EMReports | Pearls and Pitfalls - Bilateral Peritonsillar Abscesses: Double Trouble

Bilateral Peritonsillar Abscesses: Double Trouble

Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine
Medical College of Georgia

Pearl: When a peritonsillar abscess (PTA) occurs bilaterally, the physical examination findings will be confusing as the classical signs of PTA will be absent.

HPI: A 34-year-old male presented with diffuse, symmetrical erythema and swelling of the pharynx. His throat had been painful for five or six days. Two days prior to this presentation, he had been evaluated in the same emergency department with a diagnosis of "acute tonsillitis with exudates" and given a prescription for azithromycin. He had also been treated with 900 mg of intravenous clindamycin and 10 mg of decadron prior to discharge. Interestingly, the patient reported having had a peritonsillar abscess drained several years previously.

At his second emergency department visit, the patient's pain was reported to be 10/10 on the numerical descriptor scale. There was a hint of trismus, a muffling of his voice, and symmetrical swelling and erythema of the posterior pharynx with no evidence of uvular deviation or unilateral swelling. See Figure 1. The CT demonstrated bilateral peritonsillar abscesses. See Figure 2. Prior to discharge home, the patient's abscesses were drained by ENT, clindamycin (900 mg) was administered intravenously, and the patient was given a prescription for oral clindamycin.

Discussion: Peritonsillar abscess (PTA) is a collection of purulent material within the space between the tonsil and the superior constrictor muscle near the superior pole of the tonsil. Peritonsillar abscesses are common deep space infections and are a complication of acute tonsillitis when the infection spreads into the peritonsillar space. A second proposed mechanism is obstruction and swelling of the weber glands by pus formation and necrosis in the capsular area that leads to subsequent abscess formation.^1,2

Although any age group can be infected, peritonsillar abscesses are most common among adolescents and young adults. The diagnosis is made through clinical presentation and imaging with CT scan with contrast. Treatment typically involves needle aspiration or incision and drainage followed by oral antibiotic therapy.^1,2,3,4

The decision to image the pharynx of the patient discussed above was influenced by the history of a prior PTA, a negative monospot test, an elevated white count (14.8 thousand/mm3), and his lack of response to previously prescribed intravenous and oral antibiotics. Diagnosis is accomplished by reliance on clinical signs and symptoms as well as imaging. Clinical signs and symptoms include an erythematous, swollen soft palate (often asymmetrical) with uvula deviation, trismus, drooling, muffled voice, rancid breath, cervical lymphadenitis, fever, malaise, severe sore throat (typically unilateral), dysphagia, and possibly ipsilateral otalgia. Imaging modalities include CT scan and ultrasound.^1,5,6

This case is fascinating in that the classic presentation of a peritonsillar abscess with uvular deviation, unilateral pharyngeal swelling, and trismus were absent. Bilateral peritonsillar abscesses are rare,^7,8 but when they occur, they can be tricky to diagnose, especially if you don't consider the possibility.

References:

Johnson RF, Stewart MG. The contemporary approach to diagnosis and management of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005; 13:157-160.
http://emedicine.medscape.com/article/764188-overview
Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg 2003;128:332-43.
Khayr W, Taepke J. Management of Peritonsillar Abscess: Needle Aspiration Versus Incision and Drainage Versus Tonsillectomy. American Journal of Therapeutics 2005; 12, 344-350.
Lyon M, Glisson P, Blaivas M. Bilateral peritonsillar abscess diagnosed on the basis of intraoral sonography. J Ultrasound Med 2003; 22:993-996.
Blaivas M, Theodoro D, Duggal S. Ultrasound-guided drainage of peritonsillar abscess by the emergency physician. Am J Emerg Med. 2003; 21:155-158.
Kristensen S, Juul A, Nielsen E Quinsy: A bilateral presentation. J Laryngol Otol 1985;99:401-2.
Fiechtl JF, Stack LB. Images in clinical medicine. Bilateral peritonsillar abscesses. N Engl J Med. 2008 Jun 5;358(23):e27.

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