Inferior pole peritonsillar abscess

Tzu Chi Med J 2006 � 18 � No. 4 OUT

Inferior Pole Peritonsillar Abscess Successfully Treated with

Non-Surgical Approach in Four Cases

Wang-Yu Su, Wei-Chung Hsu1, Cheng-Ping Wang

1

Department of Otolaryngology, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan; Department of Otolaryngology1,

National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan

ABSTRACTInferior pole peritonsillar abscess is uncommon and easily overlooked because it has no obvious physical appearance and there is alow index of suspicion by clinicians. In this report, we present four patients with inferior pole peritonsillar abscess who all hadsevere symptoms (fever, sore throat, muffled voice, trismus and painful neck) but had no obvious distortion of the peritonsillarstructure. Careful oropharyngeal examination and a high index of suspicion are critical to make the diagnosis at an early diseasestage, when the abscess can be treated with antibiotics without immediate tonsillectomy. This treatment strategy can be used if apatient is immunocompetent and the initial treatment response is good. (Tzu Chi Med J 2006; 18:287-290)

Key words: antibiotics, deep neck infection, inferior pole, peritonsillar abscess

Received: October 14, 2005, Revised: November 1, 2005, Accepted: November 30, 2005Address reprint requests and correspondence to: Dr. Cheng-Ping Wang, Department of Otolaryngology, National TaiwanUniversity Hospital, 7, Chung Shan South Road, Taipei, Taiwan

CASE REPORT

INTRODUCTION

Peritonsillar abscess is an acute tonsillar infectionwith abscess formation in the peritonsillar space, whichis located between the tonsil bed and the tonsillar capsule.Superior pole peritonsillar abscess, which develops inthe superior part of the peritonsillar space, is notuncommon, but inferior pole peritonsillar abscess, whichis located in the inferior peritonsillar space, is rare andeasily overlooked in clinical practice [1-4]. Superior poleperitonsillar abscess is usually treated with repeated as-piration or simple incisional drainage of the pus withoutthe need for tonsillectomy. However, inferior pole peri-tonsillar abscess is always treated with immediate ton-sillectomy because this infection is much more severeand needle aspiration/incision is technically difficult tobe performed [4]. But if inferior pole peritonsillar ab-scess is diagnosed at the early stage, it may be treatedusing a non-surgical approach. In this paper, the authorsreport the clinical manifestations in four patients with

inferior pole peritonsillar abscess who were successfullytreated with medical management instead of immediatetonsillectomy.

CASE REPORTS

Case 1A 40-year-old man without systemic disease vis-

ited a hospital with a one-week history of fever, pro-gressive sore throat, dysphagia, left neck pain andmuffled voice despite taking oral antibiotics prescribedby a doctor. On examination, his left tonsil and anteriorpillar were slightly injected without exudates or uvuladeviation. Laryngoscopy revealed mild asymmetricswelling at the inferior pole of the left tonsil. The epi-glottis and hypopharynx appeared normal. The retro-mandibular area on the left side of the neck was tenderand swollen. The blood leukocyte count was 12290/µLwith left shifting. The serum C-reactive protein levelwas 6.69 mg/dL. A computed tomography (CT) scan of

W. Y. Su, W. C. Hsu, C. P. Wang

Tzu Chi Med J 2006 � 18 � No. 4OUU

the neck revealed an abscess in the inferior part of theleft peritonsillar fossa (Fig. 1A). He received parenteralantibiotics with ampicillin plus sulbactam, and his symp-toms dramatically subsided within 24 hours. Therefore,he did not receive surgical drainage. After administra-tion of parenteral antibiotics for four days, he was dis-charged and remained well without any sequelae for 42months.

Case 2A 15-year-old girl suffered from severe sore throat

and progressive dysphagia with persistent fever for oneweek despite taking oral antibiotics and analgesics. Onadmission, significantly muffled voice, trismus of one-

finger width and painful swelling in the left upper sideof the neck were noted. The uvula and soft palate ap-peared normal without deviation. The left tonsil wasslightly reddened. Laryngoscopy revealed a large bulgein the lower pole of the left tonsil. The larynx and hy-popharynx appeared normal. A CT scan of the neck re-vealed a large abscess in the lower part of the tonsil anda hazy appearance in the parapharyngeal space (Fig. 1B).She received parenteral antibiotics with ampicillin andsulbactam. She felt much better and the swelling in thelower pole of the left tonsil rapidly regressed within 48hours. She continued to receive parenteral antibioticsfor one week, and did not have tonsillectomy. The pa-tient was well without recurrence during a 34 month

Fig. 1. Axial computed tomography (CT) scan of the neck with contrast enhancement. (A) Case 1: CT of the neck reveals a smallhypodense lesion in the lower part of the left peritonsillar space with inflammatory changes in the ipsilateral tonsil. (B)Case 2: CT of the neck shows a large hypodense lesion with heterogeneous content occupying the lower part of the lefttonsil. (C) Case 3: CT of the neck reveals a hypodense lesion in the lower posterior part of the right peritonsillar space. (D)Case 4: CT of the neck reveals a small hypodense lesion in the lower part of the left peritonsillar space with inflammatorychanges around it.

A B

C D

Inferior pole peritonsillar abscess

Tzu Chi Med J 2006 � 18 � No. 4 OUV

follow-up period.

Case 3A 43-year-old man without systemic disease vis-

ited the hospital with a 5-day history of progressive sorethroat, dysphagia, right neck pain and muffled voice.On examination, the right tonsil was injected withoutexudate coating or uvula deviation. Laryngoscopy re-vealed an obvious swollen bulge in the lateral pharyn-geal wall at the inferior pole of the right tonsil. The epi-glottis and hypopharynx appeared normal. The bloodleukocyte count was 18180/µL with neutrophilspredominant. The serum C-reactive protein level was2.77 mg/dL. A CT scan of the neck revealed an abscessconfined within the inferior part of the right peritonsil-lar space (Fig. 1C). A bacterial culture of the blood grewstreptococcus pneumoniae. He received parenteral anti-biotics with ampicillin and sulbactam. The symptomsdramatically improved within 24 hours. After admini-stration of parenteral antibiotics for five days, he wasdischarged and remained well during a 2-year follow-up period.

Case 4A 20-year-old woman had a high fever and severe

sore throat for 4 days and was treated with oral antibiot-ics under the diagnosis of acute tonsillitis. However thesymptoms worsened and muffled voice and trismusdeveloped. On admission, physical examination revealedswelling of the lateral pharyngeal wall at the inferiorpole of the left tonsil without pus on the tonsillar sur-face or uvula deviation. The epiglottis and hypophar-ynx appeared normal. The blood leukocyte count was15970 /µL with neutrophils predominant. The serum C-reactive protein level was 7.11 mg/dL. A CT scan of theneck revealed an abscess in the inferior part of the leftperitonsillar space with parapharygneal space involve-ment (Fig. 1D). A bacterial culture of the blood grewstreptococcus pneumoniae. She received parenteral an-tibiotics with ampicillin plus sulbactam. The symptomsrapidly improved within 48 hours. After administrationof parenteral antibiotics for seven days, she was dis-charged and remained well during the 2-year follow-upperiod.

DISCUSSION

Peritonsillar abscess, one of the most common deepneck infections, is usually characterized by pus accu-mulation in the superior part of the unilateral periton-sillar space which can cause medial and downward dis-

placement of the tonsil and the soft palate, with anedematous uvula deviated to the opposite site. Therefore,superior pole peritonsillar abscess is easily recognizedon physical examination and can be successfully treatedwith prompt and adequate management. Peritonsillarabscess also develops in the lower part of the peritonsil-lar space, which is separated from the superior part bythe triangular ligament. But, the clinical incidence ofinferior pole peritonsillar abscess is much lower thanthat of superior pole abscess [1-4]. The etiology of thisphenomenon remains unknown. One possible reason isthat Weber's glands, the origin of peritonsillar abscess,are mainly located within the superior pole [2]. Inaddition, an inferior pole peritonsillar abscess quicklyspreads into the adjacent tissue, such as theparapharyngeal space, because the inferior peritonsillarspace is smaller and the constrictor musculature in thisarea is less resistant [3,4], and thus may be present withother more extensive neck infections clinically.Importantly, inferior pole peritonsillar abscess onlycauses erythematous changes in the affected tonsil with-out the obvious distortion of the oropharyngeal struc-ture seen in superior pole abscess [4]. Therefore, infe-rior pole peritonsillar abscess is easily overlooked andoften misdiagnosed as acute tonsillitis.

Familiarity with the clinical presentation of infe-rior pole peritonsillar abscess is the key to making thecorrect diagnosis at an early stage. Although inferior poleperitonsillar abscess causes only mild bulging of thelateral pharyngeal wall at the inferior pole of the tonsil,reports in the literature and the case reports of these 4patients [2,4] show that it always presents with fever,severe sore throat, dysphagia, trismus, muffled voice andpainful swelling in the upper neck. These synptoms areall actually indicative of severe infection and should alertthe clinician that this abscess, not simple pharyngoton-sillitis, is the correct diagnosis. Therefore, if a patienthas these symptoms without obvious changes in the peri-tonsillar structure, careful examination by a laryngoscopewith a high index of suspicion is critical to diagnoseinferior pole peritonsillar abscess. If no definitive im-pression is revealed by physical examination, computedtomography is useful for detection of an abscess in thisspace and for evaluation of the extent of infection [4,5].

Needle aspiration or incision and drainage with alocal anesthetic is the mainstay of management for su-perior pole peritonsillar abscess [6]. Immediate tonsil-lectomy is reserved for specific situations, such as anuncooperative child, bilateral peritonsillar abscess, ex-tension of a severe infection, or immunocompromisedstatus with no treatment response to antibiotics [1,6-8].Inferior pole peritonsillar abscess is another indication

W. Y. Su, W. C. Hsu, C. P. Wang

Tzu Chi Med J 2006 � 18 � No. 4OVM

for immediate tonsillectomy because needle aspirationor incision with a local anesthetic is technically difficultwhen draining an abscess below the tonsil [1,3]. But asseen in our 4 patients, it is possible to successfully treatinferior pole peritonsillar abscess with parenteral anti-biotics and close observation without immediatetonsillectomy. Our 4 patients were all under 43 yearsold and immunocompetent, and had no significant sys-temic diseases. Therefore, if a younger patient is immu-nocompetent and the treatment response with antibiot-ics is good during the first 48 hours, parenteral antibiot-ics with close observation can be used as the treatmentfor inferior pole peritonsillar abscess. Immediate tonsil-lectomy with drainage of the abscess may be reservedfor patients with an immunocompromised status, a poorresponse to antibiotics, or a life-threatening condition.From the follow-up experience with these 4 patients,the recurrence rate of inferior pole peritonsillar abscesswithout immediate tonsillectomy seems to be low, al-though the follow-up period was not long. Interval ton-sillectomy may be reserved for patients with repeatedinfections.

CONCLUSION

Inferior pole peritonsillar abscess is easily over-looked because it does not have the obvious physicalappearance of superior pole peritonsillar abscess. If apatient suffers from severe odynophagia, trismus,muffled voice and painful swelling in the upper neckbut has no significant changes in the peritonsillar

structure, careful examination with a laryngoscope anda high index of suspicion are critical to making the cor-rect diagnosis. Adequate antibiotic treatment withouttonsillectomy may be the treatment choice if a patient isyoung, immunocompetent, and has no significant sys-temic diseases and the initial treatment response is good.

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3. Stage J, Bonding P: Peritonsillar abscess withparapharyngeal involvement: Incidence and treatment.Clin Otolaryngol 1987; 12:1-5.

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