Treatment Strategies for Intra-Tonsillar Abscesses

Significance Statement

Intratonsillar abscess (ITA) is a focal area of neutrophils and necrotic debris within the tonsil parenchyma. It is rarely found in adults and is easily misdiagnosed; few studies have reported any standardized treatment. We present the case of a 60-year-old woman with an ITA. After treatment, a tonsillectomy was deemed critical to avoid recurrence. This would prevent aspiration and drainage issues associated with recurrence.

Intratonsillar abscess (ITA) is classically defined as a focal area of neutrophils and necrotic debris within the tonsil parenchyma. ¹ While it is common in children, it is considered rare in adults.^1,2 ITA is easily misdiagnosed as a peritonsillar abscess or tonsillar tumor. Infection may spread to the parapharynx or deep cervical space. The diagnosis and treatment of ITA are of great significance in clinical practice. However, few studies have reported standardized treatment for this rare disease. Here, we present the case of a 60-year-old woman with an ITA. After treatment, we concluded that a tonsillectomy treatment strategy was urgently needed to avoid recurrence. The hospital review board approved this case report after appropriate evaluation written informed consent was obtained from the patient for this case manuscript and potential future publications. All efforts have been made to ensure patient anonymity.

The patient presented with a sensation of obstruction, resembling that of a foreign object, in her pharynx. This sensation had persisted for 1 month, during which she did not experience a sore throat, restricted mouth opening, or fever and continued eating normally; however, the sensation had worsened over the past 3 days. On examination, the right tonsil was swollen beyond the midline, and the surface appeared smooth (Figure 1A). The uvula was centered without congestion or edema, the palatal and lingual arch were not congested or swollen, and the left tonsil was 1°. Her blood routine examination and liver and kidney function were unremarkable. Contrast-enhanced computed tomography (CT) revealed a linear, annular-shaped enhancement as low-density foci inside the right tonsillar parenchyma (approximately 2.1 cm × 1.4 cm; Figure 1B). Bilateral tonsils were excised using low-temperature plasma under general anesthesia. Approximately 1.5 mL of light red liquid was extracted from the right tonsillar puncture, and a cavity was seen in the tonsillar parenchyma (Figure 1C). Pathological examination using hematoxylin and eosin staining showed obvious proliferation of lymphoid tissue, increased and enlarged lymphoid follicles, an enlarged germinal center, and lymphocyte and plasma cell infiltration (Figure 1D). Examination of exfoliated cells in the puncture fluid showed a large number of neutrophils and necrotic tissue. An intratonsillar abscess was diagnosed. Symptomatic supportive care was provided postoperatively. Approximately 6 months after discharge, the surgical area turned normal, and the patient’s symptoms disappeared.

Figure 1.

(A) Right tonsil enlargement over the central line with a smooth surface. (B) Computed tomography showed low-density foci with annular enhancement. (C) Puncture revealed approximately 1.5 mL of light red liquid within the cavity. (D) Pathological examination showed lymphoid tissue hyperplasia and increased and enhanced lymphoid follicles (hematoxylin and eosin staining, ×10).

Intratonsillar abscesses usually present as unilateral tonsil hypertrophy with swallowing pain, dysphagia, and lockjaw. ³ In this case, no clinical manifestations such as sore throat, cold, or fever were observed; hence, diagnosing the patient’s condition solely based on clinical manifestations was difficult. Enhanced CT of amygdala abscess mainly showed low-density lesions in the tonsil parenchyma, with annular enhancement. CT can help in the definitive diagnosis.^3,4 Enhanced CT is recommended for a highly suspicious intratonsillar abscess.

Treatment includes needle aspiration, incision and drainage, and tonsillectomy.^1,3 We suggest that the tonsil be completely resected to prevent aspiration and drainage issues associated with recurrence.^3,4