Acute Bilateral Peritonsillar Abscesses

A 14-year-old male presented to an outside emergency department (ED) 2 days after starting penicillin for a 2-week history of intermittent sore throat. He had significant odynophagia and was unable to swallow the pills. He was noted to have a temperature of 38.7°C and was in respiratory distress with stridor and tachypnea. Patient was also noted to be drooling with trismus. In the ED, he was intubated to secure the airway due to an unclear etiology. He also received dexamethasone, racemic epinephrine, and clindamycin. He was then transferred to our institution for further evaluation.

On arrival, patient was afebrile and the oropharynx examiation, while limited by endotracheal tube, revealed bilateral palatal effacement and enlarged anterior pillars. Bloodwork was significant for leukocytosis with left shift. Computed tomography scan of neck revealed bilaterally enlarged palatine tonsils with rim-enhancing fluid collections measuring 3.0 × 2.2 × 3.5 cm on the left and 2.3 × 1.9 × 3.7 cm on the right. Inflammation and thickening of uvula were also noted. An additional faint rim-enhancing fluid collection was noted in the retropharyngeal space, extending from C2-C3 to C5-C6, measuring 0.5 cm in thickness. Multiple mildly enlarged cervical lymph nodes were noted bilaterally with the largest measuring 1.6 cm on the short axis. Finally, an abnormal tracheal contour at the level of the thoracic inlet was noted (Figure 1, 2, 3).

Figure 1.

Contrast-enhanced axial CT demonstrating bilateral peritonsillar abscess at the level of the oropharynx. Note the presence of an endotracheal tube. CT indicates computed tomography.

Figure 2.

Contrast-enhanced coronal CT demonstrating bilateral peritonsillar abscess. Note the presence of an endotracheal tube with significant edema seen in the soft palate. CT indicates computed tomography.

Figure 3.

Contrast-enhanced sagittal CT demonstrating bilateral peritonsillar abscess. Note the presence of an endotracheal tube with significant edema seen in the soft palate and nasopharynx. CT indicates computed tomography.

Patient was taken to the ED, and 10 mL of pus was drained from the peritonsillar spaces bilaterally and sent for culture. Patient was extubated on postoperative day 1 (POD1) and weaned to room air the same day. The following day, cultures grew group C β-hemolytic Streptococci. The patient was then discharged on POD2 with a 2-week course of amoxicillin–clavulanate.

Peritonsillar abscess (PTA), or quinsy, is a collection of pus within the space between the tonsillar capsule and the superior pharyngeal constrictor muscle. It is the most common deep neck space infection. ¹ It often presents with trismus, odynophagia, “hot potato” voice, fever, an edematous or erythematous tonsil, and contralateral uvular deviation. Fusobacterium necrophorum (23%) and group A Streptococcus (17%) are the most common organisms cultured from PTAs; group C (or G) Streptococcus is encountered approximately 5% of the time. ²

The true incidence of bilateral PTAs is uncommon. A thorough review of the literature leads us to believe this is the 21st case report in the English literature. Both the average and the median age across these case reports is 23 years (range 1-47 years) with an equal male to female ratio. However, the incidence of a subclinical, contralateral PTA noted at the time of surgery has been reported to be 5.5%. ³

The practicing otolaryngologist and ED physician should always consider the possibility of an occult contralateral abscess in the “classic” unilateral PTA cases but should also be vigilant for the bilateral PTAs that present with severe sore throat and odynophagia with a midline uvula.