Tag: Peritonsillar Abscess

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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 # 7: A Case of Asymmetry

A 22 year old male presents to the emergency department with a sore throat for 1 week. The pain is predominately on the left side and is associated with difficulty opening his mouth and fever. He was placed on amoxicillin 3 days ago but notes that his symptoms have progressed. He appears uncomfortable.

Vitals: T 101.4 HR 105 BP 132/81  RR 14 O2 98% on RA

A bedside ultrasound is performed, what is the next best step in management?

PTA

Answer and Learning Point

Answer

Incision and drainage. The patient presents with lateralizing pharyngitis symptoms associated with fever and trismus concerning for peritonsillar abscess (PTA). The ultrasound clip demonstrates a well circumscribed, hypoechoic fluid collection abutting the left tonsil confirming this diagnosis (see color overlay below).

Previously, physicians relied solely on the physical exam findings of peritonsillar swelling and uvular deviation to make the diagnosis of PTA. However, this approach lacks accuracy, with studies showing a sensitivity and specificity of 75% and 50% respectively [1]. This uncertainty leads to increased CT utilization, repeat drainage attempts and ENT consultation. Intraoral ultrasound is a novel technique that can be used by emergency physicians (EP), both for diagnosis and drainage of PTA. A recent randomized control trial found the use of intraoral ultrasound (vs. traditional landmark technique) to be significantly more reliable for differentiating between PTA and peritonsillar cellulitis. Additionally, this study also demonstrated increased success in PTA drainage by EPs with the use of intraoral ultrasound guidance [2].

Data from Costantino et al

Learning Points

    • An endocavitary probe should be used when PTA is suspected to differentiated between PTA and peritonsillar cellulitis; and assist with drainage if necessary.
    • If an endocavitary probe is not available, or if the patient cannot open their mouth wide enough to pass the probe, an alternative approach, known as the telescopic submandibular approach can also be used and is explained here.
    • When using ultrasound, the distance from the oral mucosa to the center of the PTA should be measure. The plastic sheath of an 18-gauge needle (preferably a spinal needle to allow the barrel of the syringe to be outside of the patients mouth) should be cut to this length to prevent puncturing any deeper structures during drainage.

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Scott PM, e. (2017). Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 2 October 2017, from https://www.ncbi.nlm.nih.gov/pubmed/10435129
    2. Costantino TG, e. (2017). Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 2 October 2017, from https://www.ncbi.nlm.nih.gov/pubmed/22687177

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