Month: January 2026

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Case 60: A Stubborn Sore Throat: Insights through Ultrasound

Sneha Thandra, Anthony Medak

Case: A 19 year old female with a history of palpitations, shortness of breath, and syncope presents to the ED with throat pain with swelling for 3 weeks. The pain was noted to be bilateral, worsened with swallowing, but she was able to tolerate some oral intake. Patient had previously been seen on multiple occasions in ED/Urgent Care and had received dexamethasone without significant relief. She had not received antibiotics. Denied fevers or cough and had no PMH or known allergies. 

Vitals: BP 127/90 | Pulse 103 | Temp 98.2 °F (36.8 °C) | Resp 16 | Wt 58.1 kg (128 lb) | SpO2 100% 

On exam she is not in acute distress, her mucous membranes are moist. She phonates normally. There is slight peritonsillar fullness and an enlarged tonsil with notable tonsillar exudate on the right. No trismus or uvular deviation noted. The rest of her exam was normal.

Labs: WBC 22k

Images: Linear probe - Ultrasound Neck

Figure 1: Transcervical ultrasound of R peritonsillar abscess. Note highlighted hypoechoic material within parenchyma of tonsil.
Figure 2: Transcervical ultrasound of R peritonsillar abscess, with no flow evident on Doppler.
Video 1: Note the hypoechoic signal within the tonsil parenchyma.

ED Course: CT neck with contrast obtained revealed advancing tonsillitis with a right-sided tonsillar abscess. Abscess drainage attempted at bedside, but no purulence was obtained. The patient was given analgesic support (ketorolac and dexamethasone), IV fluids, and started on antibiotics (cefpodoxime and clindamycin). A referral to ENT was placed, and given that the patient was stable with no airway compromise, she was discharged with outpatient management.

Discussion: 

Peritonsillar abscesses (PTA) can form secondary to tonsillitis.

PTA is a common ED diagnosis (about 1 in 10,000 patients) that is a perfect application of point-of-care ultrasound (POCUS). Given the increased availability of POCUS in most ED/Urgent Care settings, the utility of a rapid and noninvasive imaging modality to evaluate for PTA can facilitate timely management, differentiate from cellulitis, and reduce the need for unnecessary CT imaging. This case illustrated the utility of POCUS in a 19 year old female with 3 weeks of persistent throat pain, where POCUS revealed an abnormal tonsil with a loculated anechoic fluid collection. Complications from PTA include airway obstruction, retropharyngeal abscess, among others. 

Although classic features of fever, sore throat, dysphagia, trismus, and “hot potato” voice can help with clinical diagnoses, overlapping features with other conditions including peritonsillar cellulitis, requires a tool with good sensitivity and specificity. Physical exam is noted to have a sensitivity and specificity of approximately 75% and 50%, respectively. However, a systematic review analyzing 18 studies from 1992 to 2021 that involved a total of 541 patients with PTA for a meta-analysis, found that POCUS has a sensitivity of about 74% and specificity of 79%. On subgroup analysis, although no significant difference was found between intraoral vs transcervical approaches (Figure 5), intraoral had a higher sensitivity (91% vs 80%) and transcervical had a higher specificity (81% vs 75%).1 Another study utilizing retrospective chart review found that POCUS reduced ED length of stay for patients: average of 160 minutes vs 293 minutes for patients where US was used compared to patients where US was not used. Specifically, after reviewing 58 charts, they found that 0% of patients diagnosed with ultrasound were admitted to the hospital, while 36.4% of patients where US was not used were admitted.2 

Beyond diagnosis, POCUS can assist in PTA treatment, improving aspiration outcomes. One study comparing US-guided versus non US-guided aspiration identified a success rate of 99% with POCUS and 80.3% without. In addition, ENT consultation rate was 12.9% with POCUS vs. 66% without POCUS use.3,4 Overall, POCUS offers advantages in evaluation of tonsillar cellulitis/PTA, while improving rates of successful aspiration, reducing unnecessary CT imaging, and thereby decreasing ED LOS. 

Figure 3: Demonstration of transoral (A) vs. transcervical (D) POCUS techniques. Panel B and E represent a normal tonsil. Panel C and F represent an abnormal tonsil with a loculated anechoic fluid collection. (*)indicates PTA, T indicates tonsil, S indicates submandibular gland (Kim et al., 2023).

References:  

  1. Kim DJ, Burton JE, Hammad A, Sabhaney V, Freder J, Bone JN, Ahn JS. Test characteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta-analysis. Acad Emerg Med. 2023 Aug;30(8):859-869. doi: 10.1111/acem.14660. Epub 2023 Jan 30. PMID: 36625850.
  2. Bryczkowski C, Haussner W, Rometti M, Wei G, Morrison D, Geria R, Mccoy JV. Impact of Bedside Ultrasound on Emergency Department Length of Stay and Admission in Patients With a Suspected Peritonsillar Abscess. Cureus. 2022 Dec 5;14(12):e32207. doi: 10.7759/cureus.32207. PMID: 36620852; PMCID: PMC9812542.
  3. Gibbons RC, Costantino TG. Evidence-Based Medicine Improves the Emergent Management of Peritonsillar Abscesses Using Point-of-Care Ultrasound. J Emerg Med. 2020 Nov;59(5):693-698. doi: 10.1016/j.jemermed.2020.06.030. Epub 2020 Aug 19. PMID: 32826122.
  4. Costantino TG, Satz WA, Dehnkamp W, Goett H. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg Med. 2012 Jun;19(6):626-31. doi: 10.1111/j.1553-2712.2012.01380.x. PMID: 22687177.
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Case 59: Abdominal and Pelvic Pain

Eli Tran, Elaine Yu

20YO female presented to the emergency department with 4-5 days of pelvic/abdominal pain, with abrupt worsening one day prior while resting. Her pain was sharp, sudden, and improved with ED analgesics. No dizziness, lightheadedness, or vaginal bleeding. LMP 4 weeks prior. She was not using birth control.

Exam: Vital signs were within normal limits. She appeared uncomfortable but non-toxic. She had pelvic and lower abdominal tenderness without guarding or rebound. No focal cardiopulmonary or neurologic abnormalities.

Labs

  • WBC 14.6 to 18.7 with neutrophilia.
  • Hgb 11.3
  • hCG <1.
  • Lactate 1.4.
  • Coags normal.
  • UA: SG 1.042, ketonuria, mild proteinuria; no hematuria.

Bedside pelvic ultrasound was performed with the following images:

Figure 1: Transabdominal ultrasound with free fluid in the pelvic region.

Figure 2: Transvaginal ultrasound with pelvic free fluid.

Figure 3: Transvaginal ultrasound with two cystic structures in the area of the left ovary.

ED Course

A formal pelvic ultrasound was ordered.

Figure 4: Pelvic free fluid with irregular cystic structure in area of left ovary consistent with a hemorrhagic cyst.

A CT scan of the abdomen and pelvis was ordered for concern of active hemorrhage. The CT showed showed a ruptured hemorrhagic ovarian cyst without active bleeding. There was also a finding of an absent left kidney with compensatory hypertrophy of the right kidney.

The patient remained hemodynamically stable and responded to analgesia. Her repeat hemoglobin after several hours was 12.4. Gynecology was consulted and recommended conservative management with 6-8 week follow-up.

The solitary kidney was an incidental finding unrelated to the current presentation. There was no hydronephrosis, obstruction, or infection. Renal function was preserved.

Discussion

The patient’s clinical picture and imaging are most consistent with a ruptured hemorrhagic ovarian cyst, a common cause of sudden pelvic pain with hemoperitoneum in reproductive-age women. Hemodynamic stability and absence of active bleeding support conservative management.

The incidentally detected solitary kidney is important to document but does not alter acute ED management. Most solitary kidneys identified incidentally in emergency imaging are congenital1-3 (unilateral renal agenesis or multicystic dysplastic kidney) or acquired (post-nephrectomy for tumor, trauma, or severe infection). Congenital solitary kidney accounts for the majority of incidental cases, often presenting with compensatory hypertrophy of the remaining kidney, as seen here.

Solitary kidney is associated with an increased long-term risk of CKD and hypertension, with some studies demonstrating >3-fold increased risk compared to individuals with two kidneys. The risk is highest in patients with vesicoureteral reflux or ureteropelvic junction obstruction, which occur in 17–48 percent of congenital cases. Cross-sectional imaging4-5 is generally sufficient for identifying and characterizing a solitary kidney; additional imaging (e.g., nuclear scintigraphy) is rarely required unless ectopic tissue or uncertain anatomy is suspected.

ED disposition: home with Gynecology and Nephrology follow-up

References

  1. Kim S, Chang Y, Lee YR, et al. Solitary Kidney and Risk of Chronic Kidney Disease. Eur J Epidemiol. 2019;34(9):879-888.
  2. Westland R, Schreuder MF, van Goudoever JB, et al. Clinical Implications of the Solitary Functioning Kidney. CJASN. 2014;9(5):978-986.
  3. Urisarri A, Gil M, Mandiá N, et al. Risk Factors for CKD in Congenital Solitary Kidney. Medicine. 2018;97(32):e11819.
  4. Krill A, Cubillos J, Gitlin J, Palmer LS. Abdominopelvic Ultrasound as a Diagnostic Tool for Solitary Kidney. J Urol. 2012;187:2201-2204.
  5. Grabnar J, Rus RR. Is Renal Scintigraphy Necessary in Diagnosis of Congenital Solitary Kidney? Pediatr Surg Int. 2019;35:729-735.
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