Here is a great case written by one of our ultrasound fellows this year, Bill Scheels:

 

A 26-year-old male with no medical history presented to the ED with complaints of a sore throat. The pain started 2 days prior to presentation, but was increasing in severity and exacerbated with swallowing. He was reluctant to eat solids, but was still tolerating fluids. He denied any trouble breathing or other systemic symptoms, such as, fever.

Physical exam was significant for asymmetrical tonsils with the left being larger than the right and mild deviation of the uvula to the right. There was bulging of the soft palate just superior and lateral to the left tonsil. No lymphadenopathy or signs of deep space infection of the neck was present.

Differential for this patient included dental infection, peritonsillar cellulitis, mononucleosis, internal carotid aneurysm, peritonsillar abscess and neoplasm (lymphoma or leukemia). A bedside intraoral ultrasound was performed in the ED using an endocavitary transducer with a probe cover in place.

probe

probe in hand (Meet Dr. Scheels, everyone!)

To help with patient comfort, the patient was handed the transducer, and he was asked to place the transducer over the area of tenderness. (Note from Andie Rowland-Fisher: Bill taught me this technique, and it has worked perfectly every time since then. I only image PTAs this way now.) See demonstration below:

probe in mouth

probe in mouth 2

The patient immediately obtained the images below, and the diagnosis was made.

PTA

PTANotice the hypoechoic cystic structure 2.5-3.0 cm deep

The physicians taking care of the patient performed a needle aspiration with an 18 gauge needle after topical anesthesia with benzocaine. A needle guard was trimmed 2.5 cm as the ultrasound showed the abscess at a depth of 2.5-3.0 cm. (Note from Andie: This procedure can be done either statically or dynamically. When doing the procedure statically, one identifies the pocket of fluid and then puts down the ultrasound transducer and drains the abscess. If I do this procedure statically, I like to use a mac blade to hold down the tongue and provide a light source. When this procedure is done dynamically, the transducer is never put down, and you watch the needle enter the abscess in real time.)

On this patient, the procedure was done statically, and 3 mLs of purulent material was successfully aspirated. The patient was discharged on oral antibiotics and analgesics.

Here is an example of a PTA on a different patient being drained dynamically:

Above is the patient-guided identification of the PTA.

 

See the needle within the abscess above. If you could not identify the needle, here it is in a still shot:

Screen Shot 2016-04-06 at 2.55.57 PM

 

Bottom Line:

  1. Ultrasound can be used to help identify and drain a peritonsillar abscess.
  2. This procedure can be done dynamically, in “real time,” or it can by done statically by identifying where the abscess is, and then putting down the transducer and draining the abscess.

 

 

 

References

Blaivas M, Toeodoro D, Duggal S. Ultrasound-guided drainage of peritonsillar abscess by the emergency physician. Am J Emerg Med.2003;21:155-158
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