American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Technology advancements in the diagnosis and treatment of peritonsillar abscess
Abstract
A 17-year-old man with no significant medical history presented to the emergency department (ED) complaining of a 7-day history of worsening sore throat, fever to 101°F, odynophagia, and drooling. The patient’s symptoms were progressive despite treatment with antibiotics and steroids for pharyngitis. Significant findings on physical examination included bilateral tonsillar exudates, right-sided peritonsillar bulging with uvula deviation to the left, difficulty handling secretions, muffled voice, and severe trismus (Fig. 1). The diagnosis of peritonsilar abscess was suspected. A focused ultrasound examination was performed using the endocavitary probe.
This allowed confirmation of the suspected diagnosis and clear delineation of the location, depth, and extent of the peritonsillar abscess (Fig. 2). A complex abscess cavity was clearly visualized 2-cm deep with a “ring of fire” on color Doppler (Fig. 3). Because of the degree of trismus, dynamic ultrasound guidance was not possible. Instead, the abscess cavity was localized with ultrasound and video laryngoscopy (Glidescope, Bothell, WA) concurrently. The endocavitary probe was then removed. A needle attached to a syringe was put in its exact place, as the video laryngoscope remained within the oral cavity with constant visualization of the abscess. The laryngoscope then was used to dynamically aid in abscess drainage (Fig. 4). Using this technique, 7 mL of pus was removed from the peritonsillar abscess (Figs. 5 and 6). After the procedure, the patient was able to speak without a muffled voice, and he was able to eat a sandwich without pain before discharge from the ED. Follow-up was arranged with the patient’s otolaryngologist. Diagnosis: Peritonsillar abscess must be considered when a patient presents with progressive pharyngitis. Usually, some or all of the following signs are present: fever, severe unilateral throat pain, trismus, drooling, neck swelling, dysphagia, odynophagia, and muffled voice. Both computed tomography and ultrasound can be used to diagnose a peritonsillar abscess. Ultrasound can also be used to facilitate dynamic drainage.
Fig. 1. Patient’s maximum oral opening.
Fig. 2. The peritonsillar abscess was characterized using the endocavitary probe.
A 17 year-old man presented to the emergency department with signs and symptoms of a peritonsillar abscess. His trismus was so pronounced that it was too difficult to drain the abscess under dynamic ultrasound guidance. It was suggested that localization of the abscess with ultrasound be used concurrently with video laryngoscopy. The ultrasound was used to localize the abscess and visualize its depth. The laryngoscope was then used to visualize the exact spot, where the ultrasound probe characterized the abscess. The probe was then removed, and a needle attached to a syringe was used in its place. Drainage was facilitated using the video laryngoscope in the oral cavity. Seven milliliters of pus was removed, and the patient drastically improved after the procedure.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Gekle R, et al, Technology advancements in the diagnosis and treatment of peritonsillar abscess, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.017
2
R. Gekle et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Fig. 3. Color Doppler is used to visualize the “ring of fire” which signifies hyperemia. Fig. 5. The peritonsillar area was scanned with ultrasound to identify the largest portion of the abscess.
The patient is anesthetized with viscous or aerosolized lidocaine. The endocavitary or hockey stick probe is placed in a sterile sheath and directed over the area of fluctuance. A peritonsillar abscess is characterized by an anechoic or complex, irregularly shaped fluid collection with peripheral hyperemia (“ring of fire”). All abscesses should also demonstrate posterior acoustic enhancement. When a patient cannot open their mouth wide enough, video laryngoscopy can aid in direct visualization and dynamic drainage of the abscess.
Fig. 4. The video laryngoscope is used to drain the PTA using a needle inserted in the location just previously identified by ultrasound.
Robert Gekle MD Christopher Raio MD Max Falkoff MD Jenna Neufeldt MD North Shore University Hospital Dept. of Emergency Medicine, Manhasset, NY http://dx.doi.org/10.1016/j.ajem.2014.03.017
Fig. 6. Aspiration of pus was successful.
Please cite this article as: Gekle R, et al, Technology advancements in the diagnosis and treatment of peritonsillar abscess, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.017
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Technology advancements in the diagnosis and treatment of peritonsillar abscess
Abstract
A 17-year-old man with no significant medical history presented to the emergency department (ED) complaining of a 7-day history of worsening sore throat, fever to 101°F, odynophagia, and drooling. The patient’s symptoms were progressive despite treatment with antibiotics and steroids for pharyngitis. Significant findings on physical examination included bilateral tonsillar exudates, right-sided peritonsillar bulging with uvula deviation to the left, difficulty handling secretions, muffled voice, and severe trismus (Fig. 1). The diagnosis of peritonsilar abscess was suspected. A focused ultrasound examination was performed using the endocavitary probe.
This allowed confirmation of the suspected diagnosis and clear delineation of the location, depth, and extent of the peritonsillar abscess (Fig. 2). A complex abscess cavity was clearly visualized 2-cm deep with a “ring of fire” on color Doppler (Fig. 3). Because of the degree of trismus, dynamic ultrasound guidance was not possible. Instead, the abscess cavity was localized with ultrasound and video laryngoscopy (Glidescope, Bothell, WA) concurrently. The endocavitary probe was then removed. A needle attached to a syringe was put in its exact place, as the video laryngoscope remained within the oral cavity with constant visualization of the abscess. The laryngoscope then was used to dynamically aid in abscess drainage (Fig. 4). Using this technique, 7 mL of pus was removed from the peritonsillar abscess (Figs. 5 and 6). After the procedure, the patient was able to speak without a muffled voice, and he was able to eat a sandwich without pain before discharge from the ED. Follow-up was arranged with the patient’s otolaryngologist. Diagnosis: Peritonsillar abscess must be considered when a patient presents with progressive pharyngitis. Usually, some or all of the following signs are present: fever, severe unilateral throat pain, trismus, drooling, neck swelling, dysphagia, odynophagia, and muffled voice. Both computed tomography and ultrasound can be used to diagnose a peritonsillar abscess. Ultrasound can also be used to facilitate dynamic drainage.
Fig. 1. Patient’s maximum oral opening.
Fig. 2. The peritonsillar abscess was characterized using the endocavitary probe.
A 17 year-old man presented to the emergency department with signs and symptoms of a peritonsillar abscess. His trismus was so pronounced that it was too difficult to drain the abscess under dynamic ultrasound guidance. It was suggested that localization of the abscess with ultrasound be used concurrently with video laryngoscopy. The ultrasound was used to localize the abscess and visualize its depth. The laryngoscope was then used to visualize the exact spot, where the ultrasound probe characterized the abscess. The probe was then removed, and a needle attached to a syringe was used in its place. Drainage was facilitated using the video laryngoscope in the oral cavity. Seven milliliters of pus was removed, and the patient drastically improved after the procedure.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Gekle R, et al, Technology advancements in the diagnosis and treatment of peritonsillar abscess, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.017
2
R. Gekle et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Fig. 3. Color Doppler is used to visualize the “ring of fire” which signifies hyperemia. Fig. 5. The peritonsillar area was scanned with ultrasound to identify the largest portion of the abscess.
The patient is anesthetized with viscous or aerosolized lidocaine. The endocavitary or hockey stick probe is placed in a sterile sheath and directed over the area of fluctuance. A peritonsillar abscess is characterized by an anechoic or complex, irregularly shaped fluid collection with peripheral hyperemia (“ring of fire”). All abscesses should also demonstrate posterior acoustic enhancement. When a patient cannot open their mouth wide enough, video laryngoscopy can aid in direct visualization and dynamic drainage of the abscess.
Fig. 4. The video laryngoscope is used to drain the PTA using a needle inserted in the location just previously identified by ultrasound.
Robert Gekle MD Christopher Raio MD Max Falkoff MD Jenna Neufeldt MD North Shore University Hospital Dept. of Emergency Medicine, Manhasset, NY http://dx.doi.org/10.1016/j.ajem.2014.03.017
Fig. 6. Aspiration of pus was successful.
Please cite this article as: Gekle R, et al, Technology advancements in the diagnosis and treatment of peritonsillar abscess, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.017
