Inferior pole peritonsillar abscess
CASE REPORT
Inferior Pole Peritonsillar Abscess Successfully Treated with
Non-Surgical Approach in Four Cases
1
Wang-Yu Su, Wei-Chung Hsu , Cheng-Ping Wang
1
1
Department of Otolaryngology, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan; Department of Otolaryngology ,
National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
ABSTRACT
Inferior pole peritonsillar abscess is uncommon and easily overlooked because it has no obvious physical appearance and there is a
low index of suspicion by clinicians. In this report, we present four patients with inferior pole peritonsillar abscess who all had
severe symptoms (fever, sore throat, muffled voice, trismus and painful neck) but had no obvious distortion of the peritonsillar
structure. Careful oropharyngeal examination and a high index of suspicion are critical to make the diagnosis at an early disease
stage, when the abscess can be treated with antibiotics without immediate tonsillectomy. This treatment strategy can be used if a
patient is immunocompetent and the initial treatment response is good. (Tzu Chi Med J 2006; 18:287-290)
Key words: antibiotics, deep neck infection, inferior pole, peritonsillar abscess
INTRODUCTION
Peritonsillar abscess is an acute tonsillar infection
with abscess formation in the peritonsillar space, which
is located between the tonsil bed and the tonsillar capsule.
Superior pole peritonsillar abscess, which develops in
the superior part of the peritonsillar space, is not
uncommon, but inferior pole peritonsillar abscess, which
is located in the inferior peritonsillar space, is rare and
easily overlooked in clinical practice [1-4]. Superior pole
peritonsillar abscess is usually treated with repeated aspiration or simple incisional drainage of the pus without
the need for tonsillectomy. However, inferior pole peritonsillar abscess is always treated with immediate tonsillectomy because this infection is much more severe
and needle aspiration/incision is technically difficult to
be performed [4]. But if inferior pole peritonsillar abscess is diagnosed at the early stage, it may be treated
using a non-surgical approach. In this paper, the authors
report the clinical manifestations in four patients with
inferior pole peritonsillar abscess who were successfully
treated with medical management instead of immediate
tonsillectomy.
CASE REPORTS
Case 1
A 40-year-old man without systemic disease visited a hospital with a one-week history of fever, progressive sore throat, dysphagia, left neck pain and
muffled voice despite taking oral antibiotics prescribed
by a doctor. On examination, his left tonsil and anterior
pillar were slightly injected without exudates or uvula
deviation. Laryngoscopy revealed mild asymmetric
swelling at the inferior pole of the left tonsil. The epiglottis and hypopharynx appeared normal. The retromandibular area on the left side of the neck was tender
and swollen. The blood leukocyte count was 12290/µL
with left shifting. The serum C-reactive protein level
was 6.69 mg/dL. A computed tomography (CT) scan of
Received: October 14, 2005, Revised: November 1, 2005, Accepted: November 30, 2005
Address reprint requests and correspondence to: Dr. Cheng-Ping Wang, Department of Otolaryngology, National Taiwan
University Hospital, 7, Chung Shan South Road, Taipei, Taiwan
Tzu Chi Med J 2006 18 No. 4
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W. Y. Su, W. C. Hsu, C. P. Wang
the neck revealed an abscess in the inferior part of the
left peritonsillar fossa (Fig. 1A). He received parenteral
antibiotics with ampicillin plus sulbactam, and his symptoms dramatically subsided within 24 hours. Therefore,
he did not receive surgical drainage. After administration of parenteral antibiotics for four days, he was discharged and remained well without any sequelae for 42
months.
Case 2
A 15-year-old girl suffered from severe sore throat
and progressive dysphagia with persistent fever for one
week despite taking oral antibiotics and analgesics. On
admission, significantly muffled voice, trismus of one-
finger width and painful swelling in the left upper side
of the neck were noted. The uvula and soft palate appeared normal without deviation. The left tonsil was
slightly reddened. Laryngoscopy revealed a large bulge
in the lower pole of the left tonsil. The larynx and hypopharynx appeared normal. A CT scan of the neck revealed a large abscess in the lower part of the tonsil and
a hazy appearance in the parapharyngeal space (Fig. 1B).
She received parenteral antibiotics with ampicillin and
sulbactam. She felt much better and the swelling in the
lower pole of the left tonsil rapidly regressed within 48
hours. She continued to receive parenteral antibiotics
for one week, and did not have tonsillectomy. The patient was well without recurrence during a 34 month
A
B
C
D
Fig. 1.
OUU
Axial computed tomography (CT) scan of the neck with contrast enhancement. (A) Case 1: CT of the neck reveals a small
hypodense lesion in the lower part of the left peritonsillar space with inflammatory changes in the ipsilateral tonsil. (B)
Case 2: CT of the neck shows a large hypodense lesion with heterogeneous content occupying the lower part of the left
tonsil. (C) Case 3: CT of the neck reveals a hypodense lesion in the lower posterior part of the right peritonsillar space. (D)
Case 4: CT of the neck reveals a small hypodense lesion in the lower part of the left peritonsillar space with inflammatory
changes around it.
Tzu Chi Med J 2006 18 No. 4
Inferior pole peritonsillar abscess
follow-up period.
Case 3
A 43-year-old man without systemic disease visited the hospital with a 5-day history of progressive sore
throat, dysphagia, right neck pain and muffled voice.
On examination, the right tonsil was injected without
exudate coating or uvula deviation. Laryngoscopy revealed an obvious swollen bulge in the lateral pharyngeal wall at the inferior pole of the right tonsil. The epiglottis and hypopharynx appeared normal. The blood
leukocyte count was 18180/µL with neutrophils
predominant. The serum C-reactive protein level was
2.77 mg/dL. A CT scan of the neck revealed an abscess
confined within the inferior part of the right peritonsillar space (Fig. 1C). A bacterial culture of the blood grew
streptococcus pneumoniae. He received parenteral antibiotics with ampicillin and sulbactam. The symptoms
dramatically improved within 24 hours. After administration of parenteral antibiotics for five days, he was
discharged and remained well during a 2-year followup period.
Case 4
A 20-year-old woman had a high fever and severe
sore throat for 4 days and was treated with oral antibiotics under the diagnosis of acute tonsillitis. However the
symptoms worsened and muffled voice and trismus
developed. On admission, physical examination revealed
swelling of the lateral pharyngeal wall at the inferior
pole of the left tonsil without pus on the tonsillar surface or uvula deviation. The epiglottis and hypopharynx appeared normal. The blood leukocyte count was
15970 /µL with neutrophils predominant. The serum Creactive protein level was 7.11 mg/dL. A CT scan of the
neck revealed an abscess in the inferior part of the left
peritonsillar space with parapharygneal space involvement (Fig. 1D). A bacterial culture of the blood grew
streptococcus pneumoniae. She received parenteral antibiotics with ampicillin plus sulbactam. The symptoms
rapidly improved within 48 hours. After administration
of parenteral antibiotics for seven days, she was discharged and remained well during the 2-year follow-up
period.
DISCUSSION
Peritonsillar abscess, one of the most common deep
neck infections, is usually characterized by pus accumulation in the superior part of the unilateral peritonsillar space which can cause medial and downward dis-
Tzu Chi Med J 2006 18 No. 4
placement of the tonsil and the soft palate, with an
edematous uvula deviated to the opposite site. Therefore,
superior pole peritonsillar abscess is easily recognized
on physical examination and can be successfully treated
with prompt and adequate management. Peritonsillar
abscess also develops in the lower part of the peritonsillar space, which is separated from the superior part by
the triangular ligament. But, the clinical incidence of
inferior pole peritonsillar abscess is much lower than
that of superior pole abscess [1-4]. The etiology of this
phenomenon remains unknown. One possible reason is
that Weber's glands, the origin of peritonsillar abscess,
are mainly located within the superior pole [2]. In
addition, an inferior pole peritonsillar abscess quickly
spreads into the adjacent tissue, such as the
parapharyngeal space, because the inferior peritonsillar
space is smaller and the constrictor musculature in this
area is less resistant [3,4], and thus may be present with
other more extensive neck infections clinically.
Importantly, inferior pole peritonsillar abscess only
causes erythematous changes in the affected tonsil without the obvious distortion of the oropharyngeal structure seen in superior pole abscess [4]. Therefore, inferior pole peritonsillar abscess is easily overlooked and
often misdiagnosed as acute tonsillitis.
Familiarity with the clinical presentation of inferior pole peritonsillar abscess is the key to making the
correct diagnosis at an early stage. Although inferior pole
peritonsillar abscess causes only mild bulging of the
lateral pharyngeal wall at the inferior pole of the tonsil,
reports in the literature and the case reports of these 4
patients [2,4] show that it always presents with fever,
severe sore throat, dysphagia, trismus, muffled voice and
painful swelling in the upper neck. These synptoms are
all actually indicative of severe infection and should alert
the clinician that this abscess, not simple pharyngotonsillitis, is the correct diagnosis. Therefore, if a patient
has these symptoms without obvious changes in the peritonsillar structure, careful examination by a laryngoscope
with a high index of suspicion is critical to diagnose
inferior pole peritonsillar abscess. If no definitive impression is revealed by physical examination, computed
tomography is useful for detection of an abscess in this
space and for evaluation of the extent of infection [4,5].
Needle aspiration or incision and drainage with a
local anesthetic is the mainstay of management for superior pole peritonsillar abscess [6]. Immediate tonsillectomy is reserved for specific situations, such as an
uncooperative child, bilateral peritonsillar abscess, extension of a severe infection, or immunocompromised
status with no treatment response to antibiotics [1,6-8].
Inferior pole peritonsillar abscess is another indication
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W. Y. Su, W. C. Hsu, C. P. Wang
for immediate tonsillectomy because needle aspiration
or incision with a local anesthetic is technically difficult
when draining an abscess below the tonsil [1,3]. But as
seen in our 4 patients, it is possible to successfully treat
inferior pole peritonsillar abscess with parenteral antibiotics and close observation without immediate
tonsillectomy. Our 4 patients were all under 43 years
old and immunocompetent, and had no significant systemic diseases. Therefore, if a younger patient is immunocompetent and the treatment response with antibiotics is good during the first 48 hours, parenteral antibiotics with close observation can be used as the treatment
for inferior pole peritonsillar abscess. Immediate tonsillectomy with drainage of the abscess may be reserved
for patients with an immunocompromised status, a poor
response to antibiotics, or a life-threatening condition.
From the follow-up experience with these 4 patients,
the recurrence rate of inferior pole peritonsillar abscess
without immediate tonsillectomy seems to be low, although the follow-up period was not long. Interval tonsillectomy may be reserved for patients with repeated
infections.
CONCLUSION
Inferior pole peritonsillar abscess is easily overlooked because it does not have the obvious physical
appearance of superior pole peritonsillar abscess. If a
patient suffers from severe odynophagia, trismus,
muffled voice and painful swelling in the upper neck
but has no significant changes in the peritonsillar
OVM
structure, careful examination with a laryngoscope and
a high index of suspicion are critical to making the correct diagnosis. Adequate antibiotic treatment without
tonsillectomy may be the treatment choice if a patient is
young, immunocompetent, and has no significant systemic diseases and the initial treatment response is good.
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