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Let's look at one of the possible complications

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of tonsillitis and peritonsillar abscess.

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We're going to start here in the brain,

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look over the brain,

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make sure there's no abnormalities.

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Look at the blood vessels, no aneurysms.

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The orbits look pretty good.

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Patients had a previous nasal bone fracture.

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We can see in passing the nasopharynx,

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showing a little bit of asymmetry to the

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left side with a little bit of swelling,

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and we come into the parotid glands, which look fine.

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Let's focus on the aerodigestive system as we

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come into the level of the palatine tonsils.

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So, almost immediately, we see that there is

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some asymmetry in the palatine tonsils,

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and therefore we're going to call this tonsillitis.

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However, as we proceed downward,

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we notice this low density collection

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within the palatine tonsil.

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90% of these collections are peritonsillar abscesses.

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Sometimes you will see something in

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the tonsil itself, a tonsillar abscess.

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In most cases, they are not tonsillar abscesses.

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They're actually peritonsillar abscess

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outside the palatine tonsil,

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but confined by the pharyngeal constrictor muscle.

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In this case,

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it really does look like it's almost

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entirely within the tonsil.

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And so, we would probably hedge our

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bets a little bit on this specific case.

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More importantly is, as we go down into the lingual tonsillar

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tissue at the base of the tongue,

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we see that there is enlargement and asymmetry here.

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However,

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we also are struck by the thickness of the tip of the

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epiglottis. And as we continue further inferiorly,

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we see just how thick this epiglottis is, and that

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it is opposed to the lingual tonsillar tissue.

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We're also seeing asymmetry with the left

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side affected more than the right side,

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filling in the pyriform sinus.

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So, here's our pyriform sinus on the right side,

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thickened epiglottis and aryepiglottic fold.

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Markedly thickened epiglottis

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and aryepiglottic fold.

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You can see that this is of lower density than the

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more normal epiglottis and aryepiglottic fold.

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And we have lots of edema in the posterior pharyngeal

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wall, extending even to a distorted appearance,

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to the supraglottic larynx, the false vocal cord.

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Notice that the airway is narrowed here in the level

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of the supraglottic larynx, false vocal cord,

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and in point of fact,

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it almost shuts down completely.

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You still have that asymmetry and edema in the

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posterior pharynx at the level of the hypopharynx.

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And we also see paraglottic edema in this individual.

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Here we are at the true vocal cords.

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We're at the level of the thyroarytenoid muscle

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and the cricoarytenoid joint. And even at the

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level of the true vocal cords,

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there is swelling bilaterally involving

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both true vocal cords.

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We notice that the left true vocal cord is a little bit

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less dense than the right true vocal cord from edema.

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And it's not until we get to the lower

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aspect of the true vocal cords,

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the glottic larynx and then the subglottic larynx,

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that we have a more normal appearance to the airway.

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So this is a case of tonsillitis and peritonsillar or

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tonsillar abscess where there is secondary

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involvement of the supraglottis.

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And we would probably call this supraglottitis.

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We would mention the edema of the epiglottis and

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that the supraglottitis extends

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to the glottic level.

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So glottitis effectively,

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the true vocal cords are even edemonous.

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So, laryngitis , if you will. But in addition,

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we also have the involvement of the pyriform sinus.

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So this is one where I would definitely talk about airway

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compromise and have them consult with an ENT

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physician in the emergency room for whether

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or not this patient has a compromised airway.

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Certainly, clinically,

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they'll know better than we would even on imaging,

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but this is pretty impressive.

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Let's look at this from the standpoint

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of the sagittal reconstruction.

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And remember that the epiglottis is basically

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at the level of the hyoid bone.

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And what you see is the thickened epiglottis

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opposed to the lingual tonsillar tissue,

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which is this hyperdense tissue here.

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And then as we go off midline to either side,

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we come into the swollen

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aryepiglottic folds and supraglottitis.

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This is at the level of the true vocal cord,

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and you can see just how narrow we are at the

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supraglottic larynx and at the true vocal cord.

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You can see the collection in the tonsil peritonsillar

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space located here. Looking quickly at the spine,

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looks pretty good.

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Remember to look at the blood vessels.

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So the jugular vein and the carotid

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artery on that side are okay.

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We'll just check that one more time on the axials

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at three millimeter thick level.

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So carotid artery,

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jugular, carotid artery, jugular.

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No evidence of thromboflabitis.

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No involvement in the submandibular space

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or the subglottic space. And of course,

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we have scattered reactive lymph nodes bilaterally

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in the jugular chains. So read out of this case.

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Patient with pharyngitis and tonsillitis with possible

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peritonsillar abscess. On the left side,

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measuring 1.5 centimeters.

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There is supraglottitis with marked thickening of

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the epiglottis and false vocal cords. Left

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worse than right, with compromise of the airway at

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the supraglottic level, extending to the

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true vocal cords. Pick up the phone.

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Call the emergency room.

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Talk to them about potentially having an ENT

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referral for evaluation of airway compromise.