Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Complications of Acute Tonsillitis MICROBIOLOGY The microbiology of the oral cavity is very complex. The total count of anaerobic bacteria is estimated to be 1.1 x 108/ ml. Anaerobes outnumber aerobes by 2:1 in saliva. Bacterial interference between organisms is responsible for helping maintain equilibrium. The use of antibiotics can substantially alter the bacterial balance. Streptococci are the best known pathogens of the oropharynx, and of these, Group A bhemolytic streptococci (GABHS) are most often implicated. Occasionally, Group B, C, or G bhemolytic streptococci are responsible. All groups of bhemolytic streptococci have been associated with rheumatic fever. A 1983 review reported the incidence of rheumatic fever to be 1 case per 200,000 schoolaged children per year. The highest rate of recovery of streptococci is in the primary school age range, with GABHS accounting for 75% of culture-positive children. Other important pathogens are the Bacteroides species, Hemophilus influenzae, Staph aureus, Branhamella catarrhalis (Moraxella catarrhalis), Mycoplasma pneumonia. Rarely, but of note, are Corynebacterium diphtheriae (diphtheria) and Francisella tularensis (tularemia), both of which can produce a lethal membranous pharyngotonsillitis. Less common pathogens include mycobacteria, treponemes, and actinomyces. Finally, several viruses can cause pharyngotonsillitis that is clinically indistinguishable from that caused by bacteria. This includes at least 10 different types of the adenovirus, rhinovirus, and EpsteinBarr virus. In a study of the etiology of pharyngitis in a school age population from 1986, McMillan et al reported that GABHS was cultured in 40.7% of cases. Viruses were isolated in 16.3% of cases. Two or three separate organisms were cultured from 10.6% of cases. PERITONSILLAR ABSCESS Peritonsillar abscess is the most common complication of acute tonsillitis and is the most common deep infection of the head and neck. It usually occurs in the second to third decade of life and, 70% to 80% of the time is predominantly located at the superior pole. It occurs when a localized infection spreads along the connective tissue septae of the tonsil into the loose areolar tissue of the peritonsillar space. Since 1981, several large series have been published which study the efficacy of the needle aspiration technique versus incision and drainage for the outpatient treatment of peritonsillar abscess. Needle aspiration has several decided advantages. Incision and drainage are very painful as it is difficult to obtain local anesthesia in the presence of inflammation. Secondly, the abscess cavity may be in any of several locations or may be loculated making drainage very difficult. Another treatment option is quinsy or acute tonsillectomy. In one review of the literature, blood loss was not statistically different between quinsy tonsillectomy and interval tonsillectomy. Blood loss from the ipsilateral side is frequently less as the abscess itself accomplishes much of the dissection, while inflammation on the contralateral side causes slightly more bleeding. Quinsy tonsillectomy continues to be a viable treatment option under certain circumstances, especially in the military services where days of hospitalization and number of convalescent days are important issues. In the past few years, several researchers began to question the merit of performing tonsillectomy following all cases of peritonsillar abscess. Recurrent peritonsillar abscess is four times more likely to occur in patients with a previous history of recurrent tonsillitis and unlikely to occur in patients over 40 years old. On the basis of these and other data, it seems that most peritonsillar abscesses can be treated by aspiration and antibiotics, with interval tonsillectomy reserved for those patients under 40 years of age with a history of previous tonsillitis or peritonsillar abscess. INTRATONSILLAR ABSCESS Intratonsillar abscess or phlegmonous tonsillitis is a relatively rare process in which an abscess forms in the tonsil itself. It may form either from extension from an obstructed tonsillar crypt or from an intratonsillar rupture of a peritonsillar abscess. The presentation is very similar to that of peritonsillar abscess and the treatment essentially the same. DEEP NECK SPACE INFECTIONS Deep space neck infections secondary to tonsillitis are relatively uncommon. However, in one series roughly 10% of abscesses of the neck were related temporally to preceding tonsillitis or tonsillopharyngitis. Peritonsillar abscesses can extend into other spaces in the neck, the most common of which is the lateral pharyngeal space, also termed the parapharyngeal space. It consists of loose areolar tissue lateral to the pharynx and is bounded medially by the fascia of the pharynx and laterally by the pterygoids and the sheath of the parotid gland. It extends superiorly up to the skull base, but is limited inferiorly at the hyoid bone by the sheath of the submandibular gland and its attachments to the stylohyoid and the posterior belly of the digastric. Posteriorly, the space is bounded by the connective tissue around the internal carotid and internal jugular veins. Extension of a peritonsillar abscess into the lateral pharyngeal space has an incidence of 2.3% and may be occult. The episode of tonsillitis may have completely resolved and the interval between the two may be several weeks. According to Finegold (1991), the presentation is of the clinical triad of prolapse of the tonsillar fossa with swelling of the lateral pharyngeal wall, trismus, and swelling of the parotid gland all of which are readily apparent from the anatomy. These patients appear in a toxic condition with high fever and extreme misery in contradistinction to patients with uncomplicated peritonsillar abscess. The diagnosis is confirmed by CT scan and the treatment is external drainage accompanied by antibiotic therapy. The retropharyngeal space is the superior portion of the prevertebral space. The retropharyngeal space is the area of loose connective tissue behind the pharynx and in front of the alar layer of the prevertebral fascia. It extends upward between the pharynx and the vertebral column to the skullbase and inferiorly behind the lower part of the pharynx and esophagus. It is in direct communication with the pretracheal space and ends at the bifurcation of the trachea. The retropharyngeal space extends laterally around the upper pharynx and is in continuity with the lateral pharyngeal space. Retropharyngeal abscesses secondary to tonsillitis are usually via extension from the lateral pharyngeal space. The classic symptoms include dysphagia, drooling, hoarseness, swelling of the posterior pharyngeal wall, and meningismus. Again, patients appear in a toxic condition with high fever. Diagnosis is again confirmed by CT and treatment is by drainage and antibiotic therapy. Complications of these deep space infections include erosion into the internal carotid, thrombophlebitis of the internal jugular vein, airway obstruction, mediastinitis, sepsis, and necrotizing fasciitis.
INFLAMMATORY TORTICOLLIS In a recent report by Bredenkamp (1990) of 26 pediatric patients treated for acute nontraumatic torticollis, three were found to have acute tonsillitis and three had retropharyngeal abscess or cellulitis. Torticollis, or wryneck, is a contracture of the neck causing the head to be drawn and rotated so the chin points to the contralateral side. It is a common sign in the pediatric population with nearly 80 different etiologies. Inflammatory torticollis is characterized by local irritation and spasm of the sternocleidomastoid muscle with compensatory neck rotation. In a similar fashion inflamed, retropharyngeal nodes may cause edema and irritation of the longus colli and the scalenes leading to compensatory hyperextension of the neck. Radiographically this leads to loss of the normal cervical lordosis.
In this series, four children presented with nontraumatic rotary atlantoaxial joint subluxation. This is thought to be caused by pathologic relaxation of the transverse ligament of the atlantoaxial joint due to the inflammatory process. This is also known as Grisel's syndrome and has been associated with pharyngitis, tonsillitis, peritonsillar abscesses, and deep neck abscesses. The average delay in diagnosis in one series was 11.6 months. The initial management of acute torticollis is cervical spine immobilization until Cspine films exclude the possibility of fracture or rotary subluxation. HEMORRHAGIC TONSILLITIS Hemorrhagic tonsillitis is a rarely reported complication of tonsillitis. Levy reported 11 cases in a pediatric population from 1983 to 1986. Seven patients had a previous history of tonsillitis. Eight patients had dilated surfaces vessels which were the source of the hemorrhage and two had diffuse parenchymal bleeding. Fifty-five percent had cultures positive for GABHS. VASCULAR COMPLICATIONS The landmark article on vascular complications of neck space infections was written by Salinger in 1933 before the widespread use of penicillin. In his series of 227 cases, 85 cases were secondary to peritonsillar abscess and 31 cases were caused by peritonsillar abscess complicated by lateral pharyngeal space involvement. An autopsy review showed that of the 15 in the peritonsillar abscess group, seven had eroded and four had formed false aneurysms of the internal carotid artery. Of 29 cases involving the lateral pharyngeal space 15 had either eroded or formed false aneurysms of the internal carotid, 4 eroded into the internal carotid artery, 4 eroded into the common carotid artery, and 1 eroded into the internal jugular vein. There were 31 cases involving the retropharyngeal space, of which 22 involved the internal carotid artery, and 4 involved the common carotid artery. Between 1933 and 1983, there have been only 23 case reports of spontaneous tonsillar hemorrhage from major vessel erosion. In 1990, Stevens reported one case of a left peritonsillar abscess in a 15-year-old male which eroded into the internal carotid artery causing a false aneurysm extending from the carotid bifurcation to the skullbase. Several signs and symptoms are frequently cited as very significant in patients with peritonsillar or deep neck abscesses. Any recurrent bleeding from the ears, nose, or throat, no matter how small, should be viewed with suspicion as they may be sentinel hemorrhages. A protracted clinical course lasting several weeks, or prolonged trismus and pain which seems out of proportion to the patients physical exam, may be the sign of an occult abscess. The presence of a hematoma which may appear as a tense, brawny, plum colored mucosa, can be ominous. Cranial neuropathies of X and XII, as well as Horner's syndrome in association with a parapharyngeal space abscess, should be viewed with suspicion. POSTANGINAL SEPSIS Postanginal sepsis or Lemierre's disease is a rare complication of anaerobic tonsillitis seen mainly in children although it has been reported in the adult population. The implicated pathogen is Fusobacterium necrophorum; however, other fusobacterium species, bacteroides, and peptostreptococcus are occasionally seen. The initial tonsillopharyngitis infection may be mild and temporally separate from the subsequent illness. The hallmark of Lemierre's disease is thrombophlebitis of the internal jugular venous system. The symptoms are pain in the neck which increases with contraction of the sternocleidomastoid muscle, thereby compressing the mass. A palpable cord may be apparent underneath the muscle belly. Edema of the lateral pharyngeal wall extending into the true and false cords may be present. The patients have high fever, chills, and stiff neck. There is a very high incidence of septic embolization with metastatic abscesses seen primarily in the lungs and pleural space as well as septic arthritis osteomyelitis. Metastatic abscesses are also seen in the brain, liver, pericardium, and other soft tissue locations. Diagnosis of jugular venous thrombophlebitis may be by ultrasound or by CT with contrast. In addition metastatic abscess can be identified by gallium or indium scans or by CT. Antibiotics with anaerobic coverage are recommended for six weeks to prevent relapse. Drainage of local abscesses should be performed and ligation or excision of infected veins may be necessary. Anticoagulation is considered controversial. Case Presentation A 56-year-old white male without previous history of tonsillar disease, first presented to a local clinic with a 2-day history of sore throat and difficulty swallowing. The patient was placed on a course of amoxicillin for presumptive bacterial pharyngitis and returned to the clinic 3 days later with progression of his symptoms and low grade fever. The patient was referred to the Ben Taub Otolaryngology Clinic for further evaluation and treatment. Upon examination, the patient complained of severe odynophagia, dysphagia, and displayed moderate trismus. Oral exam revealed a large erythematous right supratonsillar bulge extending onto the soft palate and causing the uvula to deviate to the left. After administration of local anesthesia, 4 cc of thick yellow pus was aspirated from the superior pole of the right tonsil and the exudate was sent for culture. The patient was given 2.4 million units of Bicillin and discharged on a 10-day course of oral penicillin. The patient reported that he is taking the antibiotics as prescribed, the fever is gone, and he is eating and swallowing without difficulty. He is scheduled for a follow-up visit in the clinic. Bibliography Alexander DW, Leonard JR, Trail ML. Vascular complications of deep neck abscesses. Laryngoscope 1968;78:361-370. Bateman GH, Kodicek J. Primary quinsy tonsillectomy. Ann Otol Rhinol Laryngol 1959;68:315-321. Bluestone CD. Current indications for tonsillectomy and adenoidectomy. Ann Otol Rhinol Laryngol 1992;101(Suppl 155):58-64. Bonding P. Routine abscess tonsillectomy: late results. Laryngoscope 1976;86:286-290. Brandow EC Jr. Immediate tonsillectomy for peritonsillar abscess. Trans Am Acad Ophthalmol Otolaryngol 1973;77:ORL412-416. Bredenkamp JK, Maceri DR. Inflammatory torticollis in children. Arch Otolaryngol Head Neck Surg 1990;116:310-313. Brodsky L, Sobie SR, Korwin D, Stanievich JF. A clinical prospective study of peritonsillar abscess in children. Laryngoscope 1988;98:780-783. Brook I. Clinical microbiology of Waldeyer's ring. Otolaryngol Clin North Am 1987;20:259-272. Brook I. Medical treatment of non-streptococcal recurrent tonsillitis. Am J Otolaryngol 1989;10:227-233. Brook I. Microbiology of abscesses of the head and neck in children. Ann Otol Rhinol Laryngol 1987;96:429-433. Brook I, Frazier EH, Thompson DH. Aerobic and anaerobic microbiology of peritonsillar abscess. Laryngoscope 1991;101:289-292. Dodds B, Maniglia AJ. Peritonsillar and neck abscesses in the pediatric age group. Laryngoscope 1988;98:956-959. Finegold SM. Role of anaerobic bacteria in infections of the tonsils and adenoids. Ann Otol Rhinol Laryngol 1991;100(Suppl 154):30-33. Fried MP, Forrest JL. Peritonsillitis. Arch Otolaryngol 1981;107:283-286. Fry TL, Pillsbury HC. The implications of "controlled" studies of tonsillectomy and adenoidectomy. Otolaryngol Clin North Am 1987;20:409-413. Griffies WS, Wotowic PW, Wildes TO. Spontaneous tonsillar hemorrhage. Laryngoscope 1988;98:365-368. Hall SF. Peritonsillar abscess: the treatment options. J Otolaryngol 1990;19:226-229. Haug RH, Wible RT, Lieberman J. Measurement standards for the prevertebral region in the lateral soft-tissue radiograph of the neck. J Oral Maxillofac Surg 1991;49:1149-1151. Heffner DK. Pathology of the tonsils and adenoids. Otolaryngol Clin North Am 1987;20:279-286. Hollinshead WH. Anatomy for Surgeons: the Head and Neck, 3rd ed. Philadelphia: JB Lippincott, 1982. Horn J, Bender BS, Bartlett JG. Role of anaerobic bacteria in perimandibular space infections. Ann Otol Rhinol Laryngol 1991;100(Suppl 154):34-39. Jaakkola S, Johnsson G. The treatment of peritonsillar abscess by incision and tonsillectomy "a froid" at the Oto-Laryngological Hospital, University of Helsinki. Acta Otolaryngol Suppl 1963;188:266-269. Kornblut AD. A traditional approach to surgery of the tonsils and adenoids. Otolaryngol Clin North Am 1987;20:349-363. Kronblut AD. Non-neoplastic diseases of the tonsils and adenoids. In: Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL. Otolaryngology. Volume 3: head and neck, 3rd ed. Philadelphia: WB Saunders, 1991;2129-2147. Kronenberg J, Wolf M, Leventon G. Peritonsillar abscess: recurrence rate and the indication for tonsillectomy. Am J Otolaryngol 1987;8:82-84. Langman J. Medical Embryology, 4th ed. Baltimore: Williams & Wilkins, 1981. Lau SK. Sleep apnoea due to bilateral peritonsillar abscess. J Laryngol Otol 1987;101:617-618. Lee K-J, Traxler JH, Smith HW, Kelly JH. Tonsillectomy: treatment of peritonsillar abscess. Trans Am Acad Ophthalmol Otolaryngol 1973;77:ORL417-421. Levy S, Brodsky L, Stanievich J. Hemorrhagic tonsillitis. Laryngoscope 1989;99:15-18. Lockhart R, Parker GS, Tami TA. Role of quinsy tonsillectomy in the management of peritonsillar abscess. Ann Otol Rhinol Laryngol 1991;100:569-571. Maharaj D, Rajah V, Hemsley S. Management of peritonsillar abscess. J Laryngol Otol 1991;105:743-745. Maisel RH. Peritonsillar abscess: tonsil antibiotic levels in patients treated by acute abscess surgery. Laryngoscope 1982;92:80-87. McCormick MS, Hassett P. Spontaneous hemorrhage from the tonsil (a case report). J Laryngol Otol 1987;101:613-616. McMillan JA, Sandstrom C, Weiner LB, Forbes BA, Woods M, Howard T, et al. Viral and bacterial organisms associated with acute pharyngitis in a school-aged population. J Pediatr 1986;109:747-752. Palumbo FM. Pediatric considerations of infections and inflammations of Waldeyer's ring. Otolaryngol Clin North Am 1987;20:311-316. Paradise JL. Etiology and management of pharyngitis and pharyngotonsillitis in children: a current review. Ann Otol Rhinol Laryngol 1992;101(Suppl 155):51-57. Richardson DA, Birck H. Peritonsillar abscess in the pediatric population. Otolaryngol Head Neck Surg 1981;89:907-909. Rothfield RE, Arriaga MA, Felder H. Peritonsillar abscess in Kawasaki disease. Int J Pediatr Otorhinolaryngol 1990;20:73-79. Salinger S, Pearlman SJ. Hemorrhage from pharyngeal and peritonsillar abscesses. Report of cases, resume of the literature and discussion of ligation of the carotid artery. Arch Otolaryngol 1933;18:464-509. Schechter GL, Sly DE, Roper AL, Jackson RT. Changing face of treatment of peritonsillar abscess. Laryngoscope 1982;92:657-659. Sexton DG, Babin RW. Peritonsillar abscess: a comparison of a conservative and a more aggressive management protocol. Int J Pediatr Otorhinolaryngol 1987;14:129-132. Snow DG, Campbell JB, Morgan DW. Management of peritonsillar sepsis by needle aspiration. Clin Otolaryngol 1991;16:245-247. Snow DG, Campbell JB, Morgan DW. The microbiology of peritonsillar sepsis. J Laryngol Otol 1991;105:553-555. Spires JR, Owens JJ, Woodson GE, Miler RH. Treatment of peritonsillar abscess. A prospective study of aspiration vs incision and drainage. Arch Otolaryngol Head Neck Surg 1087;113:984-986. Sprinkle PM, Veltri RW, Kantor LM. Abscesses of the head and neck. Laryngoscope 1974;84:1142-1148. Stankiewicz JA, Talland C. Peritonsillarlike lateral oropharyngeal abscess after tonsillectomy. Arch Otolaryngol Head Neck Surg 1988;114:1181-1183. Stenfors L-E, Räisänen S. Attachment of bacteria to tonsillar epithelium during acute tonsillitis. J Laryngol Otol 1991;105:29-32. Stevens HE. Vascular complication of neck space infection: case report and literature review. J Otolaryngol 1990;19:206-210. Sugita R, Kawamura S, Icikawa G, Fujimaki Y, Oguri T, Deguchi K. Microorganisms isolated from peritonsillar abscess and indicated chemotherapy. Arch Otolaryngol 1982;108:655-658. Tom MB, Rice DH. Presentation and management of neck abscess: a retrospective analysis. Laryngoscope 1988;98:877-880. Valko P. Immediate tonsillectomy in the presence of quinsy. J Otolaryngol 1983;12:259-260. Wolf M, Kronenberg J, Kessler A, Modan M, Leventon G. Peritonsillar abscess in children and its indication for tonsillectomy. Int J Pediatr Otorhinolaryngol 1988;16:113-117. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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