Abstract
Although uncommon, bilateral peritonsillar abscess (PTA) may still present with symptoms found in unilateral cases but lack hallmark findings such as an asymmetric tonsillar bulge and uvular deviation. We present the case of an 18-year-old woman deemed to have a bilateral PTA based on physical examination and radiographic imaging. She underwent successful surgical drainage with needle aspiration, followed by incision and drainage. A computed tomography with intravenous contrast should be obtained when a patient displays signs suggestive of a bilateral PTA but the diagnosis is not certain. To our knowledge, this is the first report of 2 different bacterial species cultured from contralateral abscesses during the same encounter.
1
Introduction
Acute pharyngotonsillitis is one of the most common infections encountered in the primary care setting . Although the etiology to most cases are from viruses, up to 40% in pediatric patients and up to 10% in adult patients may have a bacterial origin . When ineffectively treated, a collection of pus may form between the fibrous capsule of the tonsil and the pharyngeal constrictor muscles, otherwise referred to as a peritonsillar abscess (PTA) or quinsy . This condition has been estimated to affect 30 people per 100 000, resulting in approximately 45 000 cases annually in the United States .
Individuals with a PTA typically present between ages 10 and 40 years , with an average age of 27 to 28 years . They classically complain of sore throat, dysphagia, odynophagia, trismus, and drooling, and they often exhibit a temperature greater than 38°C and demonstrate a unilateral swelling of the anterior palatine arch with subsequent uvular deviation . Prompt treatment is warranted because it can extend directly into the parapharyngeal space with subsequent progression to the skull base or mediastinum, or it may result in sepsis, jugular vein thrombophlebitis, or airway compromise with laryngeal edema . Most cases are unilateral, but we present the case of an individual who presented with simultaneous bilateral PTA.
2
Case report
An obese 18-year-old mother of 2 who denied any significant medical history aside from a family history of diabetes complained of a 1-week history of progressively worsening sore throat, trismus, dysphagia, and odynophagia to the point that she was unable to manage her own secretions or maintain adequate oral intake. She appeared miserable and communicated with a mild muffled voice but was afebrile and did not exhibit stridor or respiratory distress. Physical examination was notable for a 3-cm interincisal trismus and prominent bilateral tonsillar hypertrophy with associated swelling along the anterior tonsillar arches, greater on the left than on the right ( Fig. 1 ). The patient demonstrated a leukocytosis of 12 500/mm 3 with 76% granulocytes, 12% lymphocytes, and 11% monocytes. A contrast-enhanced computed tomographic (CT) scan of the neck reported bilateral PTA measuring 2.8 cm × 2.2 cm on the left and 1.7 cm × 1.2 cm on the right ( Fig. 2 ).
She was taken to the operating room to undergo surgical drainage under general anesthesia. An 18-gauge spinal needle successfully aspirated purulent material from the left tonsillar arch ( Fig. 3 ), and monopolar electrocautery was subsequently used to create a small incision along the superior lateral aspect of the arch. Copious amounts of pus were acquired, and a sample was sent for microbial analysis. Another 18-gauge spinal needle was used to aspirate the right side, but no pus was obtained. Despite such findings, the right side was incised similarly as with the left. Pus was also encountered and sent as a separate microbial specimen ( Fig. 4 ).
A Gram stain of the left abscess revealed rare Gram-positive cocci and the corresponding culture grew pan-sensitive Streptococcus pyogenes . Although this same species was present in the right abscess, the culture was notable for also growing methicillin-sensitive Staphylococcus aureus resistant to penicillin and ampicillin. Both cultures did not yield any anaerobic, acid-fast, or fungal elements. The patient tested negative for a routine surveillance screen (by nasal swab polymerase chain reaction) for methicillin-resistant S aureus during her hospital stay. A review of her medical records revealed negative serologic results for HIV, hepatitis B, and syphilis earlier in the year.
The patient had an unremarkable postoperative course and reported an improvement to her initial symptoms. Now capable of tolerating oral intake, she was discharged the next day in stable condition with a 10-day outpatient regimen of clindamycin 450 mg to be taken every 6 hours.
2
Case report
An obese 18-year-old mother of 2 who denied any significant medical history aside from a family history of diabetes complained of a 1-week history of progressively worsening sore throat, trismus, dysphagia, and odynophagia to the point that she was unable to manage her own secretions or maintain adequate oral intake. She appeared miserable and communicated with a mild muffled voice but was afebrile and did not exhibit stridor or respiratory distress. Physical examination was notable for a 3-cm interincisal trismus and prominent bilateral tonsillar hypertrophy with associated swelling along the anterior tonsillar arches, greater on the left than on the right ( Fig. 1 ). The patient demonstrated a leukocytosis of 12 500/mm 3 with 76% granulocytes, 12% lymphocytes, and 11% monocytes. A contrast-enhanced computed tomographic (CT) scan of the neck reported bilateral PTA measuring 2.8 cm × 2.2 cm on the left and 1.7 cm × 1.2 cm on the right ( Fig. 2 ).
She was taken to the operating room to undergo surgical drainage under general anesthesia. An 18-gauge spinal needle successfully aspirated purulent material from the left tonsillar arch ( Fig. 3 ), and monopolar electrocautery was subsequently used to create a small incision along the superior lateral aspect of the arch. Copious amounts of pus were acquired, and a sample was sent for microbial analysis. Another 18-gauge spinal needle was used to aspirate the right side, but no pus was obtained. Despite such findings, the right side was incised similarly as with the left. Pus was also encountered and sent as a separate microbial specimen ( Fig. 4 ).
A Gram stain of the left abscess revealed rare Gram-positive cocci and the corresponding culture grew pan-sensitive Streptococcus pyogenes . Although this same species was present in the right abscess, the culture was notable for also growing methicillin-sensitive Staphylococcus aureus resistant to penicillin and ampicillin. Both cultures did not yield any anaerobic, acid-fast, or fungal elements. The patient tested negative for a routine surveillance screen (by nasal swab polymerase chain reaction) for methicillin-resistant S aureus during her hospital stay. A review of her medical records revealed negative serologic results for HIV, hepatitis B, and syphilis earlier in the year.
The patient had an unremarkable postoperative course and reported an improvement to her initial symptoms. Now capable of tolerating oral intake, she was discharged the next day in stable condition with a 10-day outpatient regimen of clindamycin 450 mg to be taken every 6 hours.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
