American Journal of Emergency Medicine xxx (2014) xxx–xxx

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American Journal of Emergency Medicine

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Case Report

Technology advancements in the diagnosis and treatment ofperitonsillar abscess

Abstract

A 17 year-old man presented to the emergency department withsigns and symptoms of a peritonsillar abscess. His trismus was sopronounced that it was too difficult to drain the abscess underdynamic ultrasound guidance. It was suggested that localization of theabscess with ultrasound be used concurrently with video laryngos-copy. The ultrasound was used to localize the abscess and visualize itsdepth. The laryngoscope was then used to visualize the exact spot,where the ultrasound probe characterized the abscess. The probe wasthen removed, and a needle attached to a syringewas used in its place.Drainage was facilitated using the video laryngoscope in the oralcavity. Seven milliliters of pus was removed, and the patientdrastically improved after the procedure.

A 17-year-old man with no significant medical history presentedto the emergency department (ED) complaining of a 7-day history ofworsening sore throat, fever to 101°F, odynophagia, and drooling. Thepatient’s symptoms were progressive despite treatment with antibi-otics and steroids for pharyngitis.

Significant findings on physical examination included bilateraltonsillar exudates, right-sided peritonsillar bulging with uvuladeviation to the left, difficulty handling secretions, muffled voice,and severe trismus (Fig. 1).

The diagnosis of peritonsilar abscess was suspected. A focusedultrasound examination was performed using the endocavitary probe.

Fig. 1. Patient’s maximum oral opening.

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Please cite this article as: Gekle R, et al, Technology advancements in th(2014), http://dx.doi.org/10.1016/j.ajem.2014.03.017

This allowed confirmation of the suspected diagnosis and cleardelineation of the location, depth, and extent of the peritonsillarabscess (Fig. 2). A complex abscess cavity was clearly visualized 2-cmdeep with a “ring of fire” on color Doppler (Fig. 3).

Because of the degree of trismus, dynamic ultrasound guidancewas not possible. Instead, the abscess cavity was localized withultrasound and video laryngoscopy (Glidescope, Bothell, WA)concurrently. The endocavitary probe was then removed. A needleattached to a syringe was put in its exact place, as the videolaryngoscope remained within the oral cavity with constant visual-ization of the abscess. The laryngoscope then was used to dynamicallyaid in abscess drainage (Fig. 4).

Using this technique, 7 mL of pus was removed from theperitonsillar abscess (Figs. 5 and 6). After the procedure, the patientwas able to speak without a muffled voice, and he was able to eat asandwich without pain before discharge from the ED. Follow-up wasarranged with the patient’s otolaryngologist.

Diagnosis:Peritonsillar abscess must be considered when a patient

presents with progressive pharyngitis. Usually, some or all of thefollowing signs are present: fever, severe unilateral throat pain,trismus, drooling, neck swelling, dysphagia, odynophagia, andmuffled voice.

Both computed tomography and ultrasound can be used todiagnose a peritonsillar abscess. Ultrasound can also be used tofacilitate dynamic drainage.

Fig. 2. The peritonsillar abscess was characterized using the endocavitary probe.

e diagnosis and treatment of peritonsillar abscess, Am J Emerg Med

Fig. 3. Color Doppler is used to visualize the “ring of fire” which signifies hyperemia.

Fig. 5. The peritonsillar area was scannedwith ultrasound to identify the largest portionof the abscess.

2 R. Gekle et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

The patient is anesthetized with viscous or aerosolized lidocaine.The endocavitary or hockey stick probe is placed in a sterile sheathand directed over the area of fluctuance. A peritonsillar abscess ischaracterized by an anechoic or complex, irregularly shaped fluidcollection with peripheral hyperemia (“ring of fire”). All abscessesshould also demonstrate posterior acoustic enhancement.

When a patient cannot open their mouth wide enough, videolaryngoscopy can aid in direct visualization and dynamic drainage ofthe abscess.

Fig. 4. The video laryngoscope is used to drain the PTA using a needle inserted in thelocation just previously identified by ultrasound.

Please cite this article as: Gekle R, et al, Technology advancements in th(2014), http://dx.doi.org/10.1016/j.ajem.2014.03.017

Robert Gekle MDChristopher Raio MD

Max Falkoff MDJenna Neufeldt MD

North Shore University HospitalDept. of Emergency Medicine, Manhasset, NY

http://dx.doi.org/10.1016/j.ajem.2014.03.017

Fig. 6. Aspiration of pus was successful.

e diagnosis and treatment of peritonsillar abscess, Am J Emerg Med