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Case 13 - Tonsillitis

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Each of these patients were evaluated with

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enlargement of the palatine tonsils,

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or what we also call faucial tonsils.

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And in each of these cases, the question was,

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is there a peritonsillar abscess?

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Remember that the peritonsillar abscess is

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located between the pharyngeal constrictor muscles

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and the palatine tonsils themselves.

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So let's look at these two images.

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This is the first case in which we see low density

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within the palatine tonsils bilaterally,

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without a collection that is well defined.

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This low density within the tonsils often is secondary

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to the purulent material of streptococcus,

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most commonly.

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Sometimes bacillus or sometimes staphylococcus,

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but mostly it's tonsillitis. This is not an abscess.

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This is the abnormal inflamed tonsil without

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an abscess, but with tonsillar enlargement.

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And you notice that the tonsillar enlargement

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may lead to airway narrowing.

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Here's a separate case, axial and coronal.

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And here we see more airway narrowing, bilateral

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tonsillar enlargement. In this case,

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the left tonsil is larger than the right.

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And we pick up these low density areas,

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not within the tonsil, but lateral to the tonsil,

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extending to the parapharyngeal space.

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On the coronal scan, we get a better sense of this

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ill-defined, low density that is lateral to the tonsil,

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but confined by the pharyngeal constrictor

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muscles. In this case,

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we most likely call this a peritonsillar phlegmon.

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It's not well defined enough,

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it's not well shaped enough.

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It doesn't have enough walls for us to

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suggest that this represents a tonsil.

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Just like with the periosteal abscess

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in the orbit with sinusitis,

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these peritonsillar inflammatory conditions

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are generally treated with antibiotics first,

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without surgery,

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and in most situations they will resolve without

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intervention. Let's look at the next case.

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Here we have large tonsils, airway narrowing.

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Same thing here, these two images.

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This is just tonsillitis, no abscess suggested.

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How about this case?

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This case we see a low density collection

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which is found within the tonsil itself.

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And this is the very rare tonsillar abscess where

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we actually see a collection in the tonsil,

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not lateral to the tonsil.

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This collection is just purulent material

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that has formed a pocket in the tonsil.

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Again, this does not need a tonsillectomy. At the most,

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this may need a needle aspiration of the purulent

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material, but but it does not require surgery.

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It may just resolve with antibiotic therapy.

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Finally, we have this collection which is lateral

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to the tonsil but confined by the constrictor muscle.

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This is what we are concerned about for a

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"peritonsillar abscess." Once again,

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if this is not causing airway obstruction and the

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patient is able to just handle it with antibiotics,

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we can watch this patient on either intravenous

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or oral antibiotics. It may resolve on its own.

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However, if this collection is relatively large,

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we would then suggest that the patient requires either

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needle aspiration or IND, incision and

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drainage in the emergency room.

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Not under anesthesia in an operating room,

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but just a simple prick with the scalpel and allow it to

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drain in the emergency room, and then supplement

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with intravenous or oral antibiotics.

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Here is better defined collections.

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And again,

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the suggestion about whether this represents a peritonsillar

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abscess versus a phlegmon, is not as important

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because both of these could potentially

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be drained and they will all,

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at least initially be treated with a needle

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aspiration and/or emergency department incision

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and drainage without going to the OR.

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So here we have a pretty well defined collection.

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It's lateral to the palatine tonsil.

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It is a peritonsillar abscess.

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Even though the wall does not enhance very much,

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this would be definitely amenable to drainage through

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the oral introduction of a needle or scalpel

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to drain this. Here's a little less defined

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one that's in the parapharyngeal space.

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You can see that it's lateral to the pharyngeal

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tonsil. Here's the normal parapharyngeal space.

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And this is a little less defined.

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It doesn't have as much of a wall as this guy.

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These two, same thing, little ill-defined wall.

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You don't have to worry about whether

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it's an abscess or a phlegmon.

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Both of these, again, will receive antibiotic therapy.

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So a peritonsillar abscess develops when tonsillar

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infection penetrates the capsule,

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but is seen as the superior constrictor muscle

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separates the peritonsillar space from the adjacent

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parapharyngeal prestyloid space.

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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