• Users Online: 202
  • Print this page
  • Email this page


 
 
Table of Contents
CASE REPORT
Year : 2022  |  Volume : 24  |  Issue : 4  |  Page : 179-181

Bilateral peritonsillar abscess-developed ruptured Meckel's diverticulum: A case report


1 Department of Otorhinolaryngology, Division of Otolaryngology-Head and Neck Surgery, Imam Abdulrahman Bin Faisal University, KFUH, Dammam, Saudi Arabia
2 Department of Otorhinolaryngology, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, Saudi Arabia
3 Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
4 Department of Otorhinolaryngology Head and Neck Surgery, Ibn Sina National College for Health Sciences, Jeddah, Saudi Arabia

Date of Submission22-Jul-2022
Date of Decision23-Aug-2022
Date of Acceptance03-Sep-2022
Date of Web Publication10-Nov-2022

Correspondence Address:
Dr. Abdullah K AlMarri
Ibn Sina National College for Health Sciences, Jeddah 2606
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoh.sjoh_32_22

Rights and Permissions
  Abstract 


Peritonsillar abscess (PTA) is an accumulation of pus between the fibrous capsule of the palatine tonsils and the superior pharyngeal constrictor muscle. Bilateral PTA (BPTA) is a rare disease. Meckel's diverticulum (MD) is a congenital abnormality of the distal ileum associated with failed vitelline duct closure. Spontaneous MD rupture during the management of PTA never happened before. In this article, the authors present a case of BPTA-developed MD rupture. We present a case involving an 18-year-old male who presented to the emergency department (ED) for a 2-day history of worsening sore throat, trismus, fever, and odynophagia; a diagnosis of bilateral severe PTA was made. During the management of the BPTA, the patient developed severe acute abdominal pain which was diagnosed later as a case of MD rupture. In ED, the patient underwent computerized tomography (CT) scan of the neck that showed bilateral hypodense masses, consistent with BPTA. Conservative management was started on IV antibiotics, IV fluids, and IV analgesia at the time of diagnosis in the ED. The patient then underwent two attempts of needle aspiration using 18-gauge needles that showed evidence of aspirated pus. Later on, the patient developed severe abdominal pain, which is evaluated by the general surgery department (GS), and underwent ultrasonography (US) and CT scan; then, the diagnosis of rupture MD was made. The patient underwent diagnostic laparoscopy performed by the GS team and improved thereafter. In this article, the authors present a case of BPTA-developed MD rupture.

Keywords: Aspiration, bilateral peritonsillar abscess, case report, Meckel's diverticulum


How to cite this article:
Alenazi AS, AlBahlal JM, AlObaid FA, AlMahdi MJ, AlMarri AK. Bilateral peritonsillar abscess-developed ruptured Meckel's diverticulum: A case report. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:179-81

How to cite this URL:
Alenazi AS, AlBahlal JM, AlObaid FA, AlMahdi MJ, AlMarri AK. Bilateral peritonsillar abscess-developed ruptured Meckel's diverticulum: A case report. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2023 Jan 30];24:179-81. Available from: https://www.sjohns.org/text.asp?2022/24/4/179/360836




  Introduction Top


A peritonsillar abscess (PTA) is an accumulation of pus between the fibrous capsule of the palatine tonsils and the superior pharyngeal constrictor muscle. PTA is a common complication of acute tonsillitis; however, it can also be caused by infection of Weber's salivary glands.[1] PTA is the most common deep space infection of the head and neck that presents to the emergency department (ED), with an incidence of approximately 1 in 10,000.[2] PTA affects 30/100,000 individuals, with approximately 45,000 cases per year, and clinically evident bilateral PTA (BPTA) is rare.[3] Regarding PTA, the patient usually presents with fever, malaise, sore throat, dysphagia, or otalgia, and the physical findings are erythematous and swollen soft palate, deviated uvula, trismus, drooling of saliva, muffled voice, or cervical lymphadenitis.[4] Complications associated with PTA include septic shock, Lemierre's syndrome (thrombophlebitis of the internal jugular vein), dissemination of the infection to the surrounding structures, and disease recurrence.[5] Although several oropharyngeal Diseases can presents with abdominal pain such as tonsillitis, pharyngitis, and medication side eff ects.[6],[7] The inner ear, nose, and throat, like other extraintestinal involvement sites in gastrointestinal diseases, such as inflammatory bowel disease, can become targets of an autoimmune attack.[8] Meckel's diverticulum (MD) is a congenital abnormality of the distal ileum that is associated with failed vitelline duct closure. Detailed pathological studies have estimated its frequency to be approximately 2% of the general population, and it has been anecdotally recorded in patients with inflammatory disease.[9] There is a considerable evidence that MD can be triggered by group A beta-hemolytic Streptococcus infection.[10]

MD is the most common congenital complication of the gastrointestinal tract, with an incidence of 0.6%–4%.[11] It is a true diverticulum because of the persistence of the congenital vitellointestinal duct.[12] MD has a complication rate ranging from 4% to 16% including bleeding, intestinal obstruction, diverticulitis, tumors, ulceration, and perforation.[11],[13] Since the incidence of these complications is very low, it is even lower in the adult age group than in children.[11],[14] A spontaneous Meckel's diverticular rupture in adults is considered one of the rarest incidences among other complications, and it mainly presents with abdominal pain.

Nevertheless, spontaneous MD perforation is considered unusual and interesting, especially in an adult patient with PTA. To the best of our knowledge, this is the first case reporting the incidence of spontaneous MD during the management of PTA. In this article, the authors present a case of BPTA-developed MD rupture.


  Case Report Top


An 18-year-old male, medically free, admitted to the ED as a case of bilateral severe PTA, for a 2-day history of worsening sore throat, trismus, fever, and odynophagia. On physical examination, he had no fever and other vital signs were normal. Examination of the oral cavity and oropharynx revealed enlarged and inflamed tonsils and a bilaterally congested and bulging soft palate with a midline uvula. The laboratory test showed a white blood cell count of 22.060/mm3 with predominance of lymphocytes (54.6%). The level of C-reactive protein was 93.1 mg/L. A monospot test was negative. Computerized tomography (CT) scan of the neck showed bilateral hypodense masses, consistent with BPTA. Conservative management was started on IV antibiotics, IV fluids, and IV analgesia at the time of diagnosis in the ED as follows:

  • D5 ½ normal saline, 1-L bolus
  • Dexamethasone 10 mg IV
  • Ceftriaxone 2 g IV
  • Clindamycin 600 mg IV.


He went through two attempts of needle aspiration using 18-gauge needles that showed evidence of aspirated pus. Five days later, he complained of severe acute abdominal pain. His vital signs were as follows: tachycardiac, BP 119/60, RR 18, and temperature of 36.6°C. On physical examination, he has right lower quadrant abdominal pain with guarding.

The laboratory tests were as follows: sodium 136, potassium 5.1, chloride 102, BUN 4.8, creatinine 61, glucose 7.2, and CO2 25. The complete blood test showed elevated WBC 28.3 and platelets 433 and reduced RBC 4.49 and hemoglobin 134. Furthermore, the liver profile showed elevated liver enzymes AST 43 and ALT 73.

Abdominal ultrasonography was carried out to rule out acute cholecystitis, and the findings were a minimal amount of free peritoneal fluid with no significant abnormality. Enhanced CT scan of the abdomen and pelvis was done and showed a moderate intra-abdominal free air with significant free fluid, but no contrast leak or hemoperitoneum could be due to perforated appendix or rupture Meckel's diverticulum. There was also diffuse continuous wall thickening involving the jejunum down to the terminal ileum with enhancing peritoneal reflection. The result has been flagged as critical, and the general surgery team was informed about it.

The patient went through a diagnostic laparoscopy by 12-mm longitudinal supraumbilical incision; the surgeon found a large amount of turbid fluid in the abdominal cavity as well as pus in the right iliac fossa. After that, two 5-mm ports were inserted: one in reverse McBurney position and one in supraumbilical position. Suctioning was used to suck the peritoneal fluid, and a sample of the peritoneal fluid was sent for culture and sensitivity showed anaerobic Gram-positive Streptococcus pyogenes.

Dissection using suction was done in the right iliac fossa. The appendix was visualized which was normal and healthy with twisted tip, was reactive, hyperemic and it was attached to a perforated MD. Then, the MD was resected, and there was no bleeding at the site of resection. After that, the patient underwent a copious amount of irrigation with 5 L of normal saline, and suction was applied as well.

On histopathology, the specimen measures were 2.5 cm × 2.0 cm × 1.0 cm and showed a segment of small intestine and heterotopic gastric tissue with area of perforation, ulceration, and reactive change localized to the perforation site [Figure 1].
Figure 1: (a) Histopathology specimen of the small intestine shows a heterotopic gastric tissue (arrow). (b) Localized inflammatory changes at the site of perforation (arrows)

Click here to view


The patient followed up after he was improving well and discharged in stable and good condition, tolerating the medical and surgical procedures.


  Discussion Top


BPTA is a challenging condition in adults and needs early recognition,so BPTA's complications starting from fever and sore throat till airway compromise. Moreover, its incidence with MD, especially in adults, is extremely rare. In contrast, the actual frequency of BPTA is not known; however, it has been seen at rates of 1.9%–24% in reports of quinsy tonsillectomy (also known as acute abscess tonsillectomy).[15] The diagnosis of PTA is based on history and physical examination, and the treatment remains controversial among otolaryngologists. Regarding MD Suspicion classically correlated with rule of 2 : present in 2% of population, 2 feet from the ileocecal junction and 2 inches long, meanwhile most studies suggest an incidence ranging from 0.6% to 4%.[11]

A perforated Meckel's diverticulum is a rare condition, and it is challenging to diagnose it because it mimics appendicitis and presents as an acute abdomen. In this case, the patient was on treatment for a PTA for 5 days before the acute abdomen symptoms occur, and an initial diagnosis with appendicitis was made and further investigations were conducted followed by a diagnostic laparoscopy which confirmed the diagnosis of MD perforation.

We report this case as the first case that presents with BPTA and rupture of Meckel's diverticulum in adults.

Informed consent

The patient consented verbally and informed that his medical condition will be reported to a medical journal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vaikjärv R, Mändar R, Kasenõmm P. Peritonsillar abscess is frequently accompanied by sepsis symptoms. Eur Arch Otorhinolaryngol 2019;276:1721-5.  Back to cited text no. 1
    
2.
Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep 2006;8:196-202.  Back to cited text no. 2
    
3.
AlAwadh I, Aldrees T, AlQaryan S, Alharethy S, AlShehri H. Bilateral peritonsillar abscess: A case report and pertinent literature review. Int J Surg Case Rep 2017;36:34-7.  Back to cited text no. 3
    
4.
Galioto NJ. Peritonsillar abscess. Am Fam Physician 2008;77:199-202.  Back to cited text no. 4
    
5.
Lepelletier D, Pinaud V, Le Conte P, Bourigault C, Asseray N, Ballereau F, et al. Peritonsillar abscess (PTA): Clinical characteristics, microbiology, drug exposures and outcomes of a large multicenter cohort survey of 412 patients hospitalized in 13 French university hospitals. Eur J Clin Microbiol Infect Dis 2016;35:867-73.  Back to cited text no. 5
    
6.
Anderson J, Paterek E. Tonsillitis. 2022 Apr 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. PMID: 31335062.  Back to cited text no. 6
    
7.
Igarashi H, Nago N, Kiyokawa H, Fukushi M. Abdominal pain and nausea in the diagnosis of streptococcal pharyngitis in boys. Int J Gen Med 2017;10:311-8.  Back to cited text no. 7
    
8.
Available from: http://www.annalsgastro.gr/index.php/annals gastro/article/download/621/466/0. [Last accessed on 2022 Aug 11].  Back to cited text no. 8
    
9.
Freeman HJ. Meckel's diverticulum in Crohn's disease. Can J Gastroenterol 2001;15:308-11.  Back to cited text no. 9
    
10.
Bertozzi M, Verrotti A, Latini ME, Victoria ER, Di Cara G, Appignani A. Secondary involvement of Meckel's diverticulum by group A β-hemolytic Streptococcus in a child with upper airways infection treated by laparoscopic-assisted resection. Ann Pediatr Surg 2015;11:156-8.  Back to cited text no. 10
    
11.
Sagar J, Kumar V, Shah DK. Meckel's diverticulum: A systematic review. J R Soc Med 2006;99:501-5.  Back to cited text no. 11
    
12.
Opitz JM, Schultka R, Göbbel L. Meckel on developmental pathology. Am J Med Genet A 2006;140:115-28.  Back to cited text no. 12
    
13.
Matsagas MI, Fatouros M, Koulouras B, Giannoukas AD. Incidence, complications, and management of Meckel's diverticulum. Arch Surg 1995;130:143-6.  Back to cited text no. 13
    
14.
Pattanaik SK, Dandpat, Mishra JM. Incidence, complications and management of Meckel's diverticulum. Int Surg J 2017;4:3083-7.  Back to cited text no. 14
    
15.
Lin YY, Lee JC. Bilateral peritonsillar abscesses complicating acute tonsillitis. CMAJ 2011;183:1276-9.  Back to cited text no. 15
    


    Figures

  [Figure 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed340    
    Printed17    
    Emailed0    
    PDF Downloaded19    
    Comments [Add]    

Recommend this journal