Left peritonsillar abscess

Case contributed by Dr Hoe Han Guan

Presentation

Sorethroat, dysphagia and fever for three days. No trauma or foreign body ingestion

Patient Data

Age: 40 years
Gender: Male

Cervical soft tissue neck

X-ray

Loss of normal cervical lordosis. Increased width of prevertebral soft tissue at upper cervical spine, worst at the upper cervical spine, which is more than the anteroposterior AP diameter of the cervical vertebral body. No emphysema or air pocket seen within this soft tissue thickening.

The oropharynx, hypopharynx, larynx and upper trachea are displaced anteriorly by the soft tissue thickening.

Epiglottis is mildly swollen with thickening of the aryepiglottic folds.

CT

Rim-enhancing low attenuating collection with epicenter at the left tonsillar region. It has extension into the retropharyngeal space/danger space. Superiorly, it extends to the level of nasopharynx. Anteriorly, the left visceral space is involved with intramuscular abscess noted within the left strap muscles. Significant occlusion of the oropharynx, hypopharynx and supraglottis indicates airway compromise.

Fat streakiness within the left parapharyngeal space. Carotid arteries and internal jugular veins in both carotid spaces are patent. No cervical bony or thyroid cartilage erosion.

Evidence of tracheostomy.

Thick walled cavitating lung lesion at the apicoposterior segment of left upper lobe.

Case Discussion

This case shows that meticulous assessment of the cervical soft tissue lateral radiograph is still warranted for the crucial early screening assessment of patient who presents with sorethroat. The finding of the widening of preverterbal soft tissue in cervical spine is highly associated with retropharyngeal abscess which can compromise airway/pharynx in short time span. Careful airway assessment/protection and urgent contrast enhanced CT scan will be necessary for the full extension of the collection/abscess.

For any head and neck collection, the patency status of airway and any possible adjacent thrombophlebitis must be assessed and documented.

This patient went on to have urgent cricothyroidotomy and tracheostomy due to sudden cardiorespiratory arrest and sudden airway compromise prior to CT scan. Then, patient underwent incision/drainage of his left peritonsillar abscess. Intraoperatively, the left peritonsillar abscess has extension into supraglottis and retropharyngeal space.

Cavitating lung lesion leads physician to investigate for possible pulmonary tuberculosis where it is proven to be pulmonary tuberculosis from sputum.

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