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Table of Contents
CLINICAL CASE
Year : 2012  |  Volume : 14  |  Issue : 2  |  Page : 94-95

Bilateral peritonsillar abscess: A case report


Senior ENT Resident, (Otolaryngology, Head and Neck Surgery Department, Salmaniya Medical Complex.), Bahrain

Date of Web Publication3-Jan-2020

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.274783

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  Abstract 


We describe a rare case of a previously healthy 27 year old man who presented to the otolaryngology clinic with bilateral peritonsillar abscess.
The clinical presentation of sore throat, fever, odynophagia and trismus were consistent with peritonsillar abscess, but the presence of symmetric tonsillar swelling and midline uvula misguided the diagnosis.
Diagnosis can be based on clinical criteria or imaging techniques. A clinical presentation of peritonsillar abscess with a physical examination of bilateral swollen tonsils and midline uvula is suggestive of bilateral peritonsillar abscess. The general principle of treatment is systemic antibiotics and drainage of the pus.

Keywords: Onsillitis, peritonsillar abscess, tonsillectomy


How to cite this article:
Alqasim AH. Bilateral peritonsillar abscess: A case report. Saudi J Otorhinolaryngol Head Neck Surg 2012;14:94-5

How to cite this URL:
Alqasim AH. Bilateral peritonsillar abscess: A case report. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2012 [cited 2023 Jan 30];14:94-5. Available from: https://www.sjohns.org/text.asp?2012/14/2/94/274783




  Introduction Top


Peritonsillar space infection is the most common deep neck space infection. Most often it is a complication of tonsillitis.Clinically, red, swollen tonsils are seen bilaterally, usually with exudates, and there is significant swelling lateral and superior to the tonsil on one side [1].

Peritonsillar abscess is characterized by trismus, odynophagia, “hot potato” voice, and in a severe case deviation of uvula and soft palate away from the infected side.Pain on opening the mouth occurs when infection and inflammation extend to the internal pterygoid muscle in the parapharyngeal space. It usually occurs in more serious peritonsillar space infections such as severe cellulitis and abscess which may limit adequate examination and treatment.

Although bilateral peritonsillar space infections have been reported, they are rare and unilateral peritonsillar infections are seen in the vast majority of cases. The overall incidence of bilateral peritonsillar abscess is reported to reach 4.9 % [2].

We report a case of 27 years old male patient who presented with bilateral peritonsillar abscesses and literature review.


  Case report Top


A 27 year old male presented to the otolaryngology clinic of our hospital with a 6 days history of worsening sore throat, odynophagia, intermittent fever, bilateral otalgia and trismus.

Despite using oral antibiotic (Amoxicillin 500mg TDS) prescribed to him by a private practitioner, his symptoms worsened over the 4 days following initiation of the oral antibiotic.

Intra oral examination revealed a diffusely erythematous tonsils, soft palate and uvula, with prominent bilateral tonsilar swellings and a midline uvula.

Fiber optic nasolaryngoscopy was done and showed no signs of upper airway obstruction.

Laboratory tests revealed a WBC count of 17.5 with 75% neutrophils. Electrolytes showed mild hyponatreamia of 134 mmol/l. Monospot test was not done. Needle aspiration of both peritonsilar swellings revealed the presence of significant amount of pus for which incision and drainage of both sides were done, followed by immediate improvement of his odynophagia. Pus from both sides was sent for culture and sensitivity test. The main results of culture from both sides were group A beta-hemolytic streptococci and methicillin sensitive staph aureus.

Computed tomography was not done as the diagnosis of peritonsillar abscess was certain.

The patient was advised for admission to the hospital to receive intravenous antibiotic, but he refused due to some social commitments. Patient was prescribed intramuscular Ceftriaxone injections for 5 days, which he received them daily in the local health center. He was also given a 500 mg Metronidazole, three times a day for one week duration in addition to hexetidine throat gurgle and oral paracetamol.

Follow up intra oral examination one week later showed a well resolved infection and normal mucosa. Patient was advised for elective tonsillectomy in the future.


  Discussion Top


Peritonsillar abscess develops as a complication of acute tonsillitis when the infection spreads from the peripheral tonsillar crypts, penetrates the capsule, and localizes in the peritonsillar space [2],[3].It is considered to be the most common head and neck abscess [4].

If not treated adequately, there may be spontaneous rupture or extension of the abscess, leading to complications. Complications of an untreated peritonsillar abscess include airway compromise from laryngeal edema, a parapharyngeal abscess, retropharyngeal space and mediastinal extension, jugular vein thrombophlebitis, sepsis, cavernous sinus thrombosis, brain abscess, meningitis, dissection into the internal carotid artery, and, if rupture occurs, aspiration and subsequent pneumonia or a lung abscess [2].
Figure 1: Bilateral peritonsillar abscess in 27 years old patient of our case.

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Bilateral peritonsillar abscesses are rare, [5],[6] but when they occur, they can be tricky to diagnose, especially if you don’t consider the possibility.

Kessler et al [7] reported 4.9 % incidence of this bilateral variant, eventhough its incidence varies between 0 to 24% according to other studies [2],[3].

Its diagnosis should be considered in very ill patients presenting with similar symptoms and intraoral findings of huge, erythematous, bilateral tonsils with an undisplaced uvula. However other differential diagnosis should be kept in mind. Acute severe tonsillitis, infectious mononucleosis, lymphoma of tonsils, infiltrating carcinomas of the soft palate or uvula and minor salivary gland tumors (e.g., pleomorphic adenomas) are among the most important differential diagnosis [8].

Other authors have found bilateral peritonsillar abscess only incidentally during a quinsy tonsillectomy, and they report that it did not contribute to the patient’s physical appearance at the initial presentation [2].

It is generally accepted that the basic management of a peritonsillar abscess consists of drainage of the abscess and systemic antibiotics covering group Α β- hemolytic streptococci which is reported to be the most common offending organism. [2]

Currently, different modalities of drainage of a peritonsillar abscess include tonsillectomy (immediate or delayed), incision and drainage, and needle aspiration [9]. In our case the patient presented with significant erythematous bilateral peritonsillar swelling .He was managed by a diagnostic needle aspiration which was positive in both sides. This initial procedure followed by bilateral incision and drainage.

Some authors do CT scan or ultrasonography as a part of management for bilateral peritonsillar abscess as a response to unusual intraoral presentation [8]. MRI,CT scan and ultrasonography are different imaging tools which can be used in selected patients to determine bilateral peritonsillar abscess from other above mentioned differential diagnosis whenever necessary. Furthermore, we have performed diagnostic needle aspiration which was in favor of bilateral peritonsillar abscess and elevated the need for performing imaging studies.



 
  References Top

1.
James Byron Snow, Phillip A. Wackym, John Jacob Ballenger: Otorhinolaryngology, Head Neck Surg. In: Deep head and neck space infections (chap.64), 17th edition, PMPH-USA, pages: 784-785, 2009.  Back to cited text no. 1
    
2.
Dalton R, Abedi E, Sismanis A. Bilateral peritonsillar abscesses and quinsy tonsillectomy. J Nat Med Assoc. 1985; 77:807-812.  Back to cited text no. 2
    
3.
Buckley A, Moss E, Blokmanis A. Diagnosis of peritonsillar abscess: value of intraoral sonography. AJR Am J Roentgenol. 1994; 162:961-964.  Back to cited text no. 3
    
4.
Giger R, Landis BN, Dulguerov P. Haemorrhage Risk after Quinsy Tonsillectomy. Otolaryngol Head Neck Surg. 2005; 133:729-34.  Back to cited text no. 4
    
5.
Kristensen S, Juul A, Nielsen E Quinsy: A bilateral presentation. J Laryngol Otol. 1985; 99:401-2.  Back to cited text no. 5
    
6.
Fiechtl JF, Stack LB. Images in clinical medicine. Bilateral peritonsillar abscesses. N Engl J Med. 2008;358(23):e27.  Back to cited text no. 6
    
7.
Kessler A, Lapinsky J, Segal S, Berkovitch M. Bilateral Peritonsillar abscess: Relief of Upper Airway Obstruction. IMAJ. 2003; 5:126-27.  Back to cited text no. 7
    
8.
Bilateral peritonsillar abscess: Case report and presentation of its clinical appearance. Ear Nose Throat J. 2001 Jun; 80(6):381-2.  Back to cited text no. 8
    
9.
Manthey D, Harrison B. Otolaryngologic Procedures. In: Roberts JR, Hedges JR (eds). Clinical Procedures in Emergency Medicine. Philadelphia, PA: WB Saunders Co; 1998:1122-1126  Back to cited text no. 9
    


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