Article: 485

Case report

Bilateral peritonsillar abscess – A rare variant Jenny Loh, Sakina M Saad, Salina Hussain

ABSTRACT Peritonsillar abscess is frequently a unilateral disease but odynophagia, trismus and fever with centralized uvula should alert us of bilateral variant. We report a rare case of bilateral peritonsillar abscess that was missed on initial consultation. (Rawal Med J 2009;34: ). Keywords: Bilateral peritonsillar abscess, quincy, tonsillitis. INTRODUCTION Peritonsillar abscess has been termed synonymously to quinsy since Hipprocrates era, being derived from the Latin quinancia1 which initially described all types of sore throat. The incidence of peritonsillar abscess is about 30 cases per 100,000 people per year.1 It is the most common deep space infection of the head and neck region2 and is potentially life threatening if early diagnosis and treatment are not carried out. We report a case of a middle age gentleman presenting to the hospital with a rare case of bilateral peritonsillar abscess. CASE HISTORY A 40-year-old Malay gentleman presented to Taiping Hospital with six days history of sore throat, fever, limitation of mouth opening and severe odynophagia. He had diabetes mellitus but did not comply with his medication. He had previously consulted a private practitioner who prescribed him two courses of oral antibiotics but 1

Article: 485 his symptoms persisted. On examination, he was dehydrated and looked ill. Oral cavity examination showed trismus with bulging, erythematous right peritonsillar region with huge tonsils bilaterally. At the same time, the left peritonsillar region was noted to be mildly erythematous. No neck lymphadenopathy or signs of respiratory distress were noted. His total white cell count was high and HIV and hepatitis profile were negative. Incision and drainage was performed over the right bulging peritonsillar area by a resident with the drainage of 3-5cc of pus under local anesthesia. Intravenous Penicillin and Metronidazole were administered together with oral gargle and NSAIDS. Upon review by the specialist, patient was not able to tolerate orally and had persistent low-grade fever. A diagnosis of bilateral peritonsillar abscess was made with incision and drainage of left peritonsillar region drainage of 8-10 cc of pus. Soft tissue neck x-ray was unremarkable. Patient was discharged with one week of oral Amoxicillin and Clavulinic acid. Swab culture showed no growth. He recovered fully at follow up. DISCUSSION Peritonsillar abscess or quincy is the most common head and neck abscess4 and affects young adults.5 Giger et al reported 67% incidence occurring in men and 33% in women with additional increased risk in smokers and people on aspirin.4 The left or right tonsil may be equally affected.5 It is characterized by the classical triad of fever, odynophagia, trismus with shifting of the uvula to the contralateral side. Kessler et al reported 4.9 % incidence of this bilateral variant.3 Its diagnosis should be considered in very ill patients presenting with similar symptoms and intraoral findings of huge, erythematous, bilateral tonsils with an undisplaced uvula. The classical hot potato

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Article: 485 voice with drooling of saliva also point towards this distressing condition, as pus is generally formed after the fifth day.6 The most common aerobes are S. pyogenes, Streptococcus milleri and viridans whereas the Bacteroides and Fusobacterium are among the anaerobes.2 Brook et al isolated anaerobic predominance in this region with Prevotella and Porphyromonas spp.6 A proper culture and sensitivity should be taken at initial setting so as to ensure an appropriate medical treatment. In our case, the culture showed no growth probably due to the prior antibiotic therapy. Several treatment guidelines have been advocated in the recent years for the treatment of peritonsillar abscess. A protected stab incision is made in the mucosa where there is point of maximum bulge lateral to the area between the soft palate and the uvula for drainage of pus. Needle aspiration prior to this often helps in differentiating the stage of cellulitis from suppuration. Various systemic antimicrobial therapies have been found to have high efficacy against this polymicrobial pathogens. Penicillin, clindamycin, clavulanate and carbapenum group are the systemic antimicrobial therapy with high efficacy.6 Fatal complications like spread along the carotid sheath and into the deep neck spaces was common before the introduction of antimicrobial therapy.5 Once pus is formed, the antimicrobial therapy will only be effective if given concurrently with adequate surgical drainage, as seen in our patient. Quinsy tonsillectomy or acute abscess tonsillectomy has been recommended as optimal treatment for bilateral cases with multiple loculations.4 Subclinical bilateral peritonsillar abscess has been found upon this procedure. Fasano et al reported 1.9 to 24% incidence of unsuspected contralateral peritonsillar abscess at tonsillectomy. Complications like upper airway obstruction, aspiration of pus and rarely pseudoaneurysm of carotid artery has been reported.3 Medical conditions like diabetes mellitus can be of additional risk factor to complication and abscess extension into the 3

Article: 485 retropharyngeal space has been reported.5 Lethal descending necrotizing mediastinitis may occurdue to gravity, breathing and negative intrathoracic pressure7 and may require cervicotomy and even thoracotomy as a life saving procedure. CONCLUSION Bilateral peritonsillar abscess is an uncommon variant of a relatively common oropharyngeal infection. Adequate history, physical examination and sound knowledge are crucial in diagnosing this condition early to prevent further complications. Timely surgical drainage and antimicrobial therapy hold the ultimate key to treatment.

From Department of Otorhinnilaryngology-Head & Neck Surgery, Taiping Hospital, Taiping, Perak, Malaysia Correspondence: Dr. Salina Husain, MS (MSORL-HNS, UKM), PPUKM Department of Otorhinolaryngology-Head & Neck Surgery, Faculty of Medicine, University Kebangsaan Malaysia. E-mail: [email protected] Received: 10 May, 2009 Accepted: 23 May, 2009

REFERENCE 1. Mobley SR. Bilateral peritonsillar abscess: Case report and presentation of its clinical appearance. Ear, Nose and Throat J 2001;80:381-2. 2. Fasano CJ, Chudnofsky C, Vanderbeek P. Bilateral Peritonsillar Abscess: Not the Usual Sore Throat. J Emer Med 2005;29:45-47. 3. Kessler A, Lapinsky J, Segal S, Berkovitch M. Bilateral Peritonsillar abscess: Relief of Upper Airway Obstruction. IMAJ 2003;5:126-27. 4. Giger R, Landis BN, Dulguerov P. Haemorrhage Risk after Quinsy Tonsillectomy. Otolaryngol Head Neck Surg 2005;133:729-34. 5. Ong YK, Goh YH, Lee YL. Peritonsillar Infections: Local experience. Singapore Med J 2004; 45:105-9. 4

Article: 485 6. Brook I. Microbiology and Management of Peritonsillar, Retropharyngeal and Parapharyngeal Abscess. J Oral Maxillofac Surg 2004;62:1545-50. 7. Mihos P, Potaris K, Gakidis I, Papadakis D, Rallis G. Management of Descending Necrotizing Mediastinitis. J Maxillofac Surg 2004;62:966-72.

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