Peritonsillar Abscess

Magen Ross

12/2/2019

RAD 4001

Dr. Talley and Dr. Choi

McGovern Medical School

Clinical History

• 33 yr male w/ no PMH complaining of sore throat x3 days and hoarse voice

• Patient sent to TMC from urgent care after CT showed peritonsillar v tonsillar abscess

• Sent after giving 10mg Decadron and 600mg Clindamycin IV

• Vitals: 166/88 mmHg, 86 bpm, RR 18, T 98.3

• Physical Exam: • HEENT: Oropharyngeal erythema, extending across soft palate worse along

the left compared to the right

• Pulm: No labored breathing, lungs clear to auscultation

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Findings:-L. Peripherally enhancing 2x2 cm peritonsillar collection with surrounding inflammatory changes. -Reactive lymphadenopathy and diffuse lymphadenopathy in neck

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Highlight and summarize key imaging findings

• 33 yr male w/ no PMH complaining of sore throat x3 days and hoarse voice with OSH CT indicating tonsillar vs peritonsillar abscess

• In house CT confirms presence of peritonsillar abscess with surrounding inflammatory changes and diffuse lymphadenopathy

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Differential Diagnosis

• Peritonsillar Abscess

• Tonsillitis with phlegmon

• Intratonsillar abscess

• Retropharyngeal abscess

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Discussion

• Peritonsillar abscess: Collection of pus between the capsule of the palatine tonsil and pharyngeal muscles

• Typical presentation• Severe sore throat, fever, and muffled voice (as seen in this patient)

• Also can have drooling and trismus

• Exam:• Enlarged, fluctuant tonsil with deviation of uvula

• Diagnosis can be made on a clinical basis, but most clinicians get imaging to rule out para- or retropharyngeal abscess

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Continued discussion

• Most commonly caused by group A strep, S. aureus, and respiratory anaerobes.

• Antibiotics should cover all the above for at least 14 days.

• Complications to untreated or undertreated infections include spread to other deep neck spaces, adjacent structures or the bloodstream; which all can be fatal.

• Airway obstruction can occur in patients who fail to seek medical attention in a timely manner

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Final Diagnosis

• Peritonsillar Abscess

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Treatment

• Antibiotic treatment is required

• Surgical drainage is also recommended.• Needle aspiration, incision and drainage, or tonsillectomy

• Most patients have a semi-compromised airway due to the inflammation and abscess, so care should be taken when considering sedation of any type for surgical drainage

• It is suggested to try local anesthetics only if patient is able to tolerate and cooperate

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ACR appropriateness CriteriaCost for the patient:-The average cost of a neck CT in Houston is $631.-This patient had a scan at the OSH and then a repeat scan at Hermann-Even though the scan has an appropriate rating according to the ACR, the patient was exposed to double the amount of radiation and the cost by scanning his neck again. -A clinical diagnosis can be made and should have been considered in this patient before repeating the scan.

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Take Home Points

• Peritonsillar abscess presents as a patient with fever, sore throat, hoarseness, drooling, and trismus.

• Exam will show an enlarged tonsil with uvular deviation which is enough for a diagnosis

• CT scan should be considered to further classify location of lesion to rule out more serious complicated infectious locations

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References

• https://radiopaedia.org/articles/peritonsillar-abscess?lang=us

• https://www.uptodate.com/contents/peritonsillar-cellulitis-and-abscess?search=peritonsillar%20abscess&source=search_result&selectedTitle=1~53&usage_type=default&display_rank=1#H19

• https://clinicalgate.com/otolaryngologic-procedures/

• https://pedclerk.uchicago.edu/page/peritonsillar-abscess

• https://acsearch.acr.org/docs/69504/Narrative/

• https://www.newchoicehealth.com/places/texas/houston/ct-scan/ct-neck

Questions?