Bilateral peritonsillar abscess: Case report and presentation of its clinical appearance.

Abstract

Although there is no consensus on its incidence, bilateral peritonsillar abscess is an unusual variant of an otherwise relatively common otolaryngologic disease. A bilateral peritonsillar abscess can be differentiated from other oropharyngeal pathology with a detailed physical examination and complementary imaging. Its diagnosis should always be considered in patients who have signs and symptoms that are suggestive of peritonsillar abscess but whose intraoral examination yields atypical findings, as well as in patients with marked distress or trismus. This article describes the case of a young man who came to the emergency room with bilateral peritonsillar abscess. The author believes that this report contains the only published photograph of the intraoral appearance of this condition.

Introduction

Peritonsillar abscess is typically characterized by trismus, odynophagia, "hot potato" voice, edema and erythema of the superior peritonsillar tissues, and a soft palate deviation away from the infected side. Atypical presentations include inferior-pole and bilateral abscesses.

In this article, the author describes the case of a young man with bilateral peritonsillar abscess and presents visual documentation of its clinical appearance (figure 1). After reviewing the literature published since January 1965, the author has concluded that this is the first photograph of the clinical appearance of bilateral peritonsillar abscess to be published.

Case report

A 23-year-old Hispanic man came to the emergency room with a 3-day history of worsening odynophagia, difficulty swallowing solids, and subjective fever. On physical examination, the patient appeared to be moderately ill. He had a fever of 100.7 [degrees] F, but no trismus or signs or symptoms of upper airway obstruction. Intraoral examination revealed a diffusely erythematous soft palate and uvula with prominent swelling and midline protrusion (figure 1).

Laboratory tests revealed a white blood cell count of 18,800/[mm.sup.3], no monocytosis, and normal electrolytes. In response to the unusual findings on the intraoral inspection, contrast-enhanced computed tomography (CT) of the neck was performed. CT confirmed the presence of bilateral superior-pole peritonsillar abscesses (figure 2).

The patient was treated in the emergency room with a bilateral incision, drainage, and extrusion of approximately 4 ml of pus from each side. Following treatment, the patient experienced a marked alleviation of his odynophagia, and he was able to take liquids and solids by mouth. He was discharged on a 10-day course of clindamycin. A followup intraoral examination 1 week later showed a well-resolved infection and normal mucosa.

Discussion

Peritonsillar abscess has been described since the time of Hippocrates. The 14th-century French surgeon Guy de Chauliac is often cited as the first to describe its treatment by incision and drainage. [1] The term quinsy, from the Latin quinancia, dates back to medieval times. It originally referred to all sore throats, but later came to be synonymous with peritonsillar abscess.

The reported incidence of peritonsillar abscess varies in the literature, but recent reviews suggest that it affects approximately 30 persons per 100,000 population and accounts for 45,000 new cases each year. [2] Reports in the literature of the incidence of bilateral abscesses are quite varied and range from 0 to 24%. [3] The larger percentage includes cases where an unsuspected contralateral abscess was discovered during quinsy tonsillectomy. [3]

The intraoral appearance of a bilateral peritonsillar abscess lacks the classic asymmetry and uvula deviation that are the hallmarks of a unilateral abscess. A bilateral abscess can be confused with other conditions. For example, lymphoma of the tonsils can appear bilaterally and be marked by large and bulky tonsils and a relatively brief history of symptoms; imaging can help confirm this diagnosis. Infiltrating carcinomas of the soft palate or uvula can have a similar appearance, although they would normally be more insidious and manifest as ulcerative defects of the soft palate. Minor salivary gland tumors (e.g., pleomorphic adenomas) can occur in the soft palate and have a similar appearance, but they usually do not feature the symmetry and inflammation that were seen in this patient. Finally, the intraoral appearance of severe acute tonsillitis or infectious mononucleosis can be quite similar to that of bilateral peritonsillar abscess, and these conditions should be differentiated by imaging studies when the diagnosis is unclear.

Some authors have suggested that patients with bilateral peritonsillar abscess initially appear in distress, in poor condition, and with trismus. [4] However, our patient did not exhibit any marked distress and he displayed no trismus. Other authors have found bilateral peritonsillar abscess only incidentally during a quinsy tonsillectomy, and they report that it did not contribute to the patient's physical appearance at the initial presentation. [3] Finally, there are unpublished claims that bilateral peritonsillar abscess might be associated with the presence of human immunodeficiency virus (HIV). Our patient declined to undergo HIV testing, stating that he had no risk factors.

From the Department of Otolaryngology, Jackson Memorial Hospital, Miami, Fla.

References

(1.) Richardson KA, Birck H. Peritonsillar abscess in the pediatric population. Otolaryngol Head Neck Surg 1981;89:907-9.

(2.) Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: Incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995;105(Suppl 74):1-17.

(3.) Dalton RE, Abedi E, Sismanis A. Bilateral peritonsillar abscesses and quinsy tonsillectomy. J Natl Med Assoc 1985;77:807-12.

(4.) Kristensen S, Juul A, Nielsen F. Quinsy: A bilateral presentation. J Laryngol Otol 1985;99:401-2.