0:01

We are in clinical scenario three where the

0:04

patient has a sore throat and fever,

0:07

and we are evaluating the patient with postcontrast CT

0:12

scan. Here we start from the intracranial compartment.

0:16

Always good to look and make sure that

0:18

there's no intracranial pathology.

0:20

I've picked up quite a few incidental aneurysms in

0:24

patients that we were looking for neck pathology,

0:26

so be wary of the visualization of the blood

0:29

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

0:34

Associated parotid glands look good.

0:37

We're starting to come into the nasopharynx.

0:39

So at the nasopharyngeal level,

0:41

we see that already there is some asymmetry here at the

0:45

fossa of Rosenmüller and Taurus de Barius

0:48

and the orifice of the Eustachian tube.

0:51

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

0:56

As we come further down,

0:57

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

1:01

And we come into the palatine tonsils and

1:04

we see that they are enlarged bilaterally,

1:06

with a little bit of a striated appearance to the

1:09

palatine tonsils. That usually implies lymphoid hyperplasia.

1:14

However,

1:14

we also see some areas of lower density in the left

1:19

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

1:24

Don't be surprised because a lot of the peritonsillar

1:27

abscesses look like they're in the

1:28

lateral aspect of the tonsil,

1:30

when they're really outside the tonsil and still confined

1:34

by the pharyngeal constrictor muscles.

1:36

We're continuing downward, yet again,

1:39

and we come into a larger low density

1:42

area in the periphery of the left tonsil.

1:46

It's got a little bit of rim enhancement

1:49

and has some irregularity to it.

1:53

As you can see,

1:53

this looks almost like a little loculated collection

1:57

here and this represents tonsillitis with

2:01

a peritonsillar abscess. Once again,

2:04

this is usually treated with antibiotics first

2:07

and if the patient does not respond,

2:09

then they may do a needle aspiration.

2:12

However,

2:13

in your report of the case,

2:16

please make sure that you do comment on the amount of

2:20

airway narrowing because that may push the hand

2:23

for drainage of the collection earlier in the course.

2:28

So in this case, the airway looks pretty good.

2:30

Just as we saw edema in the nasopharynx,

2:34

it's important to continue downward from the

2:37

palatine tonsil and look at the lower area.

2:41

Got a little bit more constriction of the airway,

2:44

almost kissing tonsils where the

2:46

tonsils meet in the middle,

2:48

and this kind of hourglass look to the airway.

2:52

When you continue further inferiorly,

2:55

we start to see the epiglottis and

2:58

we have the laryngeal airway,

3:00

as well. Now,

3:02

notice at the epiglottic level that there still is some

3:05

asymmetry with edema along the lateral

3:08

pharyngeal wall at the level of the epiglottis.

3:11

The epiglottis and the pharyngoepiglottic fold is sort of

3:14

the marker for the beginning of the hypopharynx.

3:17

So up here, we're in the oropharynx,

3:20

and then above that we have the nasopharynx,

3:22

but we're now down into the hypopharynx.

3:26

And you notice that the left side of the hypopharynx

3:31

lateral pharyngeal wall continues to be edematous.

3:34

There's no real compromise of the airway,

3:36

but this does show you the extent of the degree to

3:40

which the pharynx has edema.

3:43

On the right side,

3:44

we see the piriform sinus and the aryepiglottic fold.

3:48

On the left side we have the area aryepiglottic fold,

3:50

but the piriform sinus again remains edematous,

3:53

even down to the false vocal cord level.

3:56

And the true vocal cord level looks pretty much back

4:00

to normal here. So how would we report this?

4:04

We would say that there is a low density collection,

4:08

likely representing a peritonsillar abscess, associated with

4:12

bilateral tonsillitis and pharyngitis extending from

4:16

the left nasopharynx to the left hypopharynx,

4:21

with modest narrowing of the airway at

4:26

the level of the lower palatine tonsils.