Bilateral peritonsillar abscesses: a challenging diagnosis.

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.

Introduction

Peritonsillar abscesses are collections of purulent material that develop outside the tonsillar capsule near the superior pole. They represent the most common complication of acute tonsillitis; approximately 45,000 cases occur annually in the United States and Puerto Rico, and there is a 2:1 male preponderance. (1)

Peritonsillar abscess is believed to be part of a disease continuum that progresses from acute tonsillitis to peritonsillar cellulitis and finally to peritonsillar abscess. The most common symptoms at presentation are sore throat and odynophagia (usually unilateral), dysphagia, otalgia, trismus, oral drooling, and high fever. (2)

Treatment of peritonsillar abscess remains controversial. The options include needle aspiration, incision and drain-age, quinsy tonsillectomy, antibiotics, and possibly steroid therapy. Early diagnosis and drainage of the abscess are important to prevent rupture and spread of the infection, either superiorly to the skull base or inferiorly into the mediastinum.

In this article, we describe the case of a patient with bilateral peritonsillar abscesses, a condition that is much less common than unilateral abscess.

Case report

A 24-year-old woman presented to the emergency department of Mercy Hospital of Pittsburgh with a 6-day history of sore throat. She had initially gone to another hospital, where she was diagnosed with strep throat and given a dose of penicillin. Three days later, she returned to the same hospital for treatment of increased pain and dysphagia. When symptoms persisted the next day, she presented to our institution.

At our emergency department, she was treated with narcotics and prescribed oral prednisone at 60 mg/day. After 3 days of steroid therapy she returned, complaining of increased pain, decreased oral intake, and a feeling of airway obstruction while supine. Her pain radiated to both ears. She denied fever and chills. Her history included recurrent episodes of sore throat in the past--approximately twice per year--but those episodes were much less severe. She was a nonsmoker, and she took no other medications. She had no other comorbid medical conditions other than exogenous obesity.

On physical examination in our emergency department, the patient was afebrile and her vital signs were normal. She was 160 cm (5 ft, 4 in) tall and weighed 119 kg (262 lbs). She exhibited no respiratory distress, trismus, or drooling. Her tonsils were enlarged, hyperemic, and symmetrical, and no exudate was seen. Her uvula was in the midline, and her oropharynx was crowded but patent. Tender upper cervical lymphadenopathy was present bilaterally. Findings on the remainder of her physical examination were within normal limits. Laboratory studies revealed a white blood cell count of 12.5/[mm.sup.3] and a neutrophil level of 72.5%. A test for mononucleosis was negative. Computed tomography (CT) of the neck detected large, bilateral peritonsillar abscesses (figure). She was treated with intravenous ampicillin/sulbactam and IV dexamethasone and admitted to the hospital.

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The patient was subsequently taken to the operating room, where she underwent incision and drainage and quinsy tonsillectomy. Foul-smelling pus was drained from both abscesses and sent for aerobic and anaerobic cultures and determination of sensitivities. The aerobic culture grew few alpha-hemolytic streptococci, occasional beta-hemolytic streptococci (not group A or B), rare Staphylococcus aureus, and rare Candida albicans. The anaerobic culture grew few beta-lactamase--positive Prevotella melaninogenica and few other beta-lactamase--positive, anaerobic, gram-negative rods. No penicillin-resistant organisms were isolated.

The patient's postoperative course was uneventful, and she was discharged home the following day on oral penicillin and oral analgesics.

Discussion

While the exact incidence of bilateral peritonsillar abscesses is not known, we know that they are much less common than unilateral abscesses. Kanesada and Mogi reported an overall incidence of 4.9%; in many of those cases, the bilaterality was not discovered until surgery. (3) In our patient, the bilaterality was diagnosed by CT prior to surgery.

Performing quinsy tonsillectomy on our patient relieved the airway obstruction and greatly reduced the chance of recurrent infection. It has been reported that needle aspiration, incision and drainage, and quinsy tonsillectomy are all highly effective for treating unilateral abscess and that recurrence rates following these procedures are low. (4) Because bilateral peritonsillar abscesses have been shown to cause sleep apnea and upper airway obstruction, (5) it is likely that affected patients will benefit most from immediate tonsillectomy.

Reports in the literature neither support nor refute the use of steroids in peritonsillar abscess. (4) Also, it has been written that patients with bilateral peritonsillar abscesses present in distress, in poor condition, and with trismus. (6) It is interesting that our patient presented without significant distress or trismus despite having large abscesses. Steroid treatment had been given to her for several days prior to the diagnosis of her abscesses. While treatment with steroids increases patient comfort by decreasing inflammation, it is possible that early steroid treatment will mask the signs and symptoms of abscess and therefore delay diagnosis and treatment.

The vast majority of peritonsillar abscesses harbor multiple organisms. In a detailed bacteriologic study of peritonsillar abscess, Jousimies-Somer et al found aerobic organisms in approximately 86% of cases and anaerobic organisms in approximately 82%. (7) The most common aerobic and facultative anaerobic organisms isolated were Streptococcus pyogenes (~45%), Streptococcus milleri (~26%), Haemophilus influenzae (~10%), and viridans group streptococci (~10%). Fusobacterium necrophorum and P melaninogenica were the most common anaerobic organisms isolated (~38% each). A maximum of 12 and a mean of 4.4 organisms per specimen were isolated.

In a study of peritonsillar abscess aspirates in the outpatient setting, Cherukuri and Benninger found Streptococcus spp in approximately 74% of aspirates, Haemophilus spp in approximately 27%, Neisseria spp in 12%, and Staphylococcus spp in 10%. (8) They concluded that routine culturing of aspirates is not necessary and does not affect clinical management or outcome in outpatients with peritonsillar abscess.

In a study of hospitalized patients who had undergone incision and drainage, Kieff et al reported that IV penicillin was as effective as broad-spectrum antibiotics despite the fact that most peritonsillar abscesses are polymicrobial and may contain penicillin-resistant organisms. (9)

Based on the published evidence, we felt that quinsy tonsillectomy and antibiotic treatment with penicillin were adequate and appropriate therapy for our patient, whose abscesses had caused some mild upper airway symptoms. The steroid treatment that our patient had received might have masked the signs and symptoms of her abscesses and, consequently, the clinical examination was not as useful as CT in making the diagnosis. Moreover, the fact that she had bilateral abscesses further complicated the clinical picture because her tonsils appeared to be symmetrical on physical examination. Therefore, it is important to keep peritonsillar abscess in mind even if the clinical picture is not entirely suggestive, especially in the face of previous steroid therapy.

References

(1.) Herzon FS, Harris P. Mosher Award thesis. Peritonsillar abscess: Incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995; 105 (8 pt 3 suppl 74):1-17.

(2.) Kessler A, Lapinsky J, Segal S, Berkovitch M. Bilateral peritonsillar abscesses: Relief of upper airway obstruction by quinsy tonsillectomy. Isr Med Assoc J 2003;5:126-7.

(3.) Kanesada K, Mogi G. Bilateral peritonsillar abscesses. Auris Nasus Larynx 1981;8:35-9.

(4.) Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg 2003;128:332-43.

(5.) Lau SK. Sleep apnoea due to bilateral peritonsillar abscess. J Laryngol Otol 1987;101:617-18.

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

(7.) Jousimies-Somer H, Savolainen S, Makitie A, Ylikoski J. Bacteriologic findings in peritonsillar abscesses in young adults. Clin Infect Dis 1993;16(suppl 4):S292-8.

(8.) Cherukuri S, Benninger MS. Use of bacteriologic studies in the outpatient management of peritonsillar abscess. Laryngoscope 2002;112:18-20.

(9.) Kieff DA, Bhattacharyya N, Siegel NS, Salman SD. Selection of antibiotics after incision and drainage of peritonsillar abscesses. Otolaryngol Head Neck Surg 1999;120:57-61.

James T. Edinger, MD; Elias Y. Hilal, MD; Khurshed J. Dastur, MD

From the Division of Otolaryngology--Head and Neck Surgery. Department of Surgery, Mercy Hospital of Pittsburgh.

Reprint requests: Elias Y. Hilal, MD. 1350 Locust St.. Suite 309. Pittsburgh, PA 15219. Phone: [phone]; fax: [phone]; e-mail: [e-mail]