Peritonsillar

Magen Ross 12/2/2019 RAD 4001 Dr. Talley and Dr. Choi Clinical History

• 33 yr male w/ no PMH complaining of 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 IV • Vitals: 166/88 mmHg, 86 bpm, RR 18, T 98.3 • Physical Exam: • HEENT: Oropharyngeal , extending across soft palate worse along the left compared to the right • Pulm: No labored breathing, lungs clear to auscultation

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

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

McGovern Medical School

• Peritonsillar Abscess • with phlegmon • Intratonsillar abscess •

McGovern Medical School Discussion

• Peritonsillar abscess: Collection of between the capsule of the palatine and pharyngeal muscles • Typical presentation • Severe sore throat, , and muffled voice (as seen in this patient) • Also can have and • 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

McGovern Medical School Continued discussion

• Most commonly caused by group A strep, S. aureus, and respiratory anaerobes. • should cover all the above for at least 14 days. • Complications to untreated or undertreated include spread to other deep neck spaces, adjacent structures or the bloodstream; which all can be fatal. • can occur in patients who fail to seek medical attention in a timely manner

McGovern Medical School Final Diagnosis

• Peritonsillar Abscess

McGovern Medical School Treatment

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

McGovern Medical School ACR appropriateness Criteria Cost 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.

McGovern Medical School 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

McGovern Medical School References

• https://radiopaedia.org/articles/peritonsillar-abscess?lang=us • https://www.uptodate.com/contents/peritonsillar-cellulitis-and- abscess?search=peritonsillar%20abscess&source=search_result&sele ctedTitle=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

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