Introduction

The author presents a case of peritonsillar abscess in a 57 year old lady with a background history of tonsillectomy at 11 years of age. (see Figs. 1 and 2 )

T1 weighted axial MRI image of neck showing resolving features of an abscess.

T2 weighted coronal MRI image of neck showing resolving features of an abscess.

Previously recorded longest interval with similar history is 35 years [ ].

Case report

A 57 year-old female presented to A&E with complains of sore throat and left sided throat swelling for 1 week, associated with dysphagia for 1 day and previous history of tonsillectomy. There were no other systemic symptoms. An ENT examination revealed a bulge at the superior pole of the left tonsil, and uvula pushed to the right. Full blood count showed slight neutrophilia; however C – reactive protein was within normal limit. Peritonsillar space should not exist following tonsillectomy; hence peritonsillar abscess as a differential was less likely. However, a diagnostic aspiration was planned and 5 ml pus was aspirated from the swelling.

Investigations

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  FBC, CRP, RFT, LFT

  
  
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  Pus culture and sensitivity

  
  
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  Fibre-optic laryngoscopy

  
  
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  MRI Neck

Treatment

The patient underwent a formal incision and drainage under local anaesthetic for complete evacuation of pus. Intra-venous Co-Amoxiclav and metronidazole was commenced immediately.

Outcome and follow-up

Pus culture and sensitivity result showed growth of streptococcus sp. (Group A) sensitive to penicillin, clarithromycin, doxycycline and amoxicillin. On Fibre-optic laryngoscopy, lymphoid hypertrophy was found on the left tonsillar bed. MRI of neck showed benign features of a resolving abscess. The patient improved rapidly after drainage of pus and intravenous antibiotics.

On follow-up at 1 month and 4 month she remained asymptomatic and there was no recurrence.

Discussion

Traditional teaching says peritonsillar abscess is a complication of acute tonsillitis. Diagnosis becomes complex when a patient presents with peritonsillar abscess like swelling with the background history of tonsillectomy. The subject becomes even more interesting when exhaustive literature search shows a handful of recorded cases with similar history [ ]. Under these circumstances the differential diagnosis should include:

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  Possible remnant of tonsillar tissue

  
  
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  Infection of Weber’s gland

  
  
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  Second branchial cleft anomaly

  
  
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  Parapharyngeal abscess/mass

  
  
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  Tumors (benign/malignant)

Even with best of techniques it is impossible to get rid of all the tonsillar tissue, especially in the inferior pole where the palatine tonsil merges with the lingual tonsil and to a lesser degree in the superior pole. This remnant tissue hypertrophies and continues to produce symptoms of tonsillitis. It is now widely believed that peritonsillar space trapped beneath acts as potential space for future pus accumulation [ ].

Weber’s glands are minor salivary glands interspersed in the oropharynx. These glands came into limelight with the hypothesis that they were involved in the pathogenesis of peritonsillar abscess [ ]. Histological evidence from the tonsillectomy specimen also shows the presence of these glands in the superior, middle and lower poles of the tonsil and also in the peritonsillar space [ , ]. Peritonsillar suppuration has also been documented in the absence of typical symptoms of tonsillitis [ ]. El-Saied et al. found high levels of amylase in peritonsillar pus, which has been attributed to these glands, further supporting the hypothesis [ ].

Second branchial cleft anomaly may present in the form of cyst, sinus or fistula. In case of fistula internal opening is found in the anterior aspect of the tonsil while the external opening is at the junction of middle and lower third of the anterior border of the sternocleidomastoid muscle. Cysts form anywhere along the tract. Infected tonsillar fossa cyst resembles quinsy which can result in missed diagnosis [ ].

Parapharyngeal space lies immediately lateral to the peritonsillar space. Autonomous parapharyngeal abscess unrelated to tonsil or space occupying lesion can displace the tonsils medially and give rise to signs and symptoms typical of quinsy.

An array of malignant tumors present as peritonsillar abscess, especially in the elderly [ , ].

Conclusion

The incidence of Peritonsillar abscess after tonsillectomy is a rare occurrence. In the event of such a finding it is worthwhile to remember other possible pathology which can present in the same anatomical site with striking similarity in clinical presentation. High index of suspicion is warranted in the elderly, as this can be a sign of a sinister pathology.

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  This study was not funded by any person/organisation.

  
  
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  All procedure performed in the case report was in accordance with the ethical standards of the institution.

  
  
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  Informed consent was obtained from the patient included in the study.

  
  
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  The authors declare there is no conflict of interest regarding the publication of this paper.

Ethical statement

All procedure performed in the case report was in accordance with the ethical standards of the institution.

Informed consent was obtained from the patient included in the study.

The authors declare there is no conflict of interest regarding the publication of this paper.