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Orobello NC, Crowder HR, Riley PE, Michel M, Behzadpour HK, Rana MS, Sanchez-Jacob R, Reilly BK. Predicting failure of detection of peritonsillar abscess with ultrasound in pediatric populations. Am J Otolaryngol 2024; 45:104021. [PMID: 37625277 DOI: 10.1016/j.amjoto.2023.104021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/28/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023]
Abstract
PURPOSE Some patients require additional imaging following ultrasound (US) to definitively diagnose a peritonsillar abscess (PTA), delaying intervention and disease resolution. We seek to evaluate patient characteristics which may predispose to a secondary imaging requirement to diagnose PTA, in order to better understand ultrasound limitations and predict who will require additional studies. MATERIALS AND METHODS Retrospective chart review of patients with an US for suspected PTA between July 2017 and July 2020. Patient age, weight, and clinical characteristics, such as pain, trismus, and reduced neck range of motion (ROM) were collected. The need for additional imaging, subsequent surgical intervention, and hospital length of stay (LOS) were also recorded. RESULTS Of 411 qualifying patients, 73 underwent additional imaging. Patients who required additional imaging were younger (9.8 vs 11.3 years, p = 0.026) and more likely to have decreased neck ROM (17.8 vs 5.3 %, p = 0.001). Surgical intervention was performed more commonly (27.4 vs 14.8 %, p = 0.015) and hospital LOS was longer (24.0 vs 5.0 h, p < 0.001) in those with secondary imaging. CONCLUSIONS Specific patient characteristics, such as younger age and decreased neck range of motion, are associated with a higher need for additional imaging. Additionally, the need for additional imaging is associated with a longer hospital LOS and increased likelihood of surgical intervention. Nearly 18 % of patients who underwent US evaluation of PTA required secondary imaging. Although transcervical US remains an excellent tool for diagnosing PTA, this data supports the utility of secondary imaging in certain instances.
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Affiliation(s)
- Nicklas C Orobello
- Department of Otolaryngology, Children's National Medical Center, Washington, DC, USA
| | - Hannah R Crowder
- Division of Otolaryngology, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Phoebe E Riley
- Department of Otolaryngology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Margaret Michel
- Division of Otolaryngology, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Hengameh K Behzadpour
- Department of Otolaryngology, Children's National Medical Center, Washington, DC, USA
| | - Md Sohel Rana
- Department of Surgery, Children's National Hospital, Washington, DC, USA
| | | | - Brian K Reilly
- Department of Otolaryngology, Children's National Medical Center, Washington, DC, USA.
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2
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Tüchert SE, Vollert K, Schuster T, Kröncke T. Use of CEUS for Imaging Evaluation of Pediatric Peritonsillar Abscess. Ultraschall Med 2023; 44:631-636. [PMID: 36690031 DOI: 10.1055/a-2017-7172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE Peritonsillar abscess can be diagnosed by B-mode ultrasound and cross-sectional imaging. The latter (with MRI being the modality of first choice in children) is associated with higher effort and risk for pediatric patients due to the administration of X-rays and/or the need of sedation. The purpose of this study is to evaluate whether the introduction of CEUS into the diagnostic algorithm for suspected pediatric peritonsillar abscess is suitable and advantageous. MATERIALS AND METHODS Single-institution retrospective review of data of pediatric patients who were presented to the department of pediatric radiology for sonographic evaluation under the suspicion of peritonsillar abscess. Diagnostic performance of CEUS was evaluated by using surgical exploration or clinical follow-up as the reference standard. RESULTS 284 children included in the study underwent B-mode ultrasound. Mean age of all patients was 6,23 years. Peritonsillar abscess was the diagnosis in 42 patients. Diagnosis of peritonsillar abscess was made by B-mode ultrasound alone in 13 of 42 patients (31 %). In 17 of 42 patients (40 %), diagnosis was made by a combination of B-mode ultrasound and CEUS. Sensitivity rose from 37 % to 86 % in cases where B-mode ultrasound remained unclear and CEUS was used. CONCLUSION Contrast-enhanced ultrasound (CEUS) is suitable and efficient for the diagnosis of peritonsillar abscess in pediatric patients. It increases the sensitivity for the diagnosis of peritonsillar abscess and thereby reduces the need of additional cross-sectional imaging for the pediatric patients.
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Affiliation(s)
- Stefanie Eliane Tüchert
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Kurt Vollert
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Tobias Schuster
- Department of Pediatric Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Thomas Kröncke
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
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3
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Vierula JP, Nurminen J, Jussila V, Nyman M, Heikkinen J, Pape B, Sorvettula K, Mattila K, Hirvonen J. Diagnostic performance of short noncontrast biparametric 3-T MRI for tonsillar infections: comparison with a full protocol including contrast-enhanced sequences. Eur Radiol Exp 2023; 7:65. [PMID: 37872406 PMCID: PMC10593634 DOI: 10.1186/s41747-023-00379-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/22/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND We investigated whether a short, 5-min magnetic resonance imaging (MRI) protocol consisting of only axial T2-weighted and diffusion-weighted imaging (DWI) sequences can discriminate between tonsillar infections, peritonsillar abscesses and deeply extending abscesses in a retrospective, blinded, multireader setting. METHODS We included patients sent by emergency physicians with suspected pharyngotonsillar infections who underwent emergency neck 3-T MRI from April 1 2013 to December 31 2018. Three radiologists (with 10-16 years of experience) reviewed the images for abscesses and their extension into deep neck spaces. Data were reviewed first using only axial T2-weighted Dixon images and DWI (short protocol) and second including other sequences and contrast-enhanced T1-weighted Dixon images (full protocol). Diagnostic accuracy, interobserver agreement, and reader confidence were measured. Surgical findings and clinical course served as standard of reference. RESULTS The final sample consisted of 52 patients: 13 acute tonsillitis with no abscesses, 19 peritonsillar abscesses, and 20 deeply extending abscesses. Using the short protocol, diagnostic accuracy for abscesses across all readers was good-to-excellent: sensitivity 0.93 (95% confidence interval 0.87-0.97), specificity 0.85 (0.70-0.93), accuracy 0.91 (0.85-0.95). Using the full protocol, respective values were 0.98 (0.93-1.00), 0.85 (0.70-0.93), and 0.95 (0.90-0.97), not significantly different compared with the short protocol. Similar trends were seen with detecting deep extension. Interobserver agreement was similar between protocols. However, readers had higher confidence in diagnosing abscesses using the full protocol. CONCLUSIONS Short MRI protocol showed good-to-excellent accuracy for tonsillar abscesses. Contrast-enhanced images improved reader confidence but did not affect diagnostic accuracy or interobserver agreement. RELEVANCE STATEMENT Short protocol consisting only of T2-weighted Dixon and DWI sequences can accurately image tonsillar abscesses, which may improve feasibility of emergency neck MRI. KEY POINTS • The short 3-T MRI protocol (T2-weighted images and DWI) was faster (5 min) than the full protocol including T1-weighted contrast-enhanced images (24 min). • The short 3-T MRI protocol showed good diagnostic accuracy for pharyngotonsillar abscesses. • Contrast-enhanced sequences improved reader confidence but did not impact diagnostic accuracy or interobserver agreement.
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Affiliation(s)
| | - Janne Nurminen
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Ville Jussila
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Mikko Nyman
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Jaakko Heikkinen
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Bernd Pape
- Department of Biostatistics, Turku University Hospital, Turku, Finland
- School of Technology and Innovations, University of Vaasa, Vaasa, Finland
| | - Kaarlo Sorvettula
- Medical Imaging Center, Department of Radiology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Kimmo Mattila
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, Turku University Hospital, Turku, Finland
- Medical Imaging Center, Department of Radiology, Tampere University and Tampere University Hospital, Tampere, Finland
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4
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Li X, Li C, Yang X. Deep cervical space abscess due to acute tonsillitis complicating mediastinal and pericardial abscess: A case report. Asian J Surg 2023; 46:4689-4690. [PMID: 37268469 DOI: 10.1016/j.asjsur.2023.05.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/01/2023] [Accepted: 05/17/2023] [Indexed: 06/04/2023] Open
Affiliation(s)
- Xin Li
- The First Clinical Medical College, Gansu University of Traditional, Chinese Medicine, Lanzhou, China
| | - Cong Li
- The First Clinical Medical College, Gansu University of Traditional, Chinese Medicine, Lanzhou, China
| | - Xiaolong Yang
- Department of E.N.T., Gansu Provincial Hospital, Lanzhou, China.
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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; 30:859-869. [PMID: 36625850 DOI: 10.1111/acem.14660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/27/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Distinguishing peritonsillar abscess (PTA) from peritonsillar cellulitis using clinical assessment is challenging as many features overlap for both conditions, and physical examination is only about 75% sensitive and 50% specific for diagnosing PTA. The primary objective of this systematic review was to determine the test characteristics of ultrasound for diagnosing PTA when compared to a reference standard of computed tomography or acquisition of pus via needle aspiration or incision and drainage. METHODS This systematic review was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy (PRISMA-DTA) guidelines. We searched seven databases from 1960 to November 2022. Two independent reviewers completed study selection, data extraction, and QUADAS-2 risk-of-bias assessment. We used a bivariate random-effects model to calculate pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-). We also conducted subgroup analyses on radiology ultrasound compared to point-of-care ultrasound (POCUS) and intraoral compared to transcervical scanning techniques. RESULTS From 339 citations, we identified 18 studies for inclusion. Because one study only reported positive cases of PTA (thereby preventing the calculation of specificity), it was excluded from the analysis, so the analysis included a total of 17 studies with 812 patients, of whom 541 had PTA. Pooled bivariate sensitivity was 86% (95% confidence interval [CI] 78%-91%), specificity 76% (95% CI 67%-82%), LR+ 3.51 (95% CI 2.59-4.89), and LR- 0.19 (95% CI 0.12-0.30). On subgroup analysis, radiology-performed ultrasound had a sensitivity and specificity of 89% and 71%, compared to POCUS, which had a sensitivity and specificity of 74% and 79%. Comparing the two different techniques, intraoral had a sensitivity and specificity of 91% and 75% while transcervical had a sensitivity and specificity of 80% and 81%. CONCLUSIONS Ultrasound demonstrates high sensitivity for ruling out PTA, but it only has moderate specificity for ruling in the diagnosis.
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Affiliation(s)
- Daniel J Kim
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Justin E Burton
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, Langley Memorial Hospital, Langley, British Columbia, Canada
| | - Abdullah Hammad
- Department of Pediatric Emergency Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia
| | - Vikram Sabhaney
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason Freder
- Department of Emergency Medicine, St. Mary's Hospital, Montreal, Quebec, Canada
- Department of Emergency Medicine, McGill University, Montreal, Quebec, Canada
| | - Jeffrey N Bone
- Biostatistics, Research Informatics, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Justin S Ahn
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, Royal Columbian Hospital, New Westminster, British Columbia, Canada
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6
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Long B, Gottlieb M. Managing Peritonsillar Abscess. Ann Emerg Med 2023; 82:101-107. [PMID: 36669912 DOI: 10.1016/j.annemergmed.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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7
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Todsen T. Otorhinolaryngologist performed transcervical versus transoral ultrasonography in the management of peritonsillar abscess. Am J Otolaryngol 2021; 42:102768. [PMID: 33109415 DOI: 10.1016/j.amjoto.2020.102768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/29/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Tobias Todsen
- Department of Otorhinolaryngology and Maxillofacial Surgery, Zealand University Hospital, Køge, Denmark; Copenhagen Academy for Medical Education and Simulation, University of Copenhagen and The Capital Region of Denmark, Copenhagen, Denmark.
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8
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Zhao X, Delaney M, Breslin K, Chamberlain JM, Rubio EI, Reilly BK, Cohen JS. Impact of Transcervical Ultrasound for the Diagnosis of Pediatric Peritonsillar Abscesses on Emergency Department Performance Measures. J Ultrasound Med 2020; 39:715-720. [PMID: 31713253 DOI: 10.1002/jum.15150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 09/06/2019] [Accepted: 09/15/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the impact of transcervical ultrasound (US) as the initial imaging study for suspected peritonsillar abscesses (PTAs) on pediatric emergency department (ED) throughput measures. METHODS A retrospective cohort study of patients evaluated for suspected PTAs between January 2009 and April 2017 was conducted. We compared the ED length of stay (LOS) before and after implementation of transcervical US to diagnose a PTA. The balancing measure was the rate of return visits within 2 weeks. RESULTS There were 387 eligible patients over the study period. A total of 101 patients were evaluated for PTAs with computed tomography and 286 with US. The mean LOS was significantly less for patients who had US (347 minutes; 95% confidence interval [CI], 330, 364 minutes) compared to computed tomography (426 minutes; 95% CI, 392, 459 minutes), with an absolute difference of 79 minutes (95% CI, 44, 113 minutes). Patients who were evaluated with US did not have an increased rate of return visits (5.9% versus 8.0%; P = .66). CONCLUSIONS The introduction of transcervical US was associated with a decrease of greater than 1 hour in the ED LOS for patients with suspected PTAs. Given the better radiation profile of US and no increase in the rate of return visits after its implementation, we propose the adoption of a transcervical US-first approach for the diagnosis of PTAs in pediatrics.
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Affiliation(s)
- Xian Zhao
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
- Departments of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Marc Delaney
- Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Kristen Breslin
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
- Departments of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
- Departments of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Eva I Rubio
- Divisions of Radiology, Children's National Health System, Washington, DC, USA
| | - Brian K Reilly
- Division of Otolaryngology, Children's National Health System, Washington, DC, USA
| | - Joanna S Cohen
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
- Departments of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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9
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Todsen T, Stage MG, Michaelsen SH, Tolsgaard MG, Melchiors J, Madsen AR, Hahn CH, Godballe C. Protocol for a randomised clinical trial of transoral ultrasound versus standard of care in the diagnosis of peritonsillar abscess. Dan Med J 2019; 66:A5573. [PMID: 31686648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Peritonsillar infection is a common complication to acute tonsillitis in younger adults. If peritonsillar cellulitis progresses to a peritonsillar abscess (PTA), the primary treatment is surgical drainage. But distinguishing cellulitis from PTA on a standard clinical examination is difficult. This trial aims to explore whether point-of-care transoral ultrasound can improve diagnostic accuracy and guide successful needle aspiration in patients referred with PTA. METHODS A randomised, controlled multicentre trial will be conducted at the departments of otorhinolaryngology, head and neck surgery at Rigshospitalet and Odense University Hospital. Patients referred with PTA will be randomised to either standard clinical examination (control) or standard clinical examination with supplemental transoral ultrasound (intervention). The diagnostic accuracy, the total number of performed needle aspirations and the proportion of successful needle aspirations will be compared between the two groups. The difference will be evaluated using binary logistic regression and a generalised estimating equation to adjust for clustering of data within each physician and each hospital. A total of 88 patients are necessary to measure the clinical effect of adding transoral ultrasound. CONCLUSIONS This study will explore the clinical benefits of adding transoral ultrasound to the diagnostic work-up of patients with peritonsillar infections. FUNDING The Rigshospitalet and Odense University Hospital Foundation. TRIAL REGISTRATION Clinicaltrials NCT03824288.
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10
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Ohori J, Iuchi H, Nagano H, Umakoshi M, Matsuzaki H, Kurono Y. The usefulness of abscess tonsillectomy followed by intraoral drainage for parapharyngeal abscess concomitant with peritonsillar abscess in the elderly. Auris Nasus Larynx 2019; 47:697-701. [PMID: 31239095 DOI: 10.1016/j.anl.2019.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 04/15/2019] [Accepted: 06/12/2019] [Indexed: 11/19/2022]
Abstract
Parapharyngeal abscess (PPA) may cause life-threatening complications and peritonsillar abscess (PTA) and tonsillitis frequently precede PPA. The optimal management of PPA caused by PTA has been the subject of debate with respect to the surgical approach. We present three cases of PPA concomitant with PTA in elderly patients. In two cases, the abscesses in parapharyngeal space were drained by abscess tonsillectomy followed by intraoral incision of the tonsillar bed. On the other hand, the third case did not undergo abscess tonsillectomy because of his refusal of surgery and needed extraoral drainage after the aggravation of PPA. Based on the experience of those three cases, it was suggested that abscess tonsillectomy followed by intraoral incision of the tonsillar bed might be a useful surgical approach for the drainage of PPA concomitant with PTA, especially in elderly patients.
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Affiliation(s)
- Junichiro Ohori
- Department of Otolaryngology, Head and Neck Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
| | - Hiroyuki Iuchi
- Department of Otolaryngology, Head and Neck Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
| | - Hiromi Nagano
- Department of Otolaryngology, Head and Neck Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
| | - Mizuo Umakoshi
- Department of Otolaryngology, Head and Neck Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
| | - Hirohisa Matsuzaki
- Department of Otolaryngology, Head and Neck Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
| | - Yuichi Kurono
- Department of Otolaryngology, Head and Neck Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
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11
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Connell JT, Park JH. Acute peritonsillar swelling: a unique presentation for Kawasaki disease in adolescence. BMJ Case Rep 2018; 2018:bcr-2018-224441. [PMID: 30042103 DOI: 10.1136/bcr-2018-224441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report the case of a 14-year-old man with unilateral peritonsillar swelling, airway compromise and fever. On physical examination, the patient was pyrexic with trismus, dysphonia, uvula deviation, exudative unilateral peritonsillar swelling and unilateral cervical lymphadenopathy. Attempts at aspirating the prominent peritonsillar region were unsuccessful. CT head and neck identified a large inflammatory mass arising from the left palatine tonsil. The patient was treated for presumptive peritonsillar abscess. After failing to respond to intravenous antimicrobials, he progressively developed the classical sequale of Kawasaki's Disease. Echocardiogram identified coronary arteritis. Intravenous immunoglobulin and high-dose aspirin were initiated and his clinical picture improved. Kawasaki's disease mimicking an acute infective process can pose a diagnostic dilemma. It is an uncommon differential in the adolescent population. Prompt recognition and initiation of appropriate therapy are imperative to minimise morbidity.
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Affiliation(s)
| | - Jae Hong Park
- Women's & Children's Hospital, Adelaide, South Australia, Australia
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12
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Yee AM, Christensen DN, Waterbrook AL, Amini R. Parapharyngeal abscess with tracheal deviation. Intern Emerg Med 2017; 12:1077-1078. [PMID: 28194696 DOI: 10.1007/s11739-017-1634-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 02/06/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Allison M Yee
- College of Medicine, The University of Arizona, Tucson, AZ, USA
| | | | - Anna L Waterbrook
- Department of Emergency Medicine, The University of Arizona, PO Box 245057, Tucson, AZ, 85724-5057, USA
| | - Richard Amini
- Department of Emergency Medicine, The University of Arizona, PO Box 245057, Tucson, AZ, 85724-5057, USA.
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Kawabata M, Umakoshi M, Makise T, Miyashita K, Harada M, Nagano H, Ohori J, Kurono Y. [Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy]. Nihon Jibiinkoka Gakkai Kaiho 2016; 119:1349-1350. [PMID: 30039689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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14
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Prokofieva A, Modayil V, Chiricolo G, Ash A, Raio C. Ultrasound-guided drainage of peritonsillar abscess: shoot with your hockey-stick. Intern Emerg Med 2016; 11:883-4. [PMID: 26543001 DOI: 10.1007/s11739-015-1343-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 10/16/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Ann Prokofieva
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Veena Modayil
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Gerardo Chiricolo
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY, USA
| | - Adam Ash
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA.
| | - Christopher Raio
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA
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Giannitto C, Esposito AA, Casiraghi E, Biondetti PR. Epidemiological profile of non-traumatic emergencies of the neck in CT imaging: our experience. Radiol Med 2014; 119:784-9. [PMID: 24553784 DOI: 10.1007/s11547-014-0389-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 10/28/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE This study was undertaken to collect information on the incidence and distribution of acute, non-traumatic conditions of the neck at our emergency radiology department and to review the literature about this topic. MATERIALS AND METHODS We retrospectively reviewed 143 consecutive patients who underwent neck computed tomography (CT) for non-traumatic emergencies between 1 December 2008 and 31 December 2012. For each of the conditions identified, we defined the overall incidence, the incidence based on the site, gender, average age and age range. RESULTS Computed tomography examination was positive in 125 out of 143 patients (87.4%), 74 men and 51 women, with an average age of 51.1 years, aged between 10 and 90 years. We found 79 inflammatory/infectious conditions (63.2% of positive cases, 55.2% of total cases), 46 men and 33 women, with an average age of 47 years. Computed tomography revealed 26 newly found tumours (20.8/18.2%), 19 men and 7 women, with an average age of 68.5 years, aged between 49 and 97 years. In 20 cases, 9 men and 11 women, with an average age of 57.3 years, aged between 21 and 90 years, we diagnosed other acute conditions: six cases of foreign body ingestion (4.8/4.2%), five benign swellings (4/3.5%), five cases of vascular disorders (4/3.5%), and four cases of oedema of the larynx (3.2/2.8 %). CONCLUSIONS Our study of emergency CT of non-traumatic conditions of the neck fundamentally revealed infectious/inflammatory diseases and newly found neoplasms.
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Chen Y, Yang Q, Wang T, Li J, Ye J, Liu X, Zhang G. [Application of enhanced CT in the differential diagnosis of peritonsillar abscess and intratonsillar abscess]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2014; 49:131-135. [PMID: 24742512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To explore the application of enhanced CT in the differential diagnosis and treatment of peritonsillar abscess (PTA) and intratonsillar abscess (ITA). METHODS Thirty-eight in-patients with clinically suspected PTA from June 2011 to June 2013 were included in this study. All these patients underwent enhanced CT scan for the throat region. According to CT results, the location of abscess was determined, and the thickness of the posterior wall of abscess as well as its distance with the internal carotid artery was calculated.Incision and drainage were then guided with this information. RESULTS Twenty-six of the 38 patients (68.4%) met the diagnosis of PTA, demonstrating a hypodense collection with rim enhancement in the peritonsillar space, including 4 cases with multilocular abscess. Ten cases (26.3%) should actually be diagnosed as ITA, with a abscess collection located in the palatine tonsil tissue. Two cases(5.3%) were diagnosed as peritonsillar cellulitis (PTC), showing diffuse isodense lesion around the peritonsillar space. The 26 cases of PTA and 10 cases of ITA patients were all cured using incision and drainage under the precise guidance of CT, while the 2 cases of PTC only treated with medicine. The mean distance between the posterior wall of abscess and the carotid artery (X(-) ± s) were (0.76 ± 0.34) cm and (0.90 ± 0.37) cm for the two entities respectively, with no significant difference (P > 0.05). CONCLUSIONS Enhanced CT scan can clearly demonstrate the characters of PTA and ITA, and make identification. Moreover, it is helpful for the determination of therapy, improving the success rate of drainage and reducing the potential risk of large artery injury.
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Affiliation(s)
- Yubin Chen
- Department of Otorhinolaryngology Head and Neck Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Qintai Yang
- Department of Otorhinolaryngology Head and Neck Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China.
| | - Tao Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Jingjia Li
- Department of Otorhinolaryngology Head and Neck Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Jin Ye
- Department of Otorhinolaryngology Head and Neck Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Xian Liu
- Department of Otorhinolaryngology Head and Neck Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Gehua Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
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Abstract
Ultrasound guidance has become the standard of care for many bedside procedures, owing to its portability, ease of use, and significant reduction in complications. This article serves as an introduction to the use of ultrasonography in several advanced procedures, including pericardiocentesis, thoracentesis, paracentesis, lumbar puncture, regional anesthesia, and peritonsillar abscess drainage.
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Affiliation(s)
- Nicholas Hatch
- Department of Emergency Medicine, Maricopa Medical Center, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA.
| | - Teresa S Wu
- EM Residency Program, Department of Emergency Medicine, Maricopa Medical Center, University of Arizona College of Medicine-Phoenix, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA
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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; 19:626-31. [PMID: 22687177 DOI: 10.1111/j.1553-2712.2012.01380.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Traditionally, emergency physicians (EPs) have used anatomic landmark-based needle aspiration to drain peritonsillar abscesses (PTAs). If this failed, an imaging study and/or consultation with another service to perform the drainage is obtained. Recently, some EPs have used ultrasound (US) to guide PTA drainage. This study seeks to determine which initial approach leads to greater successful drainage. The primary objective of this study was to compare the diagnostic accuracy of EPs for detecting PTA or peritonsillar cellulitis (PTC) using either intraoral US or initial needle aspiration after visual inspection (the landmark technique [LM]). Secondary objectives included the successful aspiration of purulent material in those patients with a PTA in each arm, the use of computed tomography (CT) scanning in each arm, and the otolaryngology (ENT) consultation rate in each arm. METHODS This was a prospective, randomized, controlled clinical trial of a convenience sample of adult patients who presented to a single, large, urban university hospital. Patients were enrolled if they presented with a constellation of signs and symptoms that were judged to be a PTA. These patients were randomized to receive intraoral US or to undergo LM drainage. The US was performed using an 8-5 MHz intracavitary transducer immediately prior to the procedure. The probe was then withdrawn and the provider who did the US also performed the needle aspiration. The LM was performed using visual landmarks in a superior to inferior approach until pus was obtained or at least two sticks were performed. Anesthesia was standardized. Patients returned for follow-up in 2 days where a final diagnosis was rendered. RESULTS There were 28 patients enrolled, with 14 in each arm. US established the correct diagnosis more often than LM [(100%, 95% confidence interval [CI] = 75% to 100% vs. 64%, 95% CI = 39% to 84%; p = 0.04)]. US also led to more successful aspiration of purulent material by the EP than LM in patients with PTA [(100%, 95% CI =63% to 100% vs. 50%, 95% CI = 24% to 76%; p = 0.04)]. The ENT consult rate was 7% (95% CI = 0% to 34%) for US versus 50% (95% CI = 27% to 73%) for LM (p = 0.03). The CT usage rate was 0% for US versus 35% for LM (p = 0.04). CONCLUSIONS An initial intraoral US performed by EPs can reliably diagnose PTC and PTA. Additionally, using intraoral US to assist in the drainage of PTAs with needle aspiration leads to greater success compared to the traditional method of LM relying on physical exam alone.
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Affiliation(s)
- Thomas G Costantino
- From the Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA
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20
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Rappaport A, Haven F, Peters C, Kessler R. Lemierre syndrome in a 19-year-old man with acute swollen neck. JBR-BTR 2008; 91:23. [PMID: 18447130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- A Rappaport
- Department of Radiology, Europaziekenhuizen-Cliniques de l'Europe, St. Elisabeth, Brussels, Belgium
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Affiliation(s)
- Joshua Nagler
- Department of Medicine, Children's Hospital Boston and Harvard Medical School, USA
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22
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Abstract
BACKGROUND Acute tonsillitis is an extremely common infection seen in children and adults. In most cases, the family doctor is initially consulted. Intratonsillar, peritonsillar and retrotonsillar abscesses are frequent complications in the course of tonsillitis. In those cases, oropharyngeal infection may lead to a descending process with consecutive mediastinitis as a life-threatening condition. PATIENTS AND METHODS We report the case of a 67-year old man who died of a mediastinitis resulting from a peritonsillar abscess. Clinical findings, radiological diagnostics and antibiotic as well as surgical therapy are illustrated. RESULTS The patient died due to a septic multi-organic failure despite aggressive antibiotic and surgical therapy by a combined enoral and cervical approach with thoracic drainage. DISCUSSION Peritonsillar abscess is a potentially life-threatening complication of acute tonsillitis. This must be kept in mind and should therefore lead to an adequate and directed management of this pathology. We discuss the stepwise diagnosis and therapy within the framework of scientific literature.
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Affiliation(s)
- S Kinzer
- Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde und Poliklinik, Universitätsklinikum Freiburg.
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23
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Edinger JT, Hilal EY, Dastur KJ. Bilateral peritonsillar abscesses: a challenging diagnosis. Ear Nose Throat J 2007; 86:162-3. [PMID: 17427778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
Peritonsillar abscess is the most common complication of acute tonsillitis. Bilateral peritonsillar abscesses are much less common, and they may be more difficult to detect on physical examination because the oropharynx often appears to be symmetrical rather than asymmetrical, as is the case in unilateral abscess. Previous steroid treatment may also complicate the diagnosis by masking the signs and symptoms of abscess. We describe the case of a young woman who presented to the emergency department with relatively mild symptoms despite having large bilateral peritonsillar abscesses. We believe that her symptoms had been masked by previous steroid therapy. We also review the treatment and microbiology of peritonsillar abscess.
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Affiliation(s)
- James T Edinger
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Mercy Hospital of Pittsburgh, PA, USA
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Abstract
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.
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Affiliation(s)
- Jeffrey P Simons
- Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, Pittsburgh, PA 15213, USA
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De Freitas RP, Fahy CP, Brooker DS, Primrose WJ, McManus KG, McGuigan JA, Hughes SJ. Descending necrotising mediastinitis: a safe treatment algorithm. Eur Arch Otorhinolaryngol 2006; 264:181-7. [PMID: 17009018 DOI: 10.1007/s00405-006-0174-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2006] [Accepted: 09/05/2006] [Indexed: 10/24/2022]
Abstract
Descending necrotising mediastinitis can complicate oropharyngeal infection and has a high associated mortality. We present three cases treated in our department and propose a treatment algorithm based on our experience and literature review. The primary oropharyngeal infection was peritonsillar abscess in two cases and odontogenic abscess in one. Two patients underwent cervicotomy and later thoracotomy. The third underwent cervicotomy with transcervical mediastinal drainage and later required pericardial drainage via a subxiphoid incision. All recovered fully and were discharged within 6 weeks. To enable successful treatment, diagnosis needs to be prompt and surgical drainage adequate. Thoracic management of the chest is essential.
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Affiliation(s)
- R P De Freitas
- Department of Otolaryngology and Head and Neck Surgery, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
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Abstract
A peritonsillar abscess is one of the most commonly occurring deep space infections of the head and neck in adults and children. A peritonsillar abscess that appears in newborns, however, is extremely rare. The treatment of a peritonsillar abscess requires both the selection of appropriate antibiotics and the best procedure to remove the abscessed material. We report a case of a peritonsillar abscess in a 40-day-old infant who was treated with antibiotic therapy alone.
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Affiliation(s)
- Soon Min Lee
- Department of Pediatrics and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
- The Brain Korea 21 Project for Medical Science, Seoul, Korea
| | - Byoung Chul Kwon
- Department of Pediatrics and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
- The Brain Korea 21 Project for Medical Science, Seoul, Korea
| | - Sung Yon Choi
- Department of Pediatrics and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
- The Brain Korea 21 Project for Medical Science, Seoul, Korea
| | - Myung Hyun Sohn
- Department of Pediatrics and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
- The Brain Korea 21 Project for Medical Science, Seoul, Korea
| | - Kyu-Earn Kim
- Department of Pediatrics and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
- The Brain Korea 21 Project for Medical Science, Seoul, Korea
| | - Choon Sik Yoon
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
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Araujo Filho BC, Sakae FA, Sennes LU, Imamura R, de Menezes MR. Intraoral and transcutaneous cervical ultrasound in the differential diagnosis of peritonsillar cellulitis and abscesses. Braz J Otorhinolaryngol 2006; 72:377-81. [PMID: 17119775 PMCID: PMC9443609 DOI: 10.1016/s1808-8694(15)30972-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2006] [Accepted: 04/03/2006] [Indexed: 11/28/2022] Open
Abstract
Aims The objective of the present study was to determine the specificity, sensitivity and accuracy of intraoral and transcutaneous ultrasound (US) in the diagnosis of peritonsillar cellulitis and abscess. Study Design Clinical-Prospective. Materials and Metods Thirty nine patients were seen at the otorhinolaryngology emergency department of the University Hospital, of the School of Medicine, University of São Paulo, with a clinical diagnosis of peritonsillar cellulitis or abscess. After initial evaluation, all patients were submitted to intraoral and transcutaneous US. Results Intraoral US was performed on 35 cases and its sensitivity was of 95.2%, the specificity was of 78.5% and the accuracy was of 86.9%. Transcutaneous US was feasible in all 39 patients and diagnosed peritonsillar abscess in 53.8%. There were 5 false-negatives and 1 false-positive result, sensitivity was 80%, specificity was 92.8% and accuracy was 84.5%. Conclusions Intraoral US was quite sensitive in the diagnosis of peritonsillar abscesses when performed by an experienced radiologist. Specificity was higher for transcutaneous US compared to intraoral US. However, when transcutaneous US was performed in patients with trismus, it was able to diagnose all peritonsillar abscesses, since they were large collections which are common in patients with trismus. These exams showed similar accuracy.
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Affiliation(s)
- Bernardo Cunha Araujo Filho
- University Hospital, Medical school of the University of São Paulo, Department of Otorhinolaryngology, Brazil.
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Abstract
PURPOSE OF REVIEW Peritonsillar abscess is a common problem, but some aspects of diagnosis and management remain controversial. We review the recent literature on peritonsillar abscess. RECENT FINDINGS Intraoral ultrasound can be a helpful diagnostic tool for peritonsillar abscess. For management, needle aspiration, incision and drainage, and quinsy tonsillectomy all yield successful results. Recent reviews have still not established that one treatment is consistently preferred. A randomized, placebo-controlled trail found that the use of intravenous steroids seems to reduce many symptoms, when used along with abscess drainage. SUMMARY The use of steroids may be beneficial in the treatment of peritonsillar abscess, and different techniques for abscess drainage are still used around the world, with consistently good results.
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Affiliation(s)
- Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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29
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Tuma J. [CME-Ultrasonography 3/Solution. Acute swallowing pain. Tonsillar abscess]. Praxis (Bern 1994) 2005; 94:353-355. [PMID: 15796465 DOI: 10.1024/0369-8394.94.9.353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- J Tuma
- Schweizerische Gesellschaft für Ultraschall in der Medizin, Uster
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30
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Abstract
BACKGROUND Infections of the deep neck spaces with accompanying mediastinitis are still a therapeutic problem with a high mortality. PATIENTS We report on three patients with deep neck space infections and accompanying mediastinitis who have been treated in the Departments of Otorhinolaryngology at the Universities of Bochum and Essen in the past 2 years. In two patients the infection originated from a peritonsillar abscess and in one patient from an odontogenic infection. THERAPY One patient was successfully treated by a tonsillectomy and drainage of the parapharyngeal abscess in conjunction with a thoracotomy because of a mediastinal abscess and bilateral pneumothorax. The second patient was cured by a tonsillectomy, wide cervical drainage und cervical mediastinotomy. The third patient with pre-existent alcohol abuse died because of multiorgan failure despite wide cervical und mediastinal drainage. CONCLUSION In every deep neck infection a mediastinal involvement has to be taken into account. Fast diagnosis and treatment are essential for the prognosis of this life-threatening disease.
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Affiliation(s)
- J Lautermann
- Klinik für Hals-Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie der Ruhr-Universität Bochum.
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Abstract
UNLABELLED Peritonsillar abscess (PTA) can be a life-threatening disease and may lead to significant complications without drainage. OBJECTIVES To describe the utility of ultrasound (US) in the evaluation of potential PTA and US-guided PTA drainage. METHODS The authors performed a retrospective US quality assurance review of all patients over 18 years of age scanned by emergency physicians for possible PTA. All patients presenting with PTA signs and symptoms including erythema and swelling of the tonsillar pillar and uvular deviation were eligible to be scanned. Patients confirmed to have an abscess on US had US-guided drainage followed by intravenous antibiotics in the emergency department and discharge home on oral antibiotics. Scans were performed by credentialed attending emergency physicians and residents. Researchers recorded patient symptoms, US findings, results of abscess drainage if performed, and any complications of drainage. All US examinations were performed with sheathed endocavity broadband US transducers on minimum depth and maximum resolution settings. Statistical analysis included descriptive statistics. RESULTS Forty-three patients received intraoral US examinations for suspected PTA. Thirty-five (81%) were diagnosed as having abscess on US. All abscesses were drained with an 18- or 14-gauge needle under US guidance. There were no drainage complications. There was one false positive with a focal area of edema yielding no pus on needle aspiration under direct US visualization. No patient returned unexpectedly after drainage. CONCLUSIONS These data suggest that intraoral US of suspected PTA allows for reliable diagnosis and safe and accurate abscess drainage.
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Affiliation(s)
- Matthew Lyon
- Department of Emergency Medicine, Medical College of Georgia, 1120 15th Street, AF-2056, Augusta, GA 30912-4007, USA
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López-Prieto MD, Guerrero-Fernández J, Ruiz I, Caravaca A. Niña con fiebre, tumefacción y procidencia velopalatina unilateral. Enferm Infecc Microbiol Clin 2004; 22:499-500. [PMID: 15482693 DOI: 10.1157/13066858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Yamada K, Hashimoto K, Tsubokawa T, Tashiro K, Ohmura S, Taniguchi T, Shibata K. Respiratory failure caused by massive pleural effusion in a patient with deep neck abscess. J Anesth 2004; 18:48-50. [PMID: 14991477 DOI: 10.1007/s00540-003-0207-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2003] [Accepted: 10/21/2003] [Indexed: 10/26/2022]
Affiliation(s)
- Keisuke Yamada
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, 920-8641, Kanazawa, Japan
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Affiliation(s)
- Matt Lyon
- Department of Emergency Medicine, Medical College of Georgia, Augusta, Georgia 30912-4007, USA
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35
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Abstract
The diagnosis of peritonsillar abscess (PTA) poses a challenge to emergency physicians (EPs). The decision to perform an invasive procedure with potential complications is based on clinical judgment that is often inaccurate. Although there is some mention of intraoral ultrasound in otolaryngology practice, there is none in the emergency medicine (EM) literature. However, this bedside emergency application of ultrasonography has the potential to be of considerable use in EM practice, and could allow EPs who previously deferred blind needle aspiration of a potential abscess to perform the procedure themselves. We report the cases of 6 patients who presented with probable PTA and were evaluated with intraoral ultrasound at the bedside by an EP. All 6 patients then underwent needle aspiration. As diagnosed on ultrasound, 3 of the patients had negative aspirations and were diagnosed with peritonsillar cellulitis. Three others were found to have PTA, with 2 requiring real-time ultrasound needle guidance to accomplish abscess drainage after multiple failures with the blind approach.
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Affiliation(s)
- Michael Blaivas
- Department of Emergency Medicine, Medical College of Georgia, Augusta, GA 30912, USA.
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Ishii K, Aramaki H, Arai Y, Uchimura K, Okabe K, Nishida M, Yoda K. [Evaluation of safe surgical treatment of peritonsillar abscess using computed tomography]. Nihon Jibiinkoka Gakkai Kaiho 2002; 105:249-56. [PMID: 11974881 DOI: 10.3950/jibiinkoka.105.249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
With the development of new antimicrobial agents, the incidence of peritonsillar abscess (PTA) is on the decline. PTA is still often encountered in general practice, however, where it requires immediate diagnosis and treatment. Because the internal carotid artery runs medially to the medial parapharyngeal space, damage to nearby vascular or other structures is a surgical risk of PTA. We used contrast computed tomography (CT) from PTA patients to investigate the anatomical relationship between the abscess and parapharyngeal space, and to determine safe surgical sites. We observed 31 patients with PTA--19 men and 12 women--between February 1997 and April 1999, all examined by contrast CT and undergoing drainage or incision. The average age was 30.7 years (range: 12-54 years). The abscess was on the right side in 20 cases and on the left side in 11. We determined the sites of the abscess and carotid artery, internal jugular vein, and surrounding soft tissue density area including nerves in the parapharyngeal space based on the angle and distance from recognizable anatomical structures in CT scans. The anterior margin of the parapharyngeal space was 29 +/- 5 mm posterior from the upper posterior alveolar margin. The medial margin of that space was at 15 +/- 2 degrees laterally from the midline of the incisors, and 24 +/- 4 mm laterally from the midline sagittal plane. The internal carotid artery was located medially to the parapharyngeal space, running on the sagittal plane containing the upper posterior alveolar margin. The distance from the anterior margin of the parapharyngeal space to the posterior wall of the PTA was 9 +/- 4 mm, and the distance to the anterior wall of the abscess (including the pharyngeal mucosa) was 31 +/- 5 cm. The relationship between the upper posterior alveolar margin and midline sagittal plane was useful for determining the site of the parapharyngeal space. Because the internal carotid artery is located on the same sagittal plane as the upper posterior alveolar margin, when conducting drainage or incision of PTA, we should advance sagittaLly from the point of incision to a depth of no more than 20 mm. If the tip of the instrument is kept medial to the sagittal plane of the upper posterior alveolar margin, effective treatment should be achievable without the risk of vascular damage.
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Affiliation(s)
- Kasumi Ishii
- Department of Otolaryngology, Tokyo Women's Medical University, Daini Hospital, Tokyo
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37
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Miziara ID, Koishi HU, Zonato AI, Valentini M, Miniti A, De Menezes MR. The use of ultrasound evaluation in the diagnosis of peritonsillar abscess. Rev Laryngol Otol Rhinol (Bord) 2002; 122:201-3. [PMID: 11799864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Peritonsillar Abscess (PTA) and Peritonsillar Cellulitis (PTC) are very similar clinical conditions. The differential diagnosis between them is made by needle aspiration, a very painful and invasive method. This study was performed at the Department of Otolaryngology at the Clinical Hospital of São Paulo University Medical School. It's aim was to evaluate the use of ultrasound as a noninvasive and inexpensive method of diagnosis, differentiating abscess from cellulitis. Twenty-one consecutive patients with a clinical diagnosis of peritonsillar infection were evaluated in the emergency service with a probable diagnosis of PTA. These patients were evaluated with intraoral and percutaneous ultrasound. Needle aspiration was used to compare and confirm the diagnosis. The sensitivity was 92.3% and specificity was 62.3%. The authors conclude that ultrasound is a good method to evaluate the differences between PTA and PTC.
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Affiliation(s)
- I D Miziara
- University of São Paulo Medical School, Department of Otolaryngology of Clinical Hospital, São Paulo SP, Brazil
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Abstract
Peritonsillar abscess, a complication of tonsillitis, is not uncommon. The usual treatment consists of needle aspiration or surgical drainage and antibiotic treatment. Tonsillectomy may be used in the management of this condition, either at the time of diagnosis or after an interval period. Severe complications of peritonsillar abscess are rare. Synergistic necrotizing cellulitis is a fulminant infection associated with spread along fascial plains, necrosis of connective tissue and muscle, and high mortality. It is usually otondogenic in origin in the cervicofacial area and occurs in debilitated or immune compromised patients. We discuss cervicofacial-necrotizing soft tissue disease and report an unusual case of extensive synergistic necrotizing cellulitis of the neck, chest, and shoulder as a result of a peritonsillar abscess.
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Affiliation(s)
- D Goldenberg
- Department of Otolaryngology-Head and Neck Surgery, Rambam Medical Center, Haifa, Israel
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Gonda RL, Gutierrez OH, Hengerer AS, De Weese JA. Pharyngeal abscess with external carotid artery erosion and pseudoaneurysm. A combined radiologic and surgical management. Pediatr Neurosurg 2001; 16:21-4. [PMID: 2133405 DOI: 10.1159/000120498] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- R L Gonda
- Department of Radiology, University of Rochester School of Medicine and Dentistry, Strong Memorial Hospital, N.Y
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Barroso Braojos G, Raboso García-Baquero E, Martínez Sanmillán J, Martínez Vidal A. [Peritonsillar abscess with parotid and peripharyngeal extension. Report of a case]. Acta Otorrinolaringol Esp 2000; 51:737-9. [PMID: 11270112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Peritonsillar abscess is the most frequent complication of a tonsillar infection. The purulent material can spread from peritonsillar space to the fascial neck spaces. These deep neck infections may be a life threatening complication. The correct treatment of these infections is an appropriate antimicrobial therapy and abscess drainage, most of the times by surgery. We present a clinical case of a large perypharyngeal, and parotid abscess originated from a peritonsillar abscess. It was necessary surgical treatment to drain it.
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Affiliation(s)
- G R Manecke
- Department of Anesthesiology, State University of New York at Stony Brook, 11794-8480, USA.
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Zirkin WM, Nadel ES, Brown DF. Recurrent pleuritic chest pain. J Emerg Med 1999; 17:329-32. [PMID: 10195495 DOI: 10.1016/s0736-4679(98)00196-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- W M Zirkin
- Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Scott PM, Loftus WK, Kew J, Ahuja A, Yue V, van Hasselt CA. Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. J Laryngol Otol 1999; 113:229-32. [PMID: 10435129 DOI: 10.1017/s0022215100143634] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Peritonsillar infections include cellulitis and abscess (quinsy). Clinical diagnosis is often supplemented by diagnostic drainage (aspiration or incision) in an effort to distinguish abscess from cellulitis. In a prospective study of 14 patients we have shown that clinical impression alone is unreliable (sensitivity 78 per cent, specificity 50 per cent). Computerized tomography (CT) (sensitivity 100 per cent, specificity 75 per cent) and intraoral ultrasound (sensitivity 89 per cent, specificity 100 per cent) are much more reliable. We propose that intraoral ultrasound could play a useful role in the clinical assessment of peritonsillar infections helping to improve accuracy in distinguishing abscesses from cellulitis.
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Affiliation(s)
- P M Scott
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T
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Abstract
The ultrasound appearances of peritonsillar abscesses (PTA) in 15 patients with clinically suspected peritonsillar infection were assessed using intra-oral sonography and computed tomography (CT). The ultrasonic appearances of an isoechoic rim with a hypoechoic centre were seen in the majority of cases, but a homogeneous isoechoic pattern was also recognized. The different ultrasonic appearances did not correlate with the number of symptomatic days. A central hypoechoic area with a surrounding isoechoic rim pattern was less likely if the volume of pus relative to the whole abscess was less than 10% on CT. Although the percentage of necrosis within the abscesses increased with time, the homogeneous isoechoic appearing abscesses, with less than 10% necrosis, did not fit in temporally and based on our findings it was not possible to predict the ultrasound appearances according to the duration of symptoms.
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Affiliation(s)
- J Kew
- Department of Diagnostic Radiology, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories
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Abstract
A retrospective review was conducted of 91 patients with deep neck infections to determine the pattern of clinical disease and formulate a management plan. The spaces involved, as determined by clinical, radiologic, and operative findings, were the peritonsillar space (72 patients), parapharyngeal space (eight patients) submandibular space (seven patients), retropharyngeal space (one patient) superficial space (one patient), anterior visceral space (one patient), and visceral vascular space (one patient). Of the 19 patients who did not have a peritonsillar space infection the origin of the infection was found in eight; four of these were odontogenic. Thirty-eight patients required surgical drainage of the abscess. Five patients underwent tracheotomy due to increasing dyspnea. One patient with diabetes mellitus and a past history of myocardial infarction died of unknown cause. All other patients had an uneventful recovery without major complications. The combination of early radiologic diagnosis, effective antimicrobial therapy, and intensive surgical management contributed to the good prognosis.
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Affiliation(s)
- M Sakaguchi
- Department of Otolaryngology, Shinshu University School of Medicine, Matsumoto, Japan
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Cannon CR, Lampton LM. Peritonsillar abscess following tonsillectomy. J Miss State Med Assoc 1996; 37:577-9. [PMID: 8709139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Peritonsillar abscess is an unusual complication following tonsillectomy. A series of five such patients is herein reported. Proper treatment begins with the initial tonsillectomy ensuring complete removal of the tonsils. Should a late peritonsillar abscess following tonsillectomy be found, the patient may be treated with needle aspiration of the affected area plus antibiotics. Removal of the remaining tonsillar tissue and surgical capsule of the tonsil is also advocated.
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Affiliation(s)
- C R Cannon
- Head and Neck Surgical Group, Jackson, MS 39296, USA
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Abstract
Peritonsillar cellulitis and peritonsillar abscess are similar clinical entities with markedly different methods of treatment. Therefore, accurate diagnosis is paramount to appropriate treatment. This pilot study was designed to evaluate the sensitivity and specificity of intraoral ultrasound as a noninvasive method of differentiating abscess from cellulitis. Sixteen consecutive patients suspected of having peritonsillar abscess were prospectively evaluated with intraoral ultrasound. The results were confirmed with imaging or surgical drainage. Correct diagnoses were made in 9 (90%) of 10 abscesses and in 5 (83%) of 6 cases of cellulitis. Our results suggest that, while there is a learning curve for intraoral ultrasound, it is an accurate, noninvasive, and inexpensive tool to differentiate abscess from cellulitis. We believe that this will be a clinically useful technique in the future.
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Affiliation(s)
- E B Strong
- Department of Otolaryngology, University of Utah, Salt Lake City 84132, USA
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Abstract
The differentiation of a peritonsillar abscess from peritonsillar cellulitis, although difficult on physical examination, is required in order to determine the appropriate treatment. Peritonsillar cellulitis can be treated with antibiotics alone, while a peritonsillar abscess should be drained. Computed tomography (CT) of the neck is often performed to identify the formation of a deep abscess in the neck, but is rarely used to diagnose peritonsillar infections. We report a patient in whom CT was a useful diagnostic tool for distinguishing peritonsillar abscess from peritonsillar cellulitis.
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Affiliation(s)
- M Sakaguchi
- Department of Otolaryngology, Shinshu University School of Medicine, Japan
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Abstract
Descending necrotising mediastinitis is a rare but serious complication of oropharyngeal infections with high mortality. Diagnosis is frequently delayed, contributing to this high mortality, but awareness of such a complication and early diagnosis using computed tomographic scanning leads to prompt surgical drainage, proper antibiotic therapy, and survival.
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Affiliation(s)
- H Alsoub
- Hamad Medical Corporation, Doha, Qatar
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Blokmanis A. Ultrasound in the diagnosis and management of peritonsillar abscesses. J Otolaryngol 1994; 23:260-2. [PMID: 7996625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This study was conducted to determine the possibility of using an intracavitary ultrasound probe to differentiate between peritonsillar cellulitis and peritonsillar abscesses. Three volunteers and 11 of 12 patients were successfully scanned. The ultrasound method successfully demonstrated four cases of peritonsillar cellulitis and seven cases of peritonsillar abscesses. We conclude that ultrasound is a simple, safe, and noninvasive method of both assessing unilateral tonsillar swelling and determining the presence or absence of peritonsillar abscess.
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Affiliation(s)
- A Blokmanis
- Department of Surgery, University of British Columbia, Vancouver
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