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CASE:
A 22-year-old man is brought to the emergency department with swelling, pain, and tenderness of the upper neck accompanied by a high fever. He relates that his illness began with a sore throat about 10 days before the swelling first appeared.
WHAT IS YOUR DIAGNOSIS?
The patient has an abscess in the parapharyngeal space of the deep soft tissue of the neck, which extends in an inverted pyramidal shape from the base of the skull to the hyoid bone. Peritonsillar infection is the most likely source, but these abscesses can also develop secondary to dental caries, retropharyngeal or parotid infection, or mastoiditis. The patient usually presents with fever, dysphagia or odynophagia, trismus, swelling over the parotid gland and the mandibular angle, and tonsillar displacement anteromedially. Multiple cranial neuropathy, or Horner's syndrome, may occur since the parapharyngeal space contains the internal carotid artery, the internal jugular vein, cranial nerves IX, X, and XII, and the cervical sympathetic trunk. Other possible complications include airway obstruction, thrombophlebitis of the jugular vein, bleeding, mediastinitis, and sepsis from septic embolization.
Dr. Park is a clinical professor of otolaryngology at Northeastern Ohio Universities College of Medicine and section head of otolaryngology at Barberton Citizens Hospital in Barberton, Ohio. Dr. Tang is an attending physician in the department of family practice at Akron General Medical Center in Akron, Ohio.
