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 extends 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.


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


  • 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.


  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.