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.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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