CASE REPORT
Acute Parapharyngeal Abscess Secondary to
Streptococcal Mastoiditis
Muhammad Ishaque1, Syed Shaukat Hussain1 and Abid Mahmood2
ABSTRACT
A rare case of parapharyngeal abscess caused by Streptococcus pneumoniae presenting as neck abscess is reported. The
patient had 20 days history of cough, fever and swelling behind right ear. He had not responded to multiple antibiotic
treatments given earlier. On the basis of clinical examination and CT scan finding, he was diagnosed as having parapharyngeal abscess pointing in the neck. The abscess was drained and the patient was treated with injectable Ceftriaxone,
due to identification of penicillin - resistant Streptococcus pneumoniae.
Key words:
Parapharyngeal abscess. Neck abscess. Streptococcus pneumoniae. Mastoiditis. Penicillin resistant streptococcus.
INTRODUCTION
Peritonsillar, retropharyngeal and parapharyngeal
abscesses are the most common deep cervical space
infections.1 Out of these the parapharyngeal ones are
less common but have the most serious morbidity and
mortality. Most of these develop secondary to tonsillar,
dental or mastoid infections.1 The organisms commonly
involved include Streptococcus pyogenes, Staphylococcus aurius
and Heamophilis influenzae.3 Streptococcus pneumoniae can
rarely cause such infections. Diagnosis depends upon
thorough clinical examination and Computerized
Tomography (CT) scan which also helps to asses the
extent of infection.4 Early surgical treatment and
appropriate antibiotic use can save these patients from
complications. Microbiological diagnosis of exact
etiology depends on isolation of the pathogens on
culture and antibiotic sensitivity tests of these isolates
can help a lot in selecting the appropriate antibiotics. We
report a case of parapharyngeal abscess caused by
Streptococcus pneumoniae who presented with fever and a
large neck abscess.
CASE REPORT
A 70 year old man of thin built presented in the
Outpatient Department of Ear, Nose and Throat, with 20
days history of cough, high grade fever and a painful
swelling behind the right ear. The patient had received
multiple antibiotic treatments from his village physicians
during this period but he did not improve. The fever
1
2
ENT Department, Combined Military Hospital, Gujranwala.
Department of Pathology, Combined Military Hospital,
Gujranwala.
Correspondence: Dr. Lt. Col. Syed Shaukat Hussain, ENT
Department, Combined Military Hospital, Gujranwala Cantt.
E-mail: [email protected]
Received April 23, 2008, accepted July 31, 2009.
798
persisted and the swelling had gradually increased to its
present size. On examination, the patient was looked
toxic with a regular pulse rate of 112/minute, blood
o
pressure of 100/60 mm Hg and a temperature of 102 F.
A swelling of 15 x 10 cm in size was visible behind the
right ear extending upto the neck. It was warm, tender
and fluctuant on palpation. His throat and nasal
examination did not reveal any abnormality. Ear
examination was unremarkable except tender mastoid
on right side.
Laboratory investigations revealed Hb of 15.1 g/dl and
9
TLC of 17.6 x 10 /L with 82% neutorphils. His blood
sugar fasting, urea, creatinine and urine routine
examination were within normal limits. Computerized
Tomography (CT) scan of the neck revealed mastoiditis/
osteomyelitis with abscess formation which was
travelling down the neck. The diagnosis of acute
parapharyngeal abscess pointing in the neck was made.
The patient was admitted to the ward, and given
antipyretics. In the operation theatre, about 50 mls of
thick creamy white pus was drained and sent for
microscopy and culture. The patient was started with
injectable Augmentin 1.2 G intravenously twice daily.
Grams stained smear of the specimen revealed
numerous pus cells and gram positive diplococci
resembling Streptococcus pneumoniae (Figure 1). Ziehl
Nelson’s smear showed no acid fast bacilli. Culture of
the specimen yielded a pure growth of Streptococcus
o
pneumoniae on 24 hours incubation at 37 C (Figure 2).
The isolate was found resistant to penicillin (A zone
diameter of 16 mm around 1 ug oxacillin disc) but was
sensitive to Ceftriaxone.
Keeping in view the sensitivity report the patient was
started with injectable Ceftriaxone 1 G intravenously
twice daily. Patient became afebrile within the next 2
days and the pain in his neck also subsided. The
drainage site also healed in the next 2 days and the
Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (12): 798-799
Acute parapharyngeal abscess secondary to streptococcal mastoiditis
when the first penicillin resistant strain was isolated.7
Now, its prevalence is increasing world wide and posing
a new challenge to physicians.8 These isolates are
routinely screened for penicillin sensitivity using the 1 ug
oxacillin disc diffusion method. Isolates with inhibitory
zones of less than 20 minutes are reported as resistant.9
The isolate in this case had a zone diameter of 16 mm
so it was reported as penicillin resistant. Ideally a
minimum inhibitory concentration (MIC) of penicillin
should be determined against the isolate. The isolate
should have an MIC of more than 1 ug/ml to be labeled
as penicillin resistant.10 But the facility for the same was
not available at our hospital.
patient was discharged symptom free on the sixth day.
He was advised Cefixime capsule 400 mg once daily for
further 14 days surgery for mastoiditis after 06 months,
visit the outpatient department for follow-up after 14
days but he went back to his village and did not
report back.
Figure 1: Gram’s stained smear
showing pus cells and lancet
shaped Gram positive diplococci
morphologically resembling Streptococcus pneumoniae.
REFERENCES
Figure 2: Pure growth of
Streptococcus pneumoniae on primary
culture plate.
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Brook I. Microbiology and management of peritonsillar,
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DISCUSSION
Parapharyngeal and retropharyngeal abscesses are life
threatening conditions although their occurence is quite
low with the use of good antibiotics.5 Patients with these
infections most commonly present with fever and
dysphagia.6 An early diagnosis by a good clinical
examination and CT scan can lead to early
management and avoidance of complications. This case
presented with a delay of about 20 days with the
abscess presenting on the outside of the neck behind
the right ear. A CT scan was done only to confirm the
deep extent and the source of infection.
Oral drainage along with the administration of
appropriate antibiotics is the main treatment for
parapharyngeal abscesses.5 In this case as the abscess
had reached near the surface and presented as a neck
abscess, it was very successfully drained from outside.
It is difficult to determine the bacterial etiology of such
infections in the absence of good microbiological
services. Penicillin-resistant Streptococcus pneumoniae was
isolated in this case. This brings forward the fact that in
addition to surgical treatment, establishing the exact
bacterial diagnosis along with the susceptibility pattern
of the isolate is extremely important, so that suitable
antibiotics can be administered. Streptococcus pneumoniae
remained universally sensitive to penicillin till 1967,
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7.
8.
9.
Hansman D, Bullen M. A resistant pneumococcus. Lancet 1967;
2:264-5.
Lu CY, Lee Pl, Hsueh PR, Chang SC, Chiu TF, Lin HC, et al.
Penicillin-non susceptible Streptococcus pneumoniae infections in
children. J Microbiol Immunol Infect 1999; 32:179-86.
National Committee for Clinical Laboratory Standards.
Performance standards for antimicrobial disk susceptibility tests:
approved standard M2-A7. 7th ed. Wayne (PA): National Committee
for Clinical Laboratory Standards; 2000.
10. Jorgensen JH, Howell AW, Maher LA. Quantitative antimicrobial
susceptibility testing of Haemophilus influenzae and Streptococcus
pneumoniae by using the E-test. J Clin Microbiol 1991; 29:109-14.
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