Interactive Transcript
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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.
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