Peritonsillar Abscess Magen Ross 12/2/2019 RAD 4001 Dr. Talley and Dr. Choi 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 McGovern Medical School Findings: -L. Peripherally enhancing 2x2 cm peritonsillar collection with surrounding inflammatory changes. -Reactive lymphadenopathy and diffuse lymphadenopathy in neck 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 peritonsillar abscess • In house CT confirms presence of peritonsillar abscess with surrounding inflammatory changes and diffuse lymphadenopathy McGovern Medical School Differential Diagnosis • Peritonsillar Abscess • Tonsillitis with phlegmon • Intratonsillar abscess • Retropharyngeal abscess McGovern Medical School 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 McGovern Medical School 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 McGovern Medical School Final Diagnosis • Peritonsillar Abscess McGovern Medical School 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 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 McGovern Medical School Questions?.