Emergency Awake Tracheostomy and Transcervical Drainage for a Mature Parapharyngeal Space Abscess with Impending Upper Airway Collapse: A Case Report

Abstract

Background: Parapharyngeal space abscesses are deep neck infections that can cause sudden airway obstruction, internal jugular thrombophlebitis, and descending mediastinitis. Early airway planning, contrast-enhanced computed tomography (CECT), and surgical drainage are essential.

Objective: To describe the airway-first management and recovery of a woman with a mature parapharyngeal abscess and impending airway collapse.

Methods: This report followed the CARE guideline, with written informed consent. A 44-year-old woman presented to a regional referral hospital in Sorong, Indonesia, with left neck swelling reaching the cheek and orbital margin, fever (38.8 °C), severe odynophagia, and trismus (maximal interincisal opening [MIO] 14.0 mm). She was followed with CECT, serial clinical and laboratory measurements, and pus culture over 10 days.

Results: CECT showed a multilocular, rim-enhancing collection (4.2 × 3.5 × 5.8 cm; 42.6 cm³) in the left prestyloid parapharyngeal space, with 68.4% airway narrowing and a patent carotid sheath. Awake tracheostomy under local anesthesia secured the airway, followed by transcervical submandibular drainage of about 120 mL of pus, which grew Streptococcus sp. sensitive to cephalosporins. Temperature fell from 38.8 to 36.5 °C, MIO rose from 14.0 to 38.0 mm, and the pain score fell from 8.5 to 0.5. She was decannulated on Day 6 and discharged on Day 10 without vascular or mediastinal complications.

Conclusion: Securing the airway with awake tracheostomy before transcervical drainage was safe and effective for a mature parapharyngeal abscess with severe airway narrowing.