Bilateral peritonsillar abscess: an unusual presentation

Bilateral Peritonsillar Abscesses: Our Experience and Clinical Features

Objectives

This study analyzed the incidence and characteristics of bilateral peritonsillar abscesses (PTAs) that were treated with immediate tonsillectomy.

Methods

The study analyzed 409 patients with PTAs treated between 1984 and 2008. The patients included 304 male and 105 female patients between 2 and 85 years of age (median age, 30 years). Immediate tonsillectomy was performed in 371 of the PTA patients (90.7%). The incidence of bilateral PTAs and candidate predictive factors for bilateral PTAs were reviewed, including age, duration of PTA symptoms, history of recurrent tonsillitis, history of PTAs, deviation of the uvula, body temperature on admission, white blood cell count on admission, and C-reactive protein level on admission.

Results

Bilateral PTAs were found in 24 of 371 patients (6.5%). Younger age, absence of a deviated uvula, and a higher C-reactive protein value were the clinical features associated with bilateral PTAs in multivariate analysis.

Conclusions

The occurrence of bilateral PTAs was not rare; this fact has to be taken into consideration in discussing therapeutic concepts. The clinical features of bilateral PTAs suggested that bilateral PTAs might be a part of the natural history of PTAs, and that they occur in cases in which there is a delay in diagnosis and treatment. Further study is necessary to confirm the causation of bilateral PTAs.

Bilateral peritonsillar abscess: case report and literature review

Although uncommon, bilateral peritonsillar abscess (PTA) may still present with symptoms found in unilateral cases but lack hallmark findings such as an asymmetric tonsillar bulge and uvular deviation. We present the case of an 18-year-old woman deemed to have a bilateral PTA based on physical examination and radiographic imaging. She underwent successful surgical drainage with needle aspiration, followed by incision and drainage. A computed tomography with intravenous contrast should be obtained when a patient displays signs suggestive of a bilateral PTA but the diagnosis is not certain. To our knowledge, this is the first report of 2 different bacterial species cultured from contralateral abscesses during the same encounter.

Bilateral peritonsillar abscesses: case report and literature review

Although unilateral peritonsillar abscesses (PTA) are a common complication of acute bacterial tonsillitis, bilateral PTA are quite rare. We present the case of a 14-year-old female teenager with a 1-week history of acute tonsillitis. Physical examination revealed significant trismus, symmetrically inflamed tonsils and soft palate, and a midline uvula. A contrast-enhanced CT scan of the neck demonstrated bilateral PTA. After bilateral needle aspiration and administration of antibiotics, complete disease resolution was rapidly achieved. Patients with bilateral PTA present a diagnostic dilemma because they do not demonstrate the classic asymmetric signs and symptoms seen in the more prevalent unilateral PTA. Contrast-enhanced CT imaging can help diagnose bilateral PTA and should be considered in the presence of marked trismus but with the absence of unilateral inflammatory findings.

Bilateral peritonsillar abscesses: Not your usual sore throat

We describe a rare case of a previously healthy 30-year-old man who presented to the Emergency Department (ED) with bilateral peritonsillar abscesses. The clinical presentation of fever, trismus and odynophagia was consistent with pertonsillar abscess (PTA), but the presence of symmetric tonsillar swelling and midline uvula confounded the diagnosis. The true incidence of bilateral peritonsillar abscesses is unknown, but the incidence of unsuspected contralateral peritonsillar abscess identified at tonsillectomy has been reported to be between 1.9% and 24%. The diagnosis of bilateral peritonsillar abscesses should be considered when the clinical presentation suggests the diagnosis of PTA, but the physical examination reveals bilateral swollen tonsils with a midline uvula.

Bilateral peritonsillar abscesses

In the discussion about the management of the peritonsillar abscess (PTA) in regard to the pros and cons of tonsillectomy à chaud versus à froid, the risk of obscure contralateral abscesses is often neglected. To the authors' knowledge, there are only a few series of PTA being analyzed for the abscess rate of bilateral PTA. A group of 541 abscess tonsillectomies was retrospectively analyzed for the presence of a bilateral manifestation of peritonsillar abscess. Twenty-one patients (3.88%) had bilateral abscesses. None of these had been detected prior to the operation. Of the 541 patients, 2.22% had postoperative hemorrhages that had to be arrested under general anesthesia. Within the discussion about abscess tonsillectomy versus stab incision followed by interval tonsillectomy (à froid), the rate of almost 4% bilateral abscesses should be taken into consideration as dangerous complications such as mediastinitis could develop from the remaining abscess formation of the contralateral side.

Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses

This review describes the microbiology, diagnosis, and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses in children. Predominant anaerobic organisms isolated in peritonsillar, lateral pharyngeal, and retropharyngeal abscesses are Prevotella, Porphyromonas, Fusobacterium and Peptostreptococcus spp.; aerobic organisms are group A streptococcus ( Streptococcus pyogenes ), Staphylococcus aureus and Haemophilus influenzae . Anaerobic bacteria can be isolated from most abscesses whenever appropriate techniques for their cultivation have been used, while S. pyogenes is isolated in only about one third of cases. More than two thirds of deep neck abscesses contain beta-lactamase producing organisms. Management of tonsillar, peritonsillar, and retropharyngeal abscesses is similar. Systemic antimicrobial therapy should be given in large doses whenever the diagnosis is made. However, when pus is formed, antimicrobial therapy is effective only in conjunction with adequate surgical drainage. Untreated abscesses can rupture spontaneously into the pharynx, causing catastrophic aspiration. Other complications are extension of infection laterally to the side of the neck or dissection into the posterior mediastinum through facial planes and the prevertebral space. Death can occur from aspiration, airway obstruction, erosion into major blood vessels, or extension to the mediastinum.

Quinsy: a bilateral presentation

Bilateral peritonsillar abscesses are rare and often not diagnosed until tonsillectomy. As the condition may create diagnostic problems and serious complications, a case history is presented. The importance of rapid otorhinolaryngological examination and treatment is stressed.