Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy
Introduction
Peritonsillar abscess (PTA) sometimes spreads through the deep fascial planes in the neck and then rapidly progresses to a more serious infection. This condition thus frequently needs prompt treatment with needle aspiration, incision and drainage (I&D), or immediate abscess tonsillectomy (IAT), accompanied by administration of antibiotics. In Japan, needle aspiration and I&D are commonly applied for PTA. However, our department prefers to perform IAT to achieve more complete drainage, since most patients with PTA are referred to our clinic by private clinicians after treatment with antibiotics, needle aspiration, and I&D. Exceptions are made for the intake of aspirin or anticoagulants or patients who would not tolerate general anesthesia. However, the indication for IAT remains controversial. IAT can offer several advantages over other management options, allowing full evacuation of the abscess cavity and drainage of any infectious material that has spread beyond the peritonsillar space. We have previously reported that the computed tomography (CT) findings of PTA could be classified into two categories by shape: Oval type and Cap type [1]. The Cap-type abscess tends to include more muscular tissue compared to the Oval type in the histological examination of specimens obtained during surgery, indicating the extra-capsular presence of abscess in the Cap type. Further, inflammatory findings such as CRP and WBC counts were significantly higher in the Cap type than in the Oval type. Those findings suggest that Cap-type PTA might have severe inflammation and cause invasive inflammation. In order to clarify the clinical characteristics of Cap-type PTA and discuss the indication for IAT, the present study compared CT classifications with the rate of PTA with extraperitonsillar spread. Though the original work has so far been only published in Japanese, the present study is for a debate with a much larger group of people.
Section snippets
Patients and methods
A retrospective study was conducted using the medical records of patients with peritonsillar abscess who underwent contrast-enhanced CT and IAT in our department at Kagoshima University Hospital, Kagoshima, Japan, between April 2009 and March 2014. Patients who underwent surgical treatments such as needle aspiration and I&D before visiting our hospital were excluded from the study. CT was performed at sequential 3-mm slices throughout the neck. Radiologically, abscess was diagnosed if a zone of
Results
Ninety-nine patients (71 males, 28 females; 108 sides) were enrolled in the study. Median age of the 99 patients was 35 years (range, 8–86 years). Table 1 depicts the clinical characteristics of the study population. Location of the abscess was superior for 81 sides (75%) and inferior for 27 sides (25%). Abscess shape was Oval type for 64 sides (59%) and Cap type for 44 patients (41%). No cases displayed equivocal shape of the abscess. Superior Oval-type PTA was the most common, at 55 sides
Case (Patient 2, Fig. 4)
A 37-year-old man visited our hospital with a 2-day history of left-sided pain in the throat. No trismus, displacement of the uvula, or tonsillitis was observed (Fig. 4A). Endoscopic examination showed medial displacement and edema of the mesopharyngeal wall below the left tonsil, extending to the left half of the supraglottis (Fig. 4C and D). Cervical palpation revealed diffuse, non-fluctuating, tender swelling in the left side of the neck.
CT demonstrated a Cap-type abscess at the lower pole
Discussion
As surgical treatments for PTA, needle aspiration and I&D are performed with administration of antibiotics. However, if those treatments prove ineffective, the abscess can spread along the deep neck fascial planes of the neck and chest, sometimes causing life-threatening complications. To obtain more sufficient and accurate drainage, IAT is considered to be superior to needle aspiration and I&D, and recommended as an initial treatment for PTA, but the indication for IAT still remains
Conclusions
Inferior Cap-type PTAs may need more intensive and reliable treatments such as IAT. In addition, IAT might be effective for PTA with extraperitonsillar spread into the para- and retropharyngeal spaces as long as the abscess remains above the hyoid bone.
Conflicts of interest
We declare that no competing financial interests exist.
Funding
No financial disclosures.
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