Archive | July, 2015

Student Corner: Peritonsillar Abscess

July 7, 2015

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Peritonsillar abscess (PTA) is one of the most common head and neck infections that is diagnosed in the emergency department. The common presenting symptoms are a muffled/altered voice, throat pain, fever and odynophagia. A non-contrast CT image of a  particularly severe example of a PTA is shown below.

PTA2

 

The next horizontal cut image is below, with red arrows to highlight the abscess.

 

PTA1 with arrows

One of the more striking aspects of the image is the large degree of airway compression, with the maximum measured diameter of the airway being 2cm. Also, the first image shows that the abscess has two distinct “pockets” that eventually coalesce.

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To backtrack, this particular patient initially presented with symptoms of fever, chills, dysphagia, dysphonia and trismus. On examination, there were thin tonsillar exudates, erythema and deviation of the uvula. A diagnosis of peritonsillar abscess was made without imaging and the patient underwent incision and drainage, given antibiotics and discharge. The above images were taken after the patient returned to the ED several days later with continued, worsening symptoms.

The options for imaging of a soft tissue infection of the head and neck include CT and ultrasound. In the ED setting, ultrasound is becoming more and more utilized as the preferred imaging modality. However, this patient received a CT because they failed therapy. CT is superior to ultrasound in differentiation between peritonsillar abscess and other infections of the oral cavity and pharynx. It also allows clinicians to determine the degree of airway compromise. Other indications for CT imaging in suspected peritonsillar abscess include: uncertain diagnosis, obstructed view through physical exam or suspicion of an associated infection such as peritonsillar cellulitis.

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Overall, peritonsillar abscess is one of the most common soft tissue infection of the head and neck that is encountered in the emergency department. Most of the time, the diagnosis is clinical. Ultrasound is the preferred imaging modality, but CT is useful in a variety of situations as well.

References:

Powell, J. and Wilson, J.A. (2012), An evidence-based review of peritonsillar abscess. Clinical Otolaryngology, 37: 136–145.
Author:  Jaymin Patel
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WWWTP #24 Answer…

July 1, 2015

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Trauma patient came in to the ED:

CXR 1

What’s Wrong With This Picture?

The patient’s chest tube is not inserted far enough.  It is also a bit high residing between ribs 3-4.

Chest tubes have a side port and a distal port for suctioning fluids, air from the pleural space.  There is a radiopaque line seen on the tube that is interrupted at the side port (see magnified image).  In this case the radiograph shows that the side port is subcutaneous and not inserted all the way into the pleural space.  The chest tube needs to be replaced!

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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