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American Journal of Emergency Medicine (2013) 31, 267.e1267.


Case Report
Identification of peritonsillar abscess by transcutaneous
cervical ultrasound,,
Intraoral evaluation with ultrasound has been shown to be
an ideal method for differentiating between peritonsillar
abscess (PTA) and peritonsillar cellulitis. Unfortunately,
many patients experience signicant trismus and are unable
to tolerate the intracavitary probe. Evaluation of the
submandibular space with a high frequency linear transducer
from the external aspect of the neck affords an alternative
technique that has been shown to have high specicity for
PTA. Unfortunately, there are no reported cases in the
emergency medicine literature detailing this novel technique.
We present a case of a 30 year old male patient with severe
throat pain and trismus. Ultrasound evaluation of the
submandibular space with a linear transducer demonstrated
a clear peritonsillar abscess and allowed for successful
aspiration of 5 mLs of purulent material.
A 30-year-old man with no medical history presented to
the emergency department with complaints of fever, sore
throat, and odynophagia for 3 days. The patient was noted to
be afebrile with normal vital signs (blood pressure, 128/58;
pulse, 67; respiratory rate, 16; O2 saturation, 99%). On
physical examination, he had trismus and uvular deviation to
the left with bulging of the right peritonsillar area. The
intracavitary ultrasound probe was attempted, but because of
trismus, the patient was not able to tolerate the procedure. A
high-frequency linear transducer was placed under the
mandible aiming at the peritonsillar region on both the
affected and unaffected sides of the neck (Fig. 1). A large
heterogeneous area was noted lateral to the right tonsil
(Fig. 1A). Subsequent needle aspiration of the right
peritonsillar membrane drained 5 mL of purulent material
(Fig. 2). Peritonsillar abscess is the most common deep space
infection of the head and neck region. The incidence is
approximated at 30 cases per 100 000 in the United States

Meetings: none.
Grant: none.
Conicts of interest: none.

0735-6757/$ see front matter 2013 Elsevier Inc. All rights reserved.

and most often occurs in children older than 10 years old and
young adults [1].
The palatine tonsils lay in the depression between the
palatoglossal and palatopharyngeal arches, covered by a
capsule formed by the intrapharyngeal aponeurosis [2].
Peritonsillar abscesses form in the potential space between
the palatine tonsil and its capsule and can spread into muscles
and adjacent vascular structures, which may lead to a lifethreatening airway obstruction and sepsis [2-4].
The progression from tonsillar cellulitis to frank abscess
can be difcult to differentiate because they have overlapping clinical presentations as both may have similar
signs and symptoms. The ability of clinicians to reliably
differentiate PTA from peritonsillar cellulitis by physical
examination alone is limited. In 1 study, the physical
examination by otolaryngologists to predict PTA had a
sensitivity of only 78% and specicity of 50% [3]. Thus,
for indeterminate cases, many clinicians use blind needle
aspiration to differentiate between cellulitis and abscess.
Unfortunately, blind needle aspiration has been reported to
carry a high false-negative rate between 10% and 24%
[5,6]. In addition, the procedure may require repeated
attempts that are both painful and theoretically risky
because of the proximity to the carotid artery. Other
imaging modalities such as computed tomographic scan of
the head and neck exposes the patient, particularly
radiosensitive organs such as the thyroid gland, to large
doses of radiation.
Bedside ultrasound in conjunction with clinical acumen
may offer an alternative method that allows the clinician the
ability to reduce false-negatives rates. A few case series in
the emergency medicine literature have demonstrated the
utility of intraoral ultrasonography in adult patients with
sensitivities of 89% to 95% [3,6-8]. Unfortunately, many
patients with either intraoral cellulitis or abscess have
signicant trismus, preventing an intraoral ultrasound
examination. This transcutaneous cervical technique was
described in a case series of 39 patients, yielding a sensitivity
of 83% and specicity of 93% [8]. We present the rst case
of transcutaneous ultrasound identication of a PTA in the
emergency medicine literature.
To perform the transcutaneous cervical technique, a highfrequency linear transducer can be used to evaluate the
peritonsillar region from the external neck. Place a highfrequency linear transducer under the mandible with the


Case Report

Fig. 1 Transcutaenous ultrasound with affected side showing arrows pointing to the heterogenous PTA lateral and deep to the tonsillar
tissue. The homogenous tonsillar tissue is circumscribed by dotted lines on affected and unaffected sides.

probe marker facing the right of the patient. The sonographer

should evaluate the unaffected side to identify the normal
tonsillar tissue and then proceed to the affected side. For
novice sonographers, we recommend locating the internal
jugular vein and carotid artery and then fanning cephalad
until the pharyngeal tonsil is located. The probe should be
moved laterally after identifying the pharyngeal tonsil. If a
heterogeneous structure suspicious for an abscess is identied
adjacent to the tonsil, place color ow on the structure to
differentiate it from vascular structures or hyperemic tonsillar
tissue. The heterogeneous structure is most likely an abscess
if no ow is seen compared with tonsillar tissue or vascular

structures that will demonstrate color enhancement. If an

abscess is not identied, we recommend the intraoral
technique if the patient will tolerate it.
We report a case that introduces an ultrasound technique
not previously described in the emergency medicine
literature. When patients are unable to tolerate an intraoral
ultrasound examination, we suggest an evaluation with the
transcutaneous cervical technique because of the high
specicity combined with its noninvasive nature.
Matthew Rehrer MD
Daniel Mantuani MD
Arun Nagdev MD
Department of Emergency Medicine
Alameda County Medical Center, Oakland, CA 94602


Fig. 2 A syringe with an 18-gauge needle is inserted with

aspiration of pus conrming PTA.

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Case Report
[5] Buckley A, Moss E, Blokmanis A. Diagnosis of peritonsillar abscess:
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[7] Miziara ID, Koishi HU, Zonato AI, Miniti A, De Menezes MR. The use
of ultrasound evaluation in the diagnosis of peritonsillar abscess. Rev
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[8] Filho B, et al. Intraoral and transcutaneous cervical ultrasound in the
differential diagnosis of peritonsillar cellulitis and abscesses. Rev Bras
Otorrinolaringol 2006;72(3):377-81.

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