0:01

Each of these patients were evaluated with

0:05

enlargement of the palatine tonsils,

0:08

or what we also call faucial tonsils.

0:11

And in each of these cases, the question was,

0:14

is there a peritonsillar abscess?

0:16

Remember that the peritonsillar abscess is

0:19

located between the pharyngeal constrictor muscles

0:23

and the palatine tonsils themselves.

0:26

So let's look at these two images.

0:28

This is the first case in which we see low density

0:32

within the palatine tonsils bilaterally,

0:34

without a collection that is well defined.

0:38

This low density within the tonsils often is secondary

0:42

to the purulent material of streptococcus,

0:45

most commonly.

0:46

Sometimes bacillus or sometimes staphylococcus,

0:49

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

0:52

This is the abnormal inflamed tonsil without

0:56

an abscess, but with tonsillar enlargement.

0:59

And you notice that the tonsillar enlargement

1:01

may lead to airway narrowing.

1:03

Here's a separate case, axial and coronal.

1:07

And here we see more airway narrowing, bilateral

1:11

tonsillar enlargement. In this case,

1:13

the left tonsil is larger than the right.

1:16

And we pick up these low density areas,

1:19

not within the tonsil, but lateral to the tonsil,

1:22

extending to the parapharyngeal space.

1:25

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

1:28

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

1:33

but confined by the pharyngeal constrictor

1:37

muscles. In this case,

1:39

we most likely call this a peritonsillar phlegmon.

1:42

It's not well defined enough,

1:44

it's not well shaped enough.

1:46

It doesn't have enough walls for us to

1:48

suggest that this represents a tonsil.

1:51

Just like with the periosteal abscess

1:54

in the orbit with sinusitis,

1:56

these peritonsillar inflammatory conditions

1:59

are generally treated with antibiotics first,

2:03

without surgery,

2:04

and in most situations they will resolve without

2:08

intervention. Let's look at the next case.

2:11

Here we have large tonsils, airway narrowing.

2:15

Same thing here, these two images.

2:18

This is just tonsillitis, no abscess suggested.

2:22

How about this case?

2:24

This case we see a low density collection

2:27

which is found within the tonsil itself.

2:30

And this is the very rare tonsillar abscess where

2:34

we actually see a collection in the tonsil,

2:37

not lateral to the tonsil.

2:39

This collection is just purulent material

2:42

that has formed a pocket in the tonsil.

2:45

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

2:49

this may need a needle aspiration of the purulent

2:53

material, but but it does not require surgery.

2:57

It may just resolve with antibiotic therapy.

3:00

Finally, we have this collection which is lateral

3:03

to the tonsil but confined by the constrictor muscle.

3:06

This is what we are concerned about for a

3:08

"peritonsillar abscess." Once again,

3:12

if this is not causing airway obstruction and the

3:15

patient is able to just handle it with antibiotics,

3:18

we can watch this patient on either intravenous

3:21

or oral antibiotics. It may resolve on its own.

3:25

However, if this collection is relatively large,

3:29

we would then suggest that the patient requires either

3:34

needle aspiration or IND, incision and

3:37

drainage in the emergency room.

3:39

Not under anesthesia in an operating room,

3:42

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

3:46

drain in the emergency room, and then supplement

3:49

with intravenous or oral antibiotics.

3:53

Here is better defined collections.

3:55

And again,

3:56

the suggestion about whether this represents a peritonsillar

3:59

abscess versus a phlegmon, is not as important

4:02

because both of these could potentially

4:04

be drained and they will all,

4:07

at least initially be treated with a needle

4:10

aspiration and/or emergency department incision

4:14

and drainage without going to the OR.

4:17

So here we have a pretty well defined collection.

4:19

It's lateral to the palatine tonsil.

4:21

It is a peritonsillar abscess.

4:24

Even though the wall does not enhance very much,

4:26

this would be definitely amenable to drainage through

4:30

the oral introduction of a needle or scalpel

4:35

to drain this. Here's a little less defined

4:38

one that's in the parapharyngeal space.

4:40

You can see that it's lateral to the pharyngeal

4:43

tonsil. Here's the normal parapharyngeal space.

4:46

And this is a little less defined.

4:49

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

4:52

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

4:56

You don't have to worry about whether

4:57

it's an abscess or a phlegmon.

4:58

Both of these, again, will receive antibiotic therapy.

5:02

So a peritonsillar abscess develops when tonsillar

5:05

infection penetrates the capsule,

5:07

but is seen as the superior constrictor muscle

5:11

separates the peritonsillar space from the adjacent

5:14

parapharyngeal prestyloid space.