic arch
(Fig. 3B). Excision of necrotic mediastinal tissue by mediastino-
scopy was performed following a thoracic surgical opinion. The
requirement for prolonged intubation necessitated tracheostomy.
The patient’s general condition improved, and he was transferred
to the ENT ward after 3 weeks of ITU care. The patient received
feeding via nasogastric tube postoperatively. He remained on in-
travenous antibiotics for another week on the ward and was dis-
charged after surgical closure of the tracheosotomy incision.
Case 3
A 41-year-old man was admitted with fever, sore throat and mild
odynophagia with some fullness in the right side of the neck. The
 347

Fig. 3 A Further CT scan 3 days later reveals locules of gas within

the previously seen collections. Gas (arrow) is also now present
within the superior mediastinum (B)

lateral pharyngeal wall was displaced medially with no signs of

tonsillitis. He was toxic and had mild stridor. A plain soft tissue
X-ray of the neck revealed air in the right parapharyngeal region. An
urgent neck CT scan demonstrated a collection and gas in the right
parapharyngeal space crossing the midline, anterior to the thyroid
and retropharynx with extension of gas into the mediastinum. Sur-
gical drainage via an external approach revealed pus mixed with
necrotic tissues, which was sent for microbiology culture. The pa-
tient continued to deteriorate postoperatively despite broad-spec-
trum antibiotic benzyl penicillin and metronidazole and ventilatory
support. Another CT scan showed collections in the mediastinum
and pericardium. The mediastinum was surgically drained through
a sternotomy by the thoracic team. Microbiology culture revealed
Bacteroid fragilis sensitive to metronidazole and Streptococcus
milleri sensitive to benzyl penicillin, amoxicillin, tetracycline and
erythromycin. Feeding via a nasogastric tube was established in
the postoperative period. The patient had fully recovered after
6 weeks and was discharged home.

Case 4
A 52-year-old man presented with sore throat, fever, severe odyno-
phagia and dysphagia of 2-day duration. Examination revealed
trismus, a congested pharynx with no signs of tonsillitis and bulging
of the right lateral pharyngeal wall. There was a tender, swollen,
ill-defined area involving the superior anterior triangle of the right
side of the neck. The patient had no respiratory difficulty, and he
was afebrile on admission. He was admitted for intravenous broad-
spectrum antibiotics (benzylpenicillin, flucloxacillin, and metron-
idazole). Urgent CT scan of the neck and upper chest showed cel-
lulitis of the parapharyngeal space with no pus collection or gas
formation (Fig. 4). Aspiration of the bulged lateral pharyngeal wall
revealed a very small amount of pus mixed with blood. The mi-
crobiology culture revealed β-haemolytic Streptococcus sensitive
to penicillin and erythromycin. An oral diet was continued after
three doses of intravenous antibiotics. The patient was discharged
10 days after parentral antibiotics treatment.
Fig. 4 Contrast-enhanced CT scan shows low attenuation swelling
of the right side of the oropharynx with loss of the normal para-
pharyngeal fat plane
Case 5
A 47-year-old female patient complained of left sided sore throat
of 3-week duration that did not resolved by oral antibiotics. She
had dysphagia, odynophagia and hoarse voice without any respira-
tory difficulty. There was no fever at the time of admission, and
the pulse and blood pressure was normal. Examination of the neck
revealed a tender, ill-defined neck mass that was 5 cm in diameter
and anterior to the middle third of the left sternocleidomastoid
muscle. There were no signs of tonsillitis or peritonsillar abscess.
Nasoendoscopy examination demonstrated bulging of the pharyn-
348
geal wall on the left side. In addition, there was swelling of the left
supraglottic region. Needle aspiration of the neck mass showed
1 ml of pus. The patient was admitted for intravenous cefotaxime
and metronidazole. An urgent neck CT scan demonstrated an in-
flammatory mass lateral to the left tonsillar fossa and oropharynx
with extension to the level of the left false cord and pushing the
left sternocleidomastoid muscle laterally. Feeding was maintained
orally a few hours after starting the intravenous antibiotics. Bacte-
riological culture revealed mixed anaerobic bacteria sensitive to
metronidazole. Microbiology culture for tuberculosis was nega-
tive. The patient made a rapid recovery and was discharged home
after 6 days.
Discussion
Acute tonsillitis is a common disease. While the incidence
of the parapharyngeal abscess has markedly declined with
the widespread use of antibiotics [11], peritonsillar abscess
is still a common complication of acute tonsillitis. Para-
pharyngeal abscess could be a secondary complication to
either peritonsillar abscess or less frequently acute tonsil-
litis [11]. However, in a significant number of patients, the
origin of these abscesses remains unknown because the
sore throat may clear by the time of presentation [20].
About 30% of parapharyngeal space abscesses begin in
the teeth and another 30% followed tonsillitis [21].
In the cases of peritonsillar abscess, pus collects be-
tween the tonsillar capsule medially and the superior con-
strictor laterally. The superior constrictor muscle repre-
sents the anteromedial boundary of the parapharyngeal
space. Therefore, infection could extend through the supe-
rior constrictor muscle to the parapharyngeal space, and
thence to the retropharyngeal space, carotid sheath and
mediastinum [22]. Mediastinitis has been described in
few cases of parapharyngeal abscess, and it mainly affects
immunosupressed patients with diabetes, agranulocytosis
and drug addiction [22].
In our series, two patients had a clear history of tonsil-
litis, while the other had a short history of sore throat
without obvious signs of tonsillitis. There was no history
of immunosuppression, and only one had a history of pos-
sible exposure to human immune deficiency virus (HIV),
but was negative on HIV testing. The HIV test should be
performed in the presence of a strong history. Two pa-
tients developed mediastinitis secondary to parapharyn-
geal abscess. All patients had pyrexia, odynophagia, dys-
phagia, tender neck swelling and medial displacement of
the lateral pharyngeal wall. The patients had no history of
repeated tonsillitis or previous quinsy, and a unilateral
tonsillectomy with histopathological examination was per-
formed in only one patient because of the abnormal ap-
pearance of the tonsil. The current practice in the United
Kingdom is not to perform tonsillectomy during acute in-
fection because of increased bleeding risk, and therefore
tonsillectomy during abscess drainage was not performed.
Tonsillectomy was not performed in four patients after re-
covery from the acute episode because the patients had no
history of repeated tonsillitis or previous peritonsillar ab-
scess. The current recommendation in the United King-
dom is to perform tonsillectomy in the presence of a his-
tory of repeated tonsillitis or after a second attack of
quinsy.
The most common symptoms of parapharyngeal abscess
are pain and odynophagia. A neck swelling has been re-
ported as a constant feature in all patients with parapha-
ryngeal abscess, with fever occurring in less than half and
trismus appearing in one third [17]. Medial displacement
of the tonsil is a characteristic sign of an expanding lesion
in the parapharyngeal space [16].
Some authors have described the lateral neck radiograph
as the single most valuable diagnostic investigation for
retropharyngeal abscess [17]. Cross-sectional imaging, par-
ticularly CT, now plays an important role in the diagnosis
and management of neck abscesses [5, 10]. At initial pre-
sentation, neck CT scan is not indicated in the presence of
signs of tonsillitis only. However, urgent neck CT scan is
required in the absence of improvement 24 h after wide-
spectrum intravenous antibiotic treatment or when the pa-
tient initially presents with signs suggesting parapharyngeal
abscess. This allows accurate anatomical localization and
size estimation of fluid collections. It now replaces the lat-
eral neck X-ray as the mean of localizing retropharyngeal
abscesses. It plays a crucial role in the differentiation be-
tween neck cellulitis and abscess formation. The presence
of gas within the neck and mediastinum of our patients as
seen on CT was associated with a more severe clinical
course requiring ITU care. The CT scan should include the
mediastinum in cases where there is inadequate response to
surgical drainage of the neck in order to exclude medias-
tinitis. Some authors believe that the main disadvantage of
the CT scan in the pediatric population is the uncertainty in
differentiating between abscess and cellulitis [18]. This was
not the case in this small group of adult patients.
The most common organisms cultured from deep neck
space infections are β-haemolytic Streptococcus, Staphy-
lococcus aureus, Bacteroides and Neisseria species [9].
The predominant anaerobes, in term of frequency, were
Fusobacterium nucleatum, Bacteroid melaninogenicus and
Peptostreptococcus [1]. The polymicrobial nature of head
and neck infections is well recognized [4]. The associa-
tion of gram-negative rods in deep neck infections is con-
sidered uncommon [4]. However, other series have shown
that gram-negative microorganisms have replaced he-
molytic streptococcus as the most common pathogen [17].
In this series, mixed streptococcus species, B-hemolytic
Streptococcus, Bacteroid fragilis and Bacteroid melanino-
genicus were cultured. This represents no changes from
the classical bacteriology of this pathology. However, the
diagnosis of five patients with parapharyngeal abscess
over a period of 6 months is a serious development and
worthy of reporting. It appears that the incidence of para-
pharyngeal abscess is rising. This could be due to delay
seeking medical advice, the change in the bacterial sensi-
tivity to current antibiotics and development of more re-
sistant bacteria. The negative blood cultures of the pa-
tients in this series could be due to the effect of intra-
venous antibiotics.
Parapharyngeal abscess should be managed as a medical
emergency. Wide-bore needle aspiration can sometimes be

negative even in the presence of pus. Broad-spectrum intra-
venous antibiotics should be started as soon as the diagno-
sis is suspected, because of the wide spectrum nature of the
involved microorganisms. The chosen antibiotics should
cover the suspected bacteria and be modified according to
clinical response and the bacteriological culture and sensi-
tivity results. Discussion with the microbiologists is an im-
portant issue to decide the antibiotics of choice.
An urgent neck CT scan should be arranged in patients
once parapharyngial abscess is suspected. Following the
CT scan, there are two possible options. In the absence of
pus collection, intravenous broad-spectrum antibiotics should
be continued. Alternatively in the presence of a collection,
urgent surgical drainage should be undertaken within the
next 24 h [12]. The presence of gas within the neck in our
small series confers a worse prognosis, and thus more ur-
gent intervention would seem to be appropriate in these
cases. A CT scan of the neck may demonstrate the pres-
ence of gas in the neck tissue without abscess formation in
cases where infection is caused by gas-forming bacteria.
This is due to rapid tissue necrosis and gas formation be-
fore pus collection.
Surgical drainage of deep neck abscess has been rec-
ommended as the appropriate treatment of parapharyngeal
space infections [8]. However, pus was aspirated from all
the cases by wide-needle aspiration. Three patients only
benefited from formal surgical drainage. The decision was
based on the clinical and radiological features on the neck
CT scan. In the first three cases, the patients showed signs
of toxemia and neck CT scan demonstrated fluid collec-
tions. However, the remaining two had neither fever nor
tachycardia, and they were generally well at presentation.
In addition, the neck CT scan showed inflammatory change
without a discrete collection. Therefore, a conservative
approach using intravenous antibiotics was adopted. Re-
cently, non-surgical management of parapharyngeal space
infection by intravenous antibiotics alone has been de-
scribed in pediatric patients without respiratory distress or
septic shock after exclusion of pus extension to other neck
spaces by CT scan [19]. Other authors have described se-
lective pus aspiration under computed tomography guid-
ance with high-dose intravenous antibiotics [6].
Feeding should be addressed in these patients. Patients
with a prolonged course of disease need nutritional sup-
port, usually by nasogastric tube feeding. In patients with
rapid recovery, oral feeding would usually be possible af-
ter a few doses of intravenous antibiotics.
Great care should be taken during intubation because
of the risk of abscess rupture. Tracheostomy may be an
option in cases of difficult intubation or incidental rupture
of the abscess. Wide opening of the neck spaces is essen-
tial to drain all the abscess loculi and to avoid recollec-
tion. In addition, it may be necessary to repeat the CT
scan if the clinical situation deteriorates after surgical
drainage to exclude recollection. Scans should also in-
clude the chest to exclude more serious complications
such as mediastinitis.
Complications of the parapharyngeal abscess have be-
come rare [13]. However, the reduction in the frequency
349
of complications is chronologically related to the intro-
duction of the antibiotics rather than to surgical treatment
[13]. We believe that the advances in the head and neck
CT scan technique and early surgical drainage have an
important role in addition to the use of wide-spectrum
combination antibiotic therapy.
Conclusion
Although the incidence of parapharyngeal abscess has been
much reduced with the introduction of antibiotics, it still
occurs. Therefore, this potentially fatal condition should
not be overlooked. Radiological investigations, especially
the neck CT scan, have a decisive role in the diagnosis,
management and early detection of complications. Early
diagnosis and prompt treatment by intravenous wide-
spectrum antibiotics and adequate surgical drainage in
case of abscess formation are the key points in the man-
agement of this condition. This abscess affects mainly im-
munocompromised persons, but as demonstrated by our
cases, it may still occur in immunocompetent patients.
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