March 2005

A 17-year-old boy is admitted to the hospital for evaluation and treatment of poor oral intake and dehydration due to prolonged sore throat. His symptoms began a little over a week earlier. When he was initially evaluated, he was diagnosed with viral pharyngitis and treated symptomatically, but because his symptoms continued to worsen, he was seen again five days later. The throat pain appeared to be worse on the left.

His past medical history is unremarkable, and immunizations are up to date.

Examination reveals a fever of 102°F and inflamed tonsils and posterior pharynx as shown in Figure 1. He also complains of difficulty opening his mouth, causing pain (trismus). There is no palpable adenopathy, and the rest of the exam is normal. A computed tomography (CT) scan of this condition is shown in Figure 2.

What’s Your Diagnosis?

1. Retropharyngeal abscess
2. Epiglottitis
3. Peritonsillar abscess
4. Dental abscess

Answer

The answer is peritonsillar abscess (C) as suggested by the history of prolonged, worsening symptoms, including trismus and visible swelling of the left tonsil with deviation of the uvula to the right. Trismus, by the way, comes from the Greek word trismos, which was used to describe the “lockjaw” appearance of tetanus. Now, anything that causes pain or limits the ability to open the mouth is referred to as trismus.

Some otolaryngologists ask for confirmation by CT scan before going to surgery. This patient was taken to the operating room, where the abscess was incised and drained (Figure 3). Historically, this condition has been referred to as “quinsy,” from the Greek word for “sore throat,” and initially applied to almost anything that caused throat pain. Nowadays, it generally refers to a peritonsillar abscess. Like other deep neck infections, the etiology often includes Streptococcus pyogenes and/or Staphylococcus aureus. However, as Brook and others have shown, when anaerobic techniques are used, these organisms are found to play a significant role, probably the dominant role.

When there is an obvious abscess, as shown in this patient, the preferred treatment is surgical drainage and IV antibiotics. Given the usual causes as noted by Brook ( Acta Paediatr Scand. 1981;70:831 and Laryngoscope. 1991;101:289), a reasonable choice would be clindamycin. If drainage is performed, ideally cultures for aerobes and anaerobes should be obtained. One never knows when it might come in handy to actually know the cause(s). Occasionally, one may be dealing with a cellulitis, or phlegmon, as determined by imaging (see below), and IV antibiotics may be all that’s needed. Without tonsillectomy, the risk of abscess recurrence can be as high as 20%.

Other choices

Retropharyngeal abscesses may have a similar presentation, although it would more likely present with stridor and possible dysphagia. These patients can also have neck stiffness but are not as likely to have trismus. CT imaging is usually diagnostic (Figure 4), but in the absence of a scan, one can often get an idea with a properly positioned lateral soft-tissue radiograph that shows thickened retropharyngeal space (Figure 5). The treatment is the same as above.

Epiglottitis is rarely seen today, thanks to the widespread use of Haemophilus influenzae type b immunization. However, it can always make a comeback or be caused by other organisms. The presentation is typically abrupt in onset and progresses rapidly with possible airway obstruction. The diagnosis should be made or ruled out in the operating room by an otolaryngologist as he or she is preparing to intubate the child. In the bad old days, lateral neck films were used (Figure 6), often times unattended by a physician in the radiology department, where resuscitation would be very difficult if the child’s airway suddenly closed. Once the airway is secure, IV antibiotics are used for a seven- to 14-day course depending on the organism (if recovered). The child can usually be safely extubated within a few days. Till then, the most important thing to do is to be sure the endotracheal tube is secured such that there is no way the child (or inattentive doctors and nurses) can accidentally pull it out.

A dental abscess (Figure 7) can certainly cause some pain in the mouth and may result in trismus, but the diagnosis is usually easy to make with a good oral exam. Occasionally, a CT scan is needed by the oral surgeon to get a better idea of the extent of the underlying abscess (Figure 8). Drainage alone is probably curative, but most will give an antibiotic for a week or so. A reasonable choice is plain old penicillin, although some experts feel clindamycin might be a better choice. It probably does not matter.

Phlegmon or cellulitis

By the way, have you ever read a report on a CT scan or an MRI that included a phlegmon in the description? A series of similar Greek words that relate to inflammation or heat include phlegma (phlegm), phlegmesia (old term for inflammation) and phlegmon. According to Dorland’s Medical Dictionary (30th edition), phlegmon is defined as “a spreading, diffuse inflammatory reaction to infection with microaerophilic streptococci, which forms a suppurative or gangrenous and undermining lesion that may extend into deep subcutaneous tissues and muscles, creating multiple small pockets of pus.” How this can be seen looking at various shades of gray shadows must be truly mystical. I know I don’t have the ability to see these small pockets of pus, even when they are pointed out to me (even though I pretend I do in order to not look stupid). So, I believe radiologists sometimes say phlegmon when they really mean cellulitis. Some do not draw any distinction between cellulitis and a phlegmon, and I must say the definitions are similar. I think in common sense terms, a phlegmon is the earliest stage of abscess development, but I don’t know how to clinically distinguish between the two.

Lastly, I would like to again plug the 39th Annual Uniformed Services Pediatric Seminar (USPS), March 20-23, in San Antonio. You can find information on the meeting at the following AAP Web site: www.pedialink.org/pedialink/cme/coursefinder/Detail.cfmId=22416&area=liveCME. You may not receive this in time to make it, but in case you do and you are looking for a very fine pediatric meeting and fun place to go, come on to San Antonio and I’ll see you there.

If you miss the USPS and are still looking for an excellent meeting to attend in March, I would strongly recommend the 25th Annual National Pediatric Infectious Diseases Seminar (NPIDS), in Washington, D.C., from March 30 to April 2. This is one of the finest pediatric infectious diseases meetings you can find, and it too will be in a fun and fascinating place. For information, go to www.npids.org or just Google it. If you can make it, I will also see you there.

For more information:

• James H. Brien, DO, Pediatric Infectious Disease, Scott and White’s Children’s Health Center and Associate Professor of Pediatrics, Texas A&M University, College of Medicine, Temple, Texas.