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Edited by Teresa Wu, MD

A 20-year-old male presents to your ED complaining of five days of throat pain and tactile fevers. He reports that the pain is worse on the left, and is associated with oropharyngeal swelling and odynophagia.  

He denies any other upper respiratory symptoms, but has had multiple sick contacts recently. He is able to tolerate liquids by mouth, but attempting to eat solids causes him significant pain. He has tried some acetaminophen at home with minimal relief and feels like the pain and swelling is getting worse. He denies any headache, posterior neck pain, meningismus, chest pain, back pain, abdominal pain, shortness of breath, foreign body ingestion, or any other associated symptoms.

On review, he has no significant past medical history. Other than over-the-counter medicatios for symptomatic relief, he is not taking anything else. His physical exam reveals a well-appearing, well-hydrated young adult, sitting upright in bed in no acute distress. There is no drooling or stridor noted. His vital signs are within normal limits and he is afebrile. Examination of the posterior oropharynx reveals bilateral erythema with minimal exudate and left-sided peritonsillar swelling. The exam is also notable for mild uvular deviation towards the right. Examination of the neck shows left anterior cervical lymphadenopathy. The rest of his physical examination is within normal limits.

He has all the signs and symptoms suggestive of a peritonsillar abscess (PTA), and you suspect he will need a needle aspiration or incision and drainage of the abscess for definitive management and symptomatic relief. Having performed countless needle aspirations in the past, you know that it is often difficult to provide adequate pain relief and anesthesia prior to the procedure and that there is always the risk of a “dry tap”. Before you commit to putting the patient through a painful and time-consuming procedure, you pause to consider: Is there really an abscess under there or is this just unilateral peritonsillar cellulitis? Should you perform the aspiration attempt now? Or should you bring the patient back to the ED after 48 hours of outpatient antibiotics and reassess for a more obvious PTA then? Should you just have the patient follow-up with ENT or call them down to the ED for a formal consult?

You decide that a bedside ultrasound can help you decide whether or not there is a drainable abscess, and determine how close the abscess is to vital adjacent structures. Prior to the scan, you prep the patient’s oropharynx with topical anesthesia and give him a “lidocaine lollipop” (a 2x2 gauze covered in lidocaine gel, wrapped around the end of a tongue depressor) to press against the affected area.  As the patient’s topical anesthetic is kicking in, you prepare your ultrasound probe and machine. You ensure that the intracavitary probe has been properly cleaned and place a protective sheath over a thin layer of gel at the tip of the transducer. You give the transducer to the patient and have him gently insert the probe into his mouth. With gentle pressure, you guide the tip of the transducer towards the area of concern and slowly fan through the cellulitic region.

alt


What do you see on bedside US?
What do you want to do next?
See next page for the case conclusion

 

 

Comments   

# freddymama 2011-07-27 01:35
with PTA, is there a certain size which you would only aspirate?

Can you discern a phlegmon from an abscess with ultrasound?
Phlegmon does not require aspiration at least for the pediatric population. but hey! PTAs affect the pediatric population only haha

Thanks!
Reply
# Meaning...James 2013-01-30 08:46
I think this is an advance guide which I am not qualified yet. Ha ha! But great to learn new things...
Reply

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