Practice CMAJ

Cases Bilateral peritonsillar complicating acute

Yuan-Yung Lin MD, Jih-Chin Lee MD

Competing interests: None 24-year-old woman presented to the declared. emergency department with a three-day This article has been peer A history of worsening , pain reviewed. with swallowing and . She had been seen by Correspondence to: her primary care physician one day before pre - Dr. Jih-Chin Lee, sentation because of sore throat and fever, and [email protected] had been given oral amoxicillin. She was previ - CMAJ 2011. DOI:10.1503 ously well with no history of recurrent tonsillitis, /cmaj.100066 previous peritonsillar or drug allergies. On physical examination, her temperature was 39.8°C, pulse rate was 90 beats/min, res - piratory rate was 24 breaths/min and blood pressure was 110/70 mm Hg. She spoke with a muffled voice without substantial stridor or res - piratory distress. Examination of the oral cavity and oropharynx showed moderate , pool - Figure 1: Oral cavity and oropharynx of a 24-year- old woman with worsening sore throat, odynopha - ing of saliva, symmetrically enlarged and in- gia and fever, showing pooling of saliva and a flamed , and a bilaterally congested and bilaterally congested and swollen soft palate bulging soft palate with a midline uvula ( Figure (arrows) with a midline uvula (asterisk). 1). There was also bilateral, tender submandibu - lar lymphadenopathy. The remainder of the (CT) of the showed bilateral hypodense physical examination was unremarkable. masses with thick rim enhancement in the supe - A complete blood count showed a leukocyte rior poles of the peritonsillar regions measuring count of 17.6 (normal 4.5–11.0) × 10 9/L with an 2.6 × 1.8 cm and 0.8 × 0.8 cm, respectively ( Fig - elevated absolute neutrophil count of 15.7 (nor - ure 2A ), and extending down to the peritonsillar mal 1.8–8.1) × 10 9/L. The absolute lymphocyte regions with a multilocular appearance ( Figure count and monocyte count were within normal 2B ), consistent with bilateral peritonsillar ab- limits. The level of C-reactive protein was 3926.8 scesses. The patient underwent bilateral needle (normal < 47.6) nmol/L. A monospot test was not aspiration by the otolaryngologist; a total of 10 done. On her arrival at the emergency depart - mL of purulent material was obtained from the ment, the patient was given intravenous (IV) flu - left side and 3 mL from the right side. Cultures ids and IV amoxicillin–clavulanic acid for a pro - from the aspiration ultimately grew Acinetobac - visional diagnosis of peritonsillar abscess. ter baumannii , which was resistant to ampicillin Contrast-enhanced computed tomography and susceptible to ampicillin–sulbactam. She was discharged home on another course of oral Key points amoxicillin–clavulanic acid for a total of 14 days of treatment. The patient’s abscesses • Peritonsillar abscess is a potentially life-threatening deep-neck resolved and there were no signs of recurrence at in adults that may complicate acute tonsillitis. six months. • Bilateral swelling of the soft palate with a midline uvula may indicate the presence of bilateral peritonsillar abscesses. Discussion • Contrast-enhanced computed tomography should be considered for assessment of patients with suggestive of bilateral peritonsillar abscesses. Although acute tonsillitis usually runs a rela - • A patient with suspected bilateral peritonsillar abscesses requires tively benign course, complications may occur urgent otolaryngologic assessment. (Box 1). 1–4 These can be life-threatening if treat - ment is delayed or inadequate. In particular, air -

1276 CMAJ, August 9, 2011, 183(11) © 2011 Canadian Medical Association or its licensors Practice way compromise can occur from or examination. In unilateral or bilateral abscesses, laryngeal ; deep-neck abscess of periton - the patient may present with a muffled voice, sillar, parapharyngeal or retropharyngeal spaces; progressive , , referred and . Other complications related to otalgia, trismus, oral pooling of saliva, the sequela of inflammation, septicemia or an and fever. 1,6,8 In unilateral peritonsillar abscess, untreated group A β-hemolytic streptococcal the classic intraoral finding is bulging of one pharyngeal infection also can cause high morbid - anterior tonsillar pillar and the adjacent soft ity and mortality. palate with contralateral displacement of the uvula. 1,2,6,8 Epidemiology of peritonsillar abscess Patients with bilateral peritonsillar abscesses Peritonsillar abscess is a collection of within present a diagnostic dilemma because they do the space between the and the superior not exhibit the above classic asymmetric signs constrictor muscle. Most instances of peritonsil - seen in unilateral peritonsillar abscess, such as lar abscess are polymicrobial, with a mix of aer - asymmetry of the tonsils and palate, and devia - obic and anaerobic organisms. The most com - tion of the uvula. The presence of a midline mon aerobes are pyogenes and uvula does not eliminate the possibility of peri - Streptococcus viridans, whereas Fusobacterium tonsillar abscess. A midline uvula with bilateral and are among the most common bulging of the soft palate appears to be a key anaerobes. 5,6 Peritonsillar abscess typically sign in bilateral peritonsillar abscesses, 8 as was occurs in adolescents and young adults. 5 It is one seen in our patient and in case reports in the lit - of the most common complications of acute ton - erature. Although this presentation is uncom - sillitis; there are about 45 000 instances annually mon in peritonsillar abscess in general, other in the and Puerto Rico. 7 It is usu - features of the physical examination in our ally unilateral, and clinically evident bilateral patient would have suggested a disease that presentation is uncommon. The actual frequency needed further diagnostic workup. The presence of bilateral peritonsillar abscesses is not known; of trismus and a muffled voice are also concern - however, it has been seen at rates of 1.9% to ing features that would warrant a thorough 24% in reports describing quinsy workup for worst-case scenarios. 1,9 (also known as acute abscess tonsillectomy), in which the unsuspected contralateral abscess was of bilateral discovered during surgery. 1,6 peritonsillar abscesses On reviewing the literature, we found reports The intraoral examination of severe acute tonsil - on 10 patients (Appendix 1, available at www litis and can be quite .cmaj.ca /lookup /suppl /doi: 10.1503 /cmaj.100066 similar to that of bilateral peritonsillar abscesses. /-/DC1) with clinical courses similar to that of Other less common conditions may be confused our patient. Like our patient, these patients had with bilateral peritonsillar abscesses, such as clinically evident bilateral peritonsillar abscesses lymphoma presenting with bilateral large and (in contrast to an unsuspected contralateral peri - tonsillar abscess found at the time of bilateral AB quinsy tonsillectomy for a presumed unilateral peritonsillar abscess). The mean age was 22.7 (range 9–32) years. All but one patient had a bilaterally bulging soft palate with a midline uvula on presentation. Six instances were diag - nosed by contrast-enhanced CT, two by needle aspiration and two by incision and drainage. Ini - tial management included needle aspiration in four instances, incision and drainage in four, and quinsy tonsillectomy (removal of tonsil to drain abscess) in two. After discharge, five patients underwent elective tonsillectomy, four were fol - lowed up (two had previously undergone quinsy tonsillectomy), and the subsequent management was not reported for one patient.

Figure 2: Contrast-enhanced computed tomographic scan of the neck showing Diagnosis of peritonsillar abscess a midline uvula (asterisk) and bilateral hypodense masses (arrows) with thick The diagnosis of peritonsillar abscess is usually rim enhancement (A) in the superior poles of the peritonsillar regions and (B) made on the basis of the history and physical extending down to the peritonsillar regions with a multilocular appearance.

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lar abscess, but needle aspiration, incision and Box 1: Complications of acute tonsillitis 1–4 drainage, and quinsy tonsillectomy are consid - • Bilateral or unilateral peritonsillar abscess ered acceptable for the surgical management of • Parapharyngeal abscess acute peritonsillar abscess. An evidence-based • review of the treatment of peritonsillar abscess • Mediastinitis (e.g., descending necrotizing reported that most series found these three mediastinitis) approaches were all highly effective for treating • Edema of the epiglottis, or both unilateral peritonsillar abscess, and the recur - • Bacteremia with metastatic seeding, or rence rates after these procedures are low. 5 Ear - both lier studies tended to stress the safety of quinsy • Intracranial venous thrombosis tonsillectomy and its definitive nature for the • Carotid artery thrombosis treatment of peritonsillar abscess. Later studies • Lemierre syndrome (thrombophlebitis of the emphasized the efficacy of needle aspiration or internal jugular vein) incision and drainage procedures. 5 In recent • Pseudoaneurysm of the internal or external decades, needle aspiration has been favoured carotid artery because it can be both diagnostic and therapeu - • Nonsuppurative sequelae of group A tic, and provides immediate relief of symptoms streptococcal infection (e.g., , with a reported 95% success rate. 5,7 acute or guttate psoriasis) In view of the proven efficacy of needle • Inflammatory torticollis, Grisel syndrome or aspiration in treating unilateral peritonsillar both abscess, one might conclude that it is reason - able to use the same technique for bilateral peritonsillar abscesses in a controlled situation. bulky tonsils or salivary gland tumours noted in Because the risk of complications may be the soft palate. 6 higher with bilateral peritonsillar abscesses than Contrast-enhanced CT may help to differenti - with unilateral disease, a period of close airway ate bilateral peritonsillar abscesses from other observation following needle aspiration is diseases and should be considered, not only to vital. 1 If there is no improvement, repeat aspira - confirm the diagnosis, but also to rule out any tion, incision and drainage, or even tonsillec - complications, extension into the deep-neck tomy can still be performed. space or other diseases. Because bilateral peri - Quinsy tonsillectomy has been indicated pre - tonsillar abscesses are not common, evidence for viously for patients not responding to intravenous this specific diagnosis option is based mainly on antibiotic treatment, needle aspiration, and inci - case reports. However, the role of CT in diag - sion and drainage of their peritonsillar abscess. 5 It nosing abscesses in the head and neck region is also has clinical value for acute management of well established. In light of the proven value of the severe complications of peritonsillar abscess. CT in assessing unilateral peritonsillar ab - If sleep apnea or occur in evi - scesses, 1,2,6 one might conclude that it is reason - dent bilateral peritonsillar abscesses, quinsy ton - able to use the same technology for bilateral sillectomy should be considered. peritonsillar abscesses. Although in our patient cultures ultimately grew A. baumannii , we are not convinced that Management this was the causative organism. The true micro - Peritonsillar abscess is a specific deep–neck bial cause may have been the more typical mix space infection. It is important to diagnose and of streptococci or anaerobes. We chose amoxi - treat peritonsillar abscess rapidly and ade - cillin–clavulanic acid for covering the group A quately, partly to prevent respiratory obstruc - β-hemolytic streptococci, the most common tion, and partly to avoid perforation of the offending organism; however, we think it was abscess into the parapharyngeal space with the drainage procedure that was curative. spread along the neck vessels to the medias - Bilateral peritonsillar abscesses are uncom - tinum or skull base. 1 In managing deep–neck mon; therefore, it is unlikely a series could be space infection, the first and most important developed that would be amenable to standard consideration in treating peritonsillar abscess is investigational analysis of treatment options. immediate securing of the airway. Based on our review of case reports, most of the should be started, empirically. specific treatment options are similar to those Once an abscess has formed, antimicrobial used in unilateral peritonsillar abscess. Treat - therapy alone may be inadequate and surgical ment with combined needle aspiration and drainage may be necessary. There is no consen - antibiotic therapy was successful in our patient, sus on the ideal surgical procedure for peritonsil - with no further complications.

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