Intratonsillar abscess

Last revised by David Bassett on 27 May 2024

Intratonsillar abscesses, or simply tonsillar abscesses, are uncommon complications of tonsillitis in which pus accumulates focally in the parenchyma of the tonsil (within the capsule).

They can occur in both children and adults, but their incidence is not well-defined. In a series from one institution, intratonsillar abscesses were 7-9% of identified cases of intratonsillar or peritonsillar abscesses 1,3

Patients present with sore throat and fever for several days 2,3,11. Compared to patients who have peritonsillar abscess, those with intratonsillar abscess are less likely to have otalgia, trismus, or voice changes 1,3,11.

It is thought that swelling of the tonsil and alterations in lymphatic flow lead to obstruction of the crypts, accumulation of inflammatory debris, and formation of an abscess 2,4.

Contrast-enhanced CT demonstrates an enlarged palatine tonsil with a central area of hypoattenuation and surrounding rim enhancement 1,2,4-9. Tonsillar tissue or capsule surrounding the abscess confirms the abscess is within the tonsil, distinguishing tonsillar from peritonsillar abscess, but the two entities can coexist 3. A peritonsillar abscess, by contrast, forms in the peritonsillar space between the tonsil (medially) and superior constrictor muscle (laterally).

MRI demonstrates a rounded lesion in the tonsil with the following appearance 10:

  • T2: central hyperintensity and hypointense rim

  • T1 FS C+: central non-enhancement and rim enhancement

The peritonsillar tissues also have high signal on T2 weighted images and T1 fat-suppressed postcontrast images, consistent with tonsillitis/peritonsillitis.

Compared to peritonsillar abscess, incision and drainage or needle aspiration of intratonsillar abscess is less likely to be successful if attempted 1. Moreover, recurrence after antibiotic therapy is less common with intratonsillar than peritonsillar abscesses 1,2. Thus, many otolaryngologists prefer medical management over procedural drainage for intratonsillar abscess 1,2,5, while some attempt drainage in some scenarios 6-9.

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