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SONOGRAPHIC EVALUATION OF PERITONSILLAR ABSCESS Ayomide Loye PGY 1 PERITONSILLAR ABSCESS • Most common deep space infection of head and neck • Incidence of 1 in 10,000. • Most common in adolescent with an antecedent sore throat • Clinical presentation: ill appearance with fevers, dysphagia/odonophagia, trismus, drooling, peritonsillar erythema + swelling and muffled “hot potato” voice • Complications • Rupture into airway • Dissection into carotid • Regional spread leading to sepsis. ANATOMY OF A PERI-TONSILLAR ABSCESS • Pathophysiology: Inflammation of minor salivary gland (Weber’s gland) which lies superior to the tonsils. • Affected tonsil is anteriorly and medially displaced. • Uvula displaced away from affected side. • Carotid artery and jugular vein located 2.5cm posterior and lateral to tonsil LANDMARK BASED PTA ULTRASOUND GUIDED PTA DRAINAGE • Equipment • Intraoral or Intracavitary probe. • Procedure and Technique • Cover intracavitary probe with a layer of gel and probe cover • With patient sitting up, insert probe into mouth to side of suspected abscess (Might be helpful for patient to insert probe to prevent gagging and anxiety) • Determine size and depth of fluid collection. • Determine depth of carotid artery • Chose appropriate needle length • Complications • Rare. Mostly due to sonographic image misinterpretation. STUDY CONCLUSION • Ultrasound established correct diagnosis (PTA vs PTC) more than LM • More successful aspiration of purulent material with US • ENT consult rate was 7% for US vs 50% for LM • CT usage rate was 0% for US vs 35% for LM ULTRASOUND VS CT SCAN Prospective single cohort study where 24 patients were evaluated in the ED for peritonsillar infection. Intraoral ultrasound was performed and presence or absence of abscess was noted. ULTRASOUND VS CLINICAL DIAGNOSIS VS CT • Scott et al: Prospective study with sample size of 14 patients to determine diagnosis of peri-tonsilar infection using clinical diagnosis, ultrasound and CT. • Clinical impression • Sensitivity: 78% • Specificity: 50% • Ultrasound • Sensitivity:89% • Specificity:100% • Computerized tomography • Sensitivity:100% • Specificity:75% • Bottom Line: Intraoral US useful in improving accuracy in distinguishing abscess from cellulitis CONCLUSION • Ultrasound can improve accuracy of diagnosing PTA when used in conjunction with clinical diagnosis • Ultrasound reduces the number of unnecessary needle aspiration attempts in patients suspected of having PTA • Ultrasound led to more successful aspirations of PTA • Ultrasound can reliably rule out abscess making CT scan for diagnosis unnecessary REFERENCES • 1) Constantino T, Satz W, Dehnkamp W, Goett H. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Academic Emerg Med. 2012; 6:626-631. • 2) Scott P.M., Loftus W.K., Kew J. et al. Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. J Laryngol Otol. 1999; 113:229–232. • 3) Roberts J, Hedges J. Clinical Procedures in Emergency Medicine, 6th ed. Philadelphia, PA: Saunders, 2014; 1282 • 4) Nogan S, Jandall D, Cipolla M, Desilva B. The use of ultrasound imaging in evaluation of peritonsillar infection. Laryngoscope 2015 Nov; 125(11): 2604-7 • 5) Scott PM, Loftus WK, Kew J, Ahuja A, Yue V, van Hasselt CA. Diagnosis of peritonsillar infection: a prospective study of ultrasound, computer tomography and clinical diagnosis.