MPMSU ENT 2018 question paper with answers

Definition: It is a collection of pus in the peritonsillar space which lies between the capsule of tonsil and the superior constrictor muscle.

Aetiology

Peritonsillar abscess usually follows acute tonsillitis though it may arise de novo without previous history of sore throats. First, one of the tonsillar crypts, usually the crypta magna, gets infected and sealed off. It forms an intratonsillar abscess which then bursts through the tonsillar capsule to set up peritonsillitis and then an abscess.

Culture of pus from the abscess may reveal pure growth of Streptococcus pyogenes, S. aureus or anaerobic organisms. More often the growth is mixed, with both aerobic and anaerobic organisms.

Clinical Features

Peritonsillar abscess mostly affects adults and rarely the children though acute tonsillitis is more common in children. Usually, it is unilateral though occasionally bilateral abscesses are recorded. Clinical features are divided into:

1. General

• Fever (up to 104 °F)
• Chills and rigors
• General malaise
• Body aches
• Headache
• Nausea and constipation

2. Local

• Severe unilateral throat pain
• Odynophagia – patient cannot swallow saliva, leading to dribbling and dehydration
• Muffled “hot potato” voice
• Foul breath due to sepsis and poor hygiene
• Ipsilateral earache (referred via CN IX)
• Trismus due to spasm of pterygoid muscles

Examination

• Tonsil, pillars and soft palate on the involved side are congested and swollen. Tonsil may appear buried in oedematous pillars.
• Uvula swollen, oedematous and pushed to opposite side.
• Bulging of soft palate and anterior pillar above the tonsil.
• Mucopus may cover the tonsillar region.
• Cervical lymphadenopathy (jugulodigastric nodes).
• Torticollis – neck tilted to side of abscess.

Investigation

• Contrast-enhanced CT or MRI shows abscess and its extent.
• Needle aspiration provides pus for culture and sensitivity.

Treatment

1. Hospitalization.
2. Intravenous fluids to combat dehydration.
3. Large dose IV antibiotics covering aerobic and anaerobic organisms.
4. Analgesics like paracetamol for pain and fever; pethidine if needed. Avoid aspirin (risk of bleeding).
5. Maintain oral hygiene with hydrogen peroxide or saline mouth washes.

The above conservative measures may cure peritonsillitis. If a frank abscess has formed, incision and drainage will be required.

Incision and Drainage of Abscess

A peritonsillar abscess is opened at the point of maximum bulge above the upper pole of tonsil or just lateral to the point of junction of anterior pillar with a line drawn through the base of uvula. With a guarded knife, a small stab incision is made and a sinus forceps inserted to open the abscess. The forceps may be reinserted the next day to drain any reaccumulation.

Interval Tonsillectomy

Tonsils are removed 4–6 weeks following an attack of quinsy.

Abscess or Hot Tonsillectomy

Some prefer “hot” tonsillectomy instead of incision and drainage. Abscess tonsillectomy carries the risk of rupture of abscess during anaesthesia and excessive bleeding at the time of operation.

Complications

• Parapharyngeal abscess (potential extension).
• Oedema of larynx – may require tracheostomy.
• Septicaemia, endocarditis, nephritis, brain abscess.
• Pneumonitis or lung abscess from aspiration of pus after spontaneous rupture.
• Jugular vein thrombosis.
• Spontaneous haemorrhage from carotid artery or jugular vein.

Surgical Anatomy of Cervical Part of Trachea

1. Extent

The trachea begins at the lower border of the cricoid cartilage (C6 vertebral level) and extends into the thorax.
The cervical part extends from C6 to the suprasternal (jugular) notch — roughly 5–6 cm in adults.
Below this, it continues as the thoracic trachea, ending at the carina (T4–T5).

2. Shape and Size

• About 2 cm in diameter (adult male).
• Slightly flattened posteriorly (due to trachealis muscle).
• Formed by 16–20 C-shaped hyaline cartilaginous rings — open posteriorly.

3. Relations of the Cervical Trachea

(A) Anterior Relations

• Skin, superficial fascia, and deep cervical fascia (investing and pretracheal layers).
• Infrahyoid (strap) muscles: sternohyoid and sternothyroid.
• Isthmus of thyroid gland — crosses 2nd, 3rd, and sometimes 4th tracheal rings.
• Inferior thyroid veins and thyroidea ima artery (if present).
• Pretracheal lymph nodes.

(B) Posterior Relation

• Esophagus — lies directly behind the trachea; slightly to the left side.
• Hence, trachea deviates slightly to the right in the lower cervical region.

(C) Lateral Relations

• Lobes of the thyroid gland and their capsule.
• Common carotid arteries and carotid sheath (containing internal jugular vein and vagus nerve).
• Recurrent laryngeal nerves — ascend in the tracheoesophageal groove on either side.

4. Blood Supply

• Arterial: Inferior thyroid arteries (branches of thyrocervical trunk).
• Venous: Inferior thyroid veins → brachiocephalic veins.
• Lymphatic: Pretracheal, paratracheal, and deep cervical lymph nodes.

5. Nerve Supply

• Sensory and motor: Recurrent laryngeal nerves.
• Sympathetic fibers: From middle cervical ganglion.

Clinical Importance

1. Tracheostomy

Common surgical procedure to create an airway.
Performed usually below the isthmus of thyroid gland (between 2nd–4th tracheal rings).
Knowledge of relations helps avoid:

• Injury to thyroid isthmus or inferior thyroid veins.
• Damage to recurrent laryngeal nerves (which run laterally and posteriorly).
• Injury to thyroidea ima artery (if present).

2. Tracheal Intubation

The trachea’s fixed position by cricoid cartilage and rigidity by cartilage rings aid intubation.
Deviation of trachea may indicate pathology (e.g., mediastinal mass, pleural effusion).

3. Compression Syndromes

Enlarged thyroid gland (goiter) can compress the trachea → dyspnea or stridor.
Retro-sternal goiters may compress the trachea posteriorly.

4. Spread of Infection

Pretracheal space infections may descend into the superior mediastinum due to continuity of fascia.

5. Foreign Bodies

Knowledge of the trachea’s anatomy helps in bronchoscopy and removal of foreign bodies.