Intratonsillar abscess: A not-so-rare clinical entity☆
Introduction
One of the most common infections affecting children and adults, tonsillitis is a frequent cause for visit to primary care or emergency department practitioners for evaluation and treatment. If left untreated, tonsillitis can progress to abscess formation. The most commonly feared complication of untreated tonsillitis is the formation of a peritonsillar abscess, defined as a collection of pus located between the tonsillar capsule and lateral pharyngeal constrictor musculature. Two separate theories for peritonsillar abscess formation have been proposed: 1. failed drainage of suppurative inflammation from crypt blockage leading to coalescence by extension into the peritonsillar space, and 2. abscess formation in a group of salivary glands (Weber's glands) located within the supratonsillar space [[1], [2], [3], [4]].
Whereas the etiology and treatment of peritonsillar abscess has been widely reported in the literature, intratonsillar abscess – classically defined in the literature as focal areas of neutrophils and necrotic debris within the parenchyma of the tonsil - is thought to be a rare clinical entity, largely existing in the literature as case reports and series [5]. While the precise etiology of intratonsillar abscess is uncertain, it is suspected that direct extension of acute suppurative inflammation into the crypts is followed by hypertrophy of the inflamed tonsil, obstructing the crypt and containing the abscess (see Fig. 1, Fig. 2). Alternatively, it has been proposed that intratonsillar abscess may arise from bacterial seeding via the bloodstream or lymphatic system [6,7].
As the availability and prevalence of computed tomography (CT) scanners in the emergency department setting has increased, CT imaging of the neck is being used to diagnose suppurative infections of the head and neck rather than history and physical examination alone [8]. For detection of peritonsillar abscess, contrast-enhanced CT has an approximate specificity of 75% and sensitivity of nearly 100%; however, it is acknowledged that false positive results are frequent due to the difficulty in differentiating a phlegmon from an abscess [9]. By radiological standards, on CT peritonsillar abscess is a hypo-attenuating, rim-enhancing fluid collection located between the tonsillar capsule and pharyngeal constrictor musculature, whereas tonsillar abscess is a hypo-attenuating fluid collection with peripheral rim enhancement located within the parenchyma of the tonsillar capsule (see Fig. 1, Fig. 2). At our institution, it was recognized that consultation of the Otolaryngology service for radiological diagnosis of intratonsillar abscess was frequently being encountered by on-call residents, countering the literature reports that this is an extremely rare clinical diagnosis, prompting us to investigate the incidence of intratonsillar abscess in the pediatric population.
Section snippets
Materials and methods
After approval for research was obtained from the University of Tennessee Health Science Center Institutional Review Board, a retrospective chart review was performed at our pediatric tertiary referral hospital. Children who presented to the emergency department from January 1, 2014 to December 31, 2014 with a diagnosis of sore throat were included in this study. The ICD-9 codes included for diagnosis of sore throat were: 462 (pharyngitis), 463 (tonsillitis), 472.1 (chronic pharyngitis), 784.1
Results
Based on radiological criteria, 22 children were diagnosed with intratonsillar abscess on CT imaging by the on-call radiologist and verified by the primary investigators (see Table 1 for patient characteristics). Of the patients diagnosed with intratonsillar abscess by radiological criteria, 9 (41%) were admitted to the hospital for intravenous fluid resuscitation, antibiotics, and corticosteroids for a mean duration of 3 days, and 13 (59%) were discharged home from the emergency department
Discussion
In the setting of suppurative infections of the head and neck, intratonsillar abscess has previously been described as a rare clinical entity, with approximately 24 cases reported in the literature [5]. At our pediatric tertiary referral center, we identified 22 cases of intratonsillar abscess diagnosed radiologically on CT imaging in the year 2014 alone. Presenting symptoms were similar to those of peritonsillar abscess, with chief complaint of sore throat and febrile temperatures lasting an
Conclusion
In our experience, intratonsillar abscess is not a rare diagnosis. Though it is infrequently described in the literature, our Otolaryngology service is frequently consulted for patients diagnosed with intratonsillar abscess on CT scan at our institution. We suspect that this does not reflect an increase in the incidence of intratonsillar abscess diagnoses, but rather a previous underdiagnosis of intratonsillar abscess in the absence of imaging, as its spectrum of symptoms can imitate
Conflicts of interest
The authors have no conflicts of interest to report.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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This paper was presented as a poster presentation at the American Academy of Otolaryngology – Head and Neck Surgery Annual Meeting in San Diego, California, on September 20, 2016