Dechu Muddaiah1, Srinivas V.2

PRESENTATION OF CASE A 65 years old female patient presented with odynophagia, fever, since 5 days and absolute dysphagia since 2 days. She had bronchial asthma and type 2 diabetes mellitus on oral hypoglycaemic agents since 15 years. On examination, there was a significant bulge in the posterior pharyngeal wall in midline extending to the left side, pushing the tonsil medially; supraglottis was oedematous obscuring the vocal cords. The patient appeared toxic and there was no external neck swelling. Haematological investigations showed raised total counts, HbA1c was 12.2 and there was presence of ketone bodies in urine. CECT scan of neck showed an irregular peripherally enhancing abscess in retropharyngeal space 3.1 cm x 3.1cm x 6.2cm dimension and extending more in the left paramedian from C1 to C4 levels. There was a mass effect and median bulge indenting the oropharyngeal air column. The abscess cavity was extending inferiorly to the supraglottic level, anteriorly to left posterior tonsillar pillar, laterally up to the level of styloid process, posteriorly up to pre-vertebral muscles. There was no evidence of rupture. Cervical spine and vertebral arteries were normal and there was no evidence of osteomyelitis. As the patient was in diabetic ketoacidosis and early sepsis, she was started on Injection piperacillin tazobactam and insulin infusion. Once the patient was medically stable, the abscess was drained by transoral incision and drainage of the abscess, approximately 40ml of the pus was drained, and the abscess cavity was washed with betadine and hydrogen peroxide. The patient needed ventilator support and she was extubated after 24 hours. Post incision and drainage patient received iv antibiotics injection piperacillin +tazobactam 4.5gm, Inj. Metronidazole 100ml 8th hourly, Inj Gentamycin 80mg 8th hourly and Inj. Dexamethasone 8mg 12th hourly for 7 days. For glucose control on post op day 2, she received IV Insulin and was shifted to Inj.Insugen R 10 units TID subcutaneously.