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Case 13 - Peritonsillar Abscess

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We are in clinical scenario three where the

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patient has a sore throat and fever,

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and we are evaluating the patient with postcontrast CT

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scan. Here we start from the intracranial compartment.

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Always good to look and make sure that

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there's no intracranial pathology.

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I've picked up quite a few incidental aneurysms in

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patients that we were looking for neck pathology,

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so be wary of the visualization of the blood

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vessels here. The orbits quick scan, no orbital inflammation.

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Associated parotid glands look good.

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We're starting to come into the nasopharynx.

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So at the nasopharyngeal level,

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we see that already there is some asymmetry here at the

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fossa of Rosenmüller and Taurus de Barius

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and the orifice of the Eustachian tube.

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So a little bit of edema in the upper left nasopharynx.

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As we come further down,

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we're getting to the palatine tonsils and the soft palate.

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And we come into the palatine tonsils and

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we see that they are enlarged bilaterally,

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with a little bit of a striated appearance to the

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palatine tonsils. That usually implies lymphoid hyperplasia.

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However,

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we also see some areas of lower density in the left

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tonsil and it seems to be on the periphery of the tonsil.

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Don't be surprised because a lot of the peritonsillar

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abscesses look like they're in the

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lateral aspect of the tonsil,

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when they're really outside the tonsil and still confined

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by the pharyngeal constrictor muscles.

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We're continuing downward, yet again,

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and we come into a larger low density

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area in the periphery of the left tonsil.

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It's got a little bit of rim enhancement

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and has some irregularity to it.

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As you can see,

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this looks almost like a little loculated collection

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here and this represents tonsillitis with

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a peritonsillar abscess. Once again,

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this is usually treated with antibiotics first

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and if the patient does not respond,

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then they may do a needle aspiration.

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However,

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in your report of the case,

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please make sure that you do comment on the amount of

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airway narrowing because that may push the hand

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for drainage of the collection earlier in the course.

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So in this case, the airway looks pretty good.

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Just as we saw edema in the nasopharynx,

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it's important to continue downward from the

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palatine tonsil and look at the lower area.

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Got a little bit more constriction of the airway,

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almost kissing tonsils where the

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tonsils meet in the middle,

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and this kind of hourglass look to the airway.

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When you continue further inferiorly,

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we start to see the epiglottis and

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we have the laryngeal airway,

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as well. Now,

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notice at the epiglottic level that there still is some

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asymmetry with edema along the lateral

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pharyngeal wall at the level of the epiglottis.

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The epiglottis and the pharyngoepiglottic fold is sort of

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the marker for the beginning of the hypopharynx.

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So up here, we're in the oropharynx,

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and then above that we have the nasopharynx,

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but we're now down into the hypopharynx.

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And you notice that the left side of the hypopharynx

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lateral pharyngeal wall continues to be edematous.

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There's no real compromise of the airway,

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but this does show you the extent of the degree to

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which the pharynx has edema.

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On the right side,

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we see the piriform sinus and the aryepiglottic fold.

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On the left side we have the area aryepiglottic fold,

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but the piriform sinus again remains edematous,

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even down to the false vocal cord level.

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And the true vocal cord level looks pretty much back

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to normal here. So how would we report this?

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We would say that there is a low density collection,

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likely representing a peritonsillar abscess, associated with

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bilateral tonsillitis and pharyngitis extending from

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the left nasopharynx to the left hypopharynx,

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with modest narrowing of the airway at

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the level of the lower palatine tonsils.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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