A 27 year old lady presenting with dysphagia, and with history of partially treated tonsillitis

A 27 year old lady presenting with dysphagia, and with history of partially treated tonsillitis

A 27-year-old lady presenting with dysphagia, and with history of partially treated tonsillitis

  • Enlarged and edematous left tonsil with fluid collection in the left tonsillar fossa and the left tonsillar
  • At the level of the oropharynx, there is significant luminal compromise. The collection and edema extend to involve the left para-laryngeal soft tissues and the left vocal cord.
  • Extension of fluid with mass effect into the left parapharyngeal space and along the left lateral wall of the oropharynx and hypopharynx up to the level of the cricoid.

DIAGNOSIS:

  • Left peritonsillar abscess (Quinsy) with extensive extension into the left parapharyngeal space. 

Discussion:

  • Patients often present to the emergency department with a wide variety of nontraumatic infectious, inflammatory, and neoplastic conditions of the head and neck.
  • Potentially life-threatening conditions include
    1. Oral cavity infections
    2. Tonsillitis and peritonsillar abscess
    3. Sialadenitis & parotiditis
    4. Thrombophlebitis
    5. Periorbital and orbital cellulitis 
    6. Infectious cervical lymphadenopathy.
    7. Less common conditions include epiglottitis, invasive fungal sinusitis, angioedema, and deep neck abscess
  • Modalities for diagnosis:
  • Ultrasound has low sensitivity for deep neck infections; however can be utilized in emergency setting.
  • CT is the first-line imaging modality in the emergency setting.
  • Magnetic resonance imaging plays an important secondary role due to superior soft-tissue contrast.
  • Routes of spread:
  • Tonsillitis suppurates and internally cavitates to create an intratonsillar abscess; however, a true tonsillar abscess is rare. 
  • The infection penetrates the tonsillar capsule and the peritonsillar space—a potential space between the tonsillar capsule and the superior constrictor muscle
  • The infection may then continue to extend into the parapharyngeal, masticator, or submandibular space. 
  • The resulting peritonsillar cellulitis resolves over several days; however, if it goes untreated, a peritonsillar abscess develops, typically along the superior tonsillar pole.

Imaging features 

  • Ultrasound features 
  • Mild hypoechoic collection is anteromedial to the internal carotid artery.
  • Probe pressure may elicit movement of the debris within the abscess
  • Color flow or power Doppler may demonstrate circumferential hyperemia.
  • CT features peritonsillar cellulitis 
  • Tonsillar enlargement 
  • Linear, striated enhancement of the palatine tonsils and posterior pharyngeal soft tissues 
  • Medial apposition of the enlarged tonsils resulting in a “kissing tonsils” appearance. 
  • Central liquefaction surrounding him like enhancement is diagnostic of peritonsillar abscess.
  • Fluid collection dissecting along multiple planes as in our case.

REFERENCES:

  1. Emergency Imaging Assessment of Acute, Nontraumatic Conditions of the Head and Neck Erin Frankie Capps, James J. Kinsella, Manu Gupta, Amol Madhav Bhatki, and Michael Jeffrey Opatowsky. RadioGraphics 2010 30:5, 1335-1352
  2. Ong YK, Goh YH, Lee YL. Peritonsillar infections: local experience. Singapore Med J. 2004;45 (3): 105-9. 

Dr. Sushant Mittal MD
Cross-sectional Fellow
Columbia Asia Radiology Group.

Dr Anita Nagadi MD, MRCPCH, FRCR
Senior Consultant Radiologist
Columbia Asia Radiology Group.