Inferior pole peritonsillar abscess

CASE REPORTS SERGE A. MARTINEZ, MD Case Report Editor

Inferior pole peritonsillar abscess GREG R. LICAMELI, MD,* and GREGORY A. GRILLONE, MD, Boston, Massachusetts

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nfections of the throat have been described as far back as the second century AD by Aretaues of Cappadocia. One of the first references to the practice of incision and drainage of a peritonsillar abscess was by Hippocrates. The method of performing such drainage was described by Guy de Chauliac, a fourteenth century French surgeon, whose technique has essentially remained unchanged to the present day. In 1859 Chassaignac described the first quinsy tonsillectomy, but this operation fell into disfavor until the turn of the century when it was revived by Winkler. Opinion continues to be divided as to the best method of drainage. Peritonsillar abscess is a localized accumulation of pus within the peritonsillar tissues that usually results from suppurative infection of the tonsils.1 The infection may spread through the capsule to involve the peritonsillar space or originate outside of the tonsillar capsule in the mucous glands of Weber, which are located above the capsule of the superior pole of the tonsil.2 Typically, a patient with a peritonsillar abscess will appear acutely ill, with fever (usually >102° F), chills, and malaise. Trismus and marked odynophagia are prominent findings and are often accompanied by an inability to handle oral secretions. The voice has a characteristic “hot potato” quality. Often these symptoms are preceded by a persistent tonsillitis that has increased in severity despite medical therapy. Physical examination shows dehydration, tender cervical adenopathy, and marked edema and erythema of the involved superior peritonsillar tissues and soft palate. The uvula is often edematous and displaced to the opposite side. Inadequately treated infections may have serious complications. Pus may spread through the pharyngeal constrictor muscles into the parapharyngeal space. This space communi-

From the Department of Otolaryngology, Boston University School of Medicine. *Dr. Licameli is currently affiliated with the Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago. Reprint requests: Gregory A. Grillone, MD, Department of Otolaryngology, Boston University School of Medicine, 88 E. Boston St., Boston, MA 02118. Otolaryngol Head Neck Surg 1998;118:95-9. Copyright © 1998 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/98/$5.00 + 0 23/4/76132

cates inferomedially with the submandibular space, posteromedially with the retropharyngeal space, and laterally with the parotid and masticator space.3 Airway obstruction, aspiration of pus causing pneumonia or lung abscess, internal jugular vein thrombophlebitis, carotid artery wall invasion with rupture, mediastinitis caused by spread along the carotid sheath, and pericarditis may occur.4 Distal complications include endocarditis, nephritis, peritonitis, and brain abscess. Prompt surgical treatment combined with the advent of antibiotics has markedly decreased the morbidity and mortality rates associated with peritonsillar abscess. Acute treatment of an anterosuperior peritonsillar abscess may include drainage by needle aspiration, as described by Herzon and Aldridge5 and others,6-8 incision and drainage,9 or immediate (quinsy) tonsillectomy.10-12 Regardless of the treatment option chosen, all have in common the immediate evacuation of pus, which is in accordance with the treatment of localized abscess elsewhere in the body. Superior pole peritonsillar abscess is, in general, easily diagnosed and therefore definitive treatment is not delayed. However, inferior pole peritonsillar abscess is an unusual disorder characterized by severe unilateral odynophagia that is far out of proportion to the physical findings. The typical findings of superior pole abscess are absent, and this may result in delayed or missed diagnosis. Several investigators examining the benefits of quinsy tonsillectomy report an intraoperative incidence of inferior pole abscess ranging from 0% to 37%.11,13-16 Clinical descriptions of the patients were not offered, and it is not known if these patients had typical symptoms. In a review of the English literature from 1900 to 1993, few clinical descriptions of inferior pole peritonsillar abscess were found. Wills and Vernon4 reported a 35-year-old man who had odynophagia and fever after a 7-day history of progressive sore throat. Examination was significant for mild trismus, mild epiglottic edema, and associated swelling of the right hypopharyngeal wall. He was diagnosed to have an inferior pole peritonsillar abscess and given intravenous penicillin. Spontaneous drainage occurred shortly after admission. Symptomatic improvement occurred until 72 hours after spontaneous drainage, when the patient became febrile, dyspneic, and ultimately required surgical drainage of the right pharyngomaxillary space. Stage and Bonding17 reviewed 217 cases of peritonsillar abscess and found five patients with atypical symptoms. Two of these patients were found to have an inferior pole abscess at tonsillectomy. Common clinical symptoms 95

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Fig. 1. Case 1: CT scan demonstrates large area of low attenuation in region of left inferior pole consistent with abscess in peritonsillar space.

and findings in these two patients included absence of trismus, absent or minimal tonsil displacement, and a normal midline uvula. Both had edema and displacement of the hypopharyngeal wall below the involved tonsil and unilateral, tender neck adenopathy. Both were treated with parenteral antibiotics and abscess tonsillectomy with an uneventful recovery. We report four patients with inferior pole peritonsillar abscess who had atypical symptoms out of proportion to their physical findings. This resulted in a delay in diagnosis. We will discuss the clinical presentation, hospital course, and operative findings of these patients. PATIENTS AND METHODS Four patients with inferior pole peritonsillar abscess were treated at Boston City Hospital and the University Hospital between 1990 and 1993. Two patients were men and two were women with an age range between 35 and 49 years. Each patient was examined initially in the emergency ward by a senior otolaryngology resident and a member of the emergency medicine department with subsequent admission to the otolaryngology service. A retrospective review of each patient’s hospital course is summarized in the following case histories. A review of the English-language literature from 1990 to 1993 specifically addressing clinical descriptions of inferior pole tonsillar abscess was performed. CASE REPORTS

Case 1. A 35-year-old black woman was seen in the emergency department with a 24-hour history of severe

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odynophagia, rigor, decreased oral intake, and left-sided neck pain with otalgia. She denied any shortness of breath, hoarseness, or recent upper respiratory tract infection. There were no prior episodes of recurrent tonsillitis or pharyngitis. Physical examination revealed an ill-appearing woman expectorating saliva. Temperature was 99.6° F. There was no trismus. The oropharynx was diffusely erythematous with scant whitish exudate on both tonsils. The tonsils were 2+ in size. There was slight edema of the left posterior tonsillar pillar. The palate was erythematous without edema. The uvula was normal and midline. The hypopharynx and larynx were normal. The left jugulodigastric nodes were slightly enlarged and mildly tender without fluctuance. White blood cell count was 4.9 × 103 units/L. A mononucleosis spot test result was negative. Blood cultures were negative after 7 days. The patient was admitted to the otolaryngology service with a diagnosis of severe pharyngitis and empirically given parenteral ceftriaxone. After 24 hours of therapy, the patient’s symptoms were worse and she had a fever of 101.3° F. The left-sided neck adenopathy became exquisitely tender. The oropharyngeal examination remained normal; however, fiberoptic examination now showed boggy edema of the left lateral hypopharyngeal wall below the inferior pole of the tonsil. A CT scan of the neck was obtained and demonstrated an area of low attenuation consistent with an inferior pole peritonsillar abscess on the left side (Fig. 1). The patient was taken to the operating room and underwent a tonsillectomy. A collection of brown, foul-smelling pus was found in the peritonsillar space at the left inferior pole, as well as a smaller collection at the right inferior pole. Of note, fibers of the superior constrictor muscles on both sides were splayed by pockets of pus that were protruding toward the parapharyngeal space. Aerobic, anaerobic, and fungal cultures were sent during surgery; results showed normal upper respiratory tract flora. The tube remained in place for 8 hours after surgery and the patient was discharged home in stable condition on the third postoperative day. Because we had seen several patients with positive test results for human immunodificiency virus who had bilateral peritonsillar abscesses, the patient was queried as to specific risk factors, which she denied. Serologic testing was refused. Two years later the patient was admitted to the hospital for unrelated medical problems and was diagnosed with acquired immune deficiency syndrome. Case 2. A 35-year-old white man with ulcerative colitis was seen with a 1-week history of progressive odynophagia on the left side. Six days before admission to the hospital, the patient awoke with a sensation of a lump in the left side of the throat that became increasingly painful with swallowing during the next several days. He was evaluated in the emergency department 2 days before admission by a senior otolaryngology resident. He was diagnosed with acute pharyngitis and empirically given oral penicillin and discharged home. He returned to the emergency department on the day of admission, with no change in symptoms. He denied fever or chills and there was no history of recurrent tonsillitis. Medications included dipentum, 1 gm twice a day, and prednisone, 5 mg

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every day. Temperature on examination was 99.4° F. There was diffuse tenderness over the left anterior triangle of the neck without discrete mass or adenopathy. Oropharynx was moderately erythematous, the tonsils were 2+ enlarged without exudate, and the uvula was normal and nondisplaced. Trismus was not present. Fiberoptic examination revealed moderate edema and erythema of the left lateral pharyngeal wall extending from the inferior pole of the tonsil to the level of the epiglottis. Admission laboratory test results were within normal range including a normal white blood cell count. A throat swab culture showed normal oral flora. An emergency CT scan was obtained that revealed a left inferior pole tonsillar abscess (Fig. 2). The patient was admitted to the otolaryngology service and given intravenous ampicillin/sulbactam. While awaiting tonsillectomy, spontaneous drainage of the abscess into the pharynx occurred, with a marked resolution of symptoms. The patient was discharged home 48 hours later receiving oral antibiotic therapy. Case 3. A 49-year-old black woman with non-insulindependent diabetes mellitus was seen in the emergency department with a 3-day history of right-sided odynophagia and neck pain, dysphagia, nausea, and mild trismus. She denied fever, chills, respiratory difficulties, hoarseness, or prior tonsil infections. Medications included glyburide prescribed daily but taken sporadically. On examination, the temperature was 98.6° F. There was mild trismus. The tonsils were without exudate, mildly erythematous, and 2+ in size. The uvula was normal and not deviated. The right side of the neck was exquisitely tender from the angle of the mandible to the hyoid without discrete adenopathy or masses. Laryngoscopy showed moderate edema of the right lateral pharyngeal wall below the palatine tonsil with a normalappearing epiglottis and glottis. The white blood cell count was 11.0 × 103 units/L with a normal differential; the serum glucose level was 458 mg/dl and the remainder of serum chemistry results were within normal limits. Blood cultures were negative. The patient was admitted and empirically given intravenous clindamycin. CT scan of the neck demonstrated an area of low attenuation consistent with an inferior pole abscess in the right peritonsillar space, and the patient underwent tonsillectomy. A 5 ml collection of pus in the right inferior peritonsillar space was found. The left tonsil was normal. Intraoperative cultures from the abscess were positive for β-hemolytic group A streptococcus. The patient’s serum glucose levels and poor oral intake were management issues after surgery. On postoperative day 6, she was discharged home in stable condition taking oral penicillin. Case 4. A 35-year-old black man was seen in the emergency department with a 3-day history of right-sided throat pain, moderate dysphagia, and mild trismus. He denied respiratory difficulties or change in voice quality. One month before admission to the hospital, the patient underwent incision and drainage of a left anterosuperior abscess under local anesthesia in the emergency department and was discharged home taking oral antibiotics. On examination, tem-

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Fig. 2. Case 2: Area of low attenuation is seen at inferior most part of left peritonsillar space. Abscess drained spontaneously before tonsillectomy could be performed.

perature was 99.1° F. The tonsils were moderately erythematous without exudate. The uvula was normal in size and not deviated. The right side of the neck was tender to palpation with mild jugulodigastric adenopathy. Admission laboratory test results were within normal limits, including a normal white blood cell count. The patient was admitted to the otolaryngology service with a diagnosis of severe acute tonsillitis/pharyngitis and dehydration and was empirically given intravenous penicillin G with fluid replacement and saline gargles. After 12 hours, the patient became febrile to 101.6° F and symptoms worsened without a change in the physical examination. A CT scan of the neck was obtained that showed an area of slightly altered attenuation at the inferior aspect of the right peritonsillar space consistent with a phlegmon. It was elected to continue medical management, and during the course of the next 48 hours the patient improved dramatically and was released home on hospital day 4 in stable condition. RESULTS All four patients had dysphagia and severe unilateral odynophagia. They were initially afebrile or had a low-grade fever. Trismus was absent or minimal. None had airway compromise or a “hot potato” voice. Admission laboratory values were unremarkable. Physical findings were similar in each case. The uvula was normal and nondisplaced. The tonsils and superior peritonsillar tissues were normal in size and remarkable only for erythema. There was no superior pole tonsillar asymmetry. The neck was

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tender on the affected side with minimal adenopathy. The initial clinical diagnosis was uncertain or incorrect in all cases. All patients were admitted to the hospital for parenteral antibiotics and intravenous fluid resuscitation. In three cases CT scan revealed an area of abnormal attenuation at the inferior pole consistent with abscess; two of these patients underwent immediate tonsillectomy and the third patient had spontaneous drainage while awaiting tonsillectomy. In one case, CT scan demonstrated an area of slightly altered attenuation at the inferior pole consistent with edema or phlegmon; this patient responded to intravenous antibiotics. All patients recovered uneventfully. DISCUSSION The formation of an inferior pole peritonsillar abscess may be related to the anatomic relationship of the palatine tonsil to the surrounding tissues. The medial wall of the peritonsillar space is formed by the capsule of the tonsil. The capsule, in turn, is formed by the pharyngobasilar fascia and covers the lateral aspect of the tonsil. It is attached to the underlying musculature by loose connective tissue that constitutes the peritonsillar space.18 The lateral wall of the peritonsillar space is made up of horizontal fibers of the superior constrictor muscle and vertical fibers of the palatopharyngeal muscle. However, at the lower one third of the deep surface of the tonsil, fibers of the palatopharyngeal muscle leave the lateral muscular wall and extend horizontally across the peritonsillar space to attach to the capsule; this attachment has been named the triangular ligament or tonsillopharyngeal band.2 This essentially forms a bridge that separates the inferior third of the space from the superior two thirds. This small and relatively tightly bound area may form an area of pus under pressure more readily than a superiorly based abscess and therefore produce symptoms earlier and with relatively few physical findings. Another possible explanation is scarring between the lateral muscular wall and the capsule as a result of previous tonsillitis or peritonsillar abscess. Such scarring might also create a confined area at the lower third of the peritonsillar space. Only one of our patients had a recent history of peritonsillar disease, but it is not known whether recurrent tonsillitis occurred in any of our patients in childhood. Our findings are similar to those of Stage and Bonding,17 who hypothesized that this entity may represent an early stage of parapharyngeal abscess. Like their patients, all of our patients had unilateral neck tenderness below the angle of the mandible. Furthermore, one of our patients was found to have early perforation of the constrictor musculature by the abscess. Because of the anatomic constraints or scarring between the constrictor musculature and the capsule, the most common path of least resistance in an inferior peritonsillar abscess may be through the constrictor musculature. This may explain the relatively early involvement of the parapharyngeal space. The possibility of such involvement underscores the importance of early diagnosis of inferior pole abscess.

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The use of CT scanning in the diagnosis and management of peritonsillar abscess has recently been discussed by Patel et al.19 Accurate localization of the abscess, distinction between cellulitis and abscess, and demonstration of secondary spread of infection were cited as useful reasons to employ this modality. Although we do not advocate the use of CT scanning in typical cases of peritonsillar abscess, we found it useful in the diagnosis of inferior peritonsillar abscess. In all four cases it was useful in localizing the exact area of inflammation and differentiating between abscess and phlegmon. Ultrasonography has recently been reported to be highly specific in diagnosing peritonsillar abscess and may have been a clinically useful alternative in these cases.20,21 Treatment options for classic peritonsillar abscess include tonsillectomy, drainage by needle aspiration, or incision and drainage. However, in the case of an inferior pole tonsillar abscess, needle drainage or incision and drainage with a local anesthetic would be technically difficult and potentially dangerous. We believe that immediate tonsillectomy under an umbrella of antibiotics provides a safe and easy method of evacuating such abscesses and ensures complete drainage. Several studies have shown that quinsy tonsillectomy is not associated with any greater risks than a cold tonsillectomy. Of interest was the observation that three of the four patients discussed were immunocompromised to varying degrees: one patient was subsequently diagnosed to have acquired immune deficiency syndrome, one patient was taking chronic oral prednisone, and one patient was a poorly compliant diabetic taking an oral hypoglycemic agent. Although the significance of this finding is unclear, it may have contributed to the relative paucity of physical findings on presentation (e.g., lack of fever and normal white blood cell count), as well as influence the location of the abscess. Few clinical reports of inferior peritonsillar abscess exist in the literature. Our experience agrees with those cases reported and noted in our article.4,17 Early recognition of this entity will ensure prompt treatment and avoid complications. In conclusion, inferior pole peritonsillar abscess is characterized by symptoms that are out of proportion to the physical findings. The “classic” findings seen with superior pole abscess are notably absent. A high index of suspicion is therefore required on the part of the examining otolaryngologist. A CT scan of the neck will confirm the diagnosis. Quinsy tonsillectomy is the treatment of choice. REFERENCES 1. Kornblut AD. Non-neoplastic diseases of the tonsils and adenoids. In: Paparella MM, Shumrick DA, Glukman JL, et al., editors. Otolaryngology–head and neck. Philadelphia: WB Saunders; 1991. p. 2137. 2. Parkinson RH. Tonsil and allied problems. New York: Macmillian; 1951. 3. Levitt GW. Cervical fascia and deep neck infections. Laryngoscope 1970;80:409-35. 4. Wills PI, Vernon RP. Complications of space infections of the head and neck. Laryngoscope 1981;91:1129-36.

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5. Herzon FS, Aldridge JH. Peritonsillar abscess: needle aspiration. Otolaryngol Head Neck Surg 1981;89:910-1. 6. Schecter GL, Sly DE, Roper AL, et al. Changing the face of treatment of peritonsillar abscess. Laryngoscope 1982;92:657-9. 7. Ophri D, Bawnik J, Poria Y, et al. Peritonsillar abscess: a prospective evaluation of outpatient management by needle aspiration. Arch Otolaryngol Head Neck Surg 1988;113:661-3. 8. Stringer SP, Schaefer SD, Close LG. A randomized trial for outpatient management of peritonsillar abscess. Arch Otolaryngol Head Neck Surg 1988;114:296-8. 9. Chowdhury CR, Bricknell BM. The management of quinsy: a prospective study. J Laryngol Otol 1992;106:986-8. 10. Lee KJ, Traxler JH, Smith HW, et al. Treatment of peritonsillar abscess. Trans Am Acad Ophthalmol Otolaryngol 1973;17:417-21. 11. Yung AK, Cantrell RW. Quinsy tonsillectomy. Laryngoscope 1976;86:1714-7. 12. McCurdy JA. Peritonsillar abscess: a comparison of treatment by immediate tonsillectomy and interval tonsillectomy. Arch Otoloaryngol 1977;103:414-5. 13. Brandow EG Jr. Immediate tonsillectomy for peritonsillar abscess. Trans Am Acad Opthalmol Otolaryngol 1973;77:412-6.

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14. Beeden AG, Evans JN. Quinsy tonsillectomy: a further report. J Laryngol Otol 1970;84:443-8. 15. Bonding P. Tonsillectomy aí chaud. J Laryngol Otol 1982;87: 1171-82. 16. Maisel RH. Peritonsillar abscess: tonsil antibiotic levels in patients treated by acute abscess surgery. Laryngoscope 1982; 92:80-7. 17. Stage J, Bonding P. Peritonsillar abscess with parapharyngeal involvement: incidence and treatment. Clin Otolaryngol 1987; 12:1-5. 18. Hollinshead WH. Anatomy for surgeons: the head and neck. 3rd ed. Philadelphia: JB Lippincott; 1982. p. 394-5. 19. Patel KS, Ahmad S, OíLeary G, Michel M. The role of computed tomography in the management of peritonsillar abscess. Otolaryngol Head Neck Surg 1992;107:727-32. 20. Strong ES, Woodward PJ, Johnson LP. Intraoral ultrasound evaluation of peritonsillar abscess. Laryngoscope 1995;105: 779-82. 21. Ahmed K, Jones AS, Shah K, Smethurst A. The role of ultrasound in the management of peritonsillar abscess. J Laryngol Otol 1994;108:610-2.