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We present a rare case of renal cell carcinoma metastatic to the tonsil. Tonsillectomy was inadvertently performed during an attempt to drain what was clinically a peritonsillar abscess.
Streptococcus constellatus, S. intermedius, and S. anginosus, the three species of the S. milleri group, form part of the normal flora most commonly found in the mouth, throat, gastrointenstinal tract, and genital tract. The S. milleri group has become known as an important pathogen in abscess disease, but little attention has been paid to their role in deep neck abscesses. We have treated 9 patients with deep neck abscesses relating to the S. milleri group since 1991, and regarded this group as an important pathogen also in these abscesses. We studied the frequency of the S. milleri group isolated from deep neck abscesses in our cases and from the literature and discuss clinical significance and bacteriological pathogenesis. Cases numbered 27 treated at our facility since 1991 and 200 cases reported in the Japanese literature since 1990. Of our 9 cases, 4 originated from acute pharyngitis, 3 from peritonsillar abscesses, and 2 from odontogenic infection. Serious complications such as mediastinitis, cervical necrotizing fasciitis, sepsis accompanied by disseminated intravascular coagulation, and spondylitis of the cervical vertebrae were seen in 4 cases. Among organisms isolated, the S. milleri group appeared to be a pathogen contributing to abscess formation and to serious complications. The genus Streptococcus was most frequently isolated both in our 27 cases (66.7%) and the 200 in the literature (45.5%). Among species of the genus Streptococcus, the S. milleri group numbered the highest in our cases at 33.3% but only 8.5% in the literature. Cases in the literature, however, contained many unknown species of Streptococci--31.5% vs. 18.5% in our cases. alpha-streptococcus was frequently reported in the literature among unknown species of Streptococci--36 of 63. Culture-negative cases were also numbered more in the literature than in our case--29.0% vs. 18.5%. Special conditions and procedures are required to suitably isolate and detect the S. milleri group. Since not all facilities use identical techniques in routine bacteriological examination, a considerable number of the S. milleri group could be missed in unknown species of Streptococci or alpha-streptococcus and culture-negative cases. The detailed pathogenesis of the S. milleri group remains to be clarified. Infection by normal flora on mucosa is thought to occur due to an imbalance between organisms and host defense in deep neck abscesses. Some strains of the S. milleri group have been reported to produce many tissue-destroying enzymes such as collagenase and hyaluronidase. The co-existence of the S. milleri group with some anaerobe strains has also been suggested to accelerate inflammation. We discuss the mechanism inducing the massive release of cytokines through T cell response to certain exotoxins produced by S. milleri group, as reported in toxic shock-like syndrome due to the group A beta-streptococcus and in alpha-streptococcal shock syndrome due to viridans streptococci (alpha-streptococci).
The case describes a 21-year-old patient who was referred to the casualty ward due to post tonsillectomy haemorrhage. The patient who had been operated for a peritonsillar abscess eight days earlier, died in spite of optimal treatment.
Peritonsillitis and peritonsillar abscess (quinsy) are commonly encountered emergencies in day to day ENT practice. However the value of a tonsillectomy as well as its timing in these cases is debatable amongst Otolaryngologists. A postal survey performed amongst practising ENT surgeons in the U.K. revealed that 475 out of 571 ENT surgeons (83%) prefer to "wait and observe" for a single isolated attack of peritonsillitis/peritonsillar abscess while 86 surgeons (15%) would routinely advocate interval tonsillectomy after an attack of peritonsillitis/quinsy. In patients without a background history of tonsillitis, 432 of the 475 ENT surgeons (90.9%) would advise a tonsillectomy after the second attack of peritonsillitis/quinsy whereas 30 surgeons (6.3%) would do so only after a third attack. A retrospective study of 207 patients was performed to evaluate the safety of a "wait and observe" policy. One hundred and four of the 129 adults (88.3%) and 5 out of the 6 children (83.2%) who did not undergo a tonsillectomy remained asymptomatic after the single isolated attack of peritonsillitis/quinsy. Four adults (3.1%) and 1 child (16.6%) required a tonsillectomy eventually for recurring attacks of tonsillitis. Recurrence of peritonsillitis/peritonsillar abscess was observed in 11 patients (8.5%). These results suggest that a "wait and observe" policy is safe for most patients presenting with a single attack of peritonsillitis/peritonsillar abscess without a background history of tonsillitis.
A case of the neck phlegmon on the seventh day after the tonsillectomy due to recurrent peritonsillar abscesses was described. Intravenous antibiotic therapy (Amikacin) and drainage prevented complications was applied. The complete recovery was observed.
Antibiotic therapy has changed the face of medicine radically, and physicians no longer have the empirical knowledge of bacterial infections that they once had. Consequently, the diagnosis and management of complicated infections presents a significant challenge to today's otolaryngologists. We present a rare complication, even before the advent of antibiotics, of a head and neck infection: a carotid artery pseudoaneurysm resulting from peritonsillar abscess. The diagnosis and management of this problem is discussed and the pertinent literature reviewed.
Pus obtained by needle aspiration of 91 peritonsillar abscesses was examined microbiologically. A positive culture was obtained in 55 patients (60 per cent). Sixty-four bacteriological isolates were grown. Forty patients had a pure growth of a single organism, of which 21 (53 per cent) were beta Haemolytic streptococci. Pure growths of Staphylococcus aureus were found in only three patients. Fifteen patients had mixed organisms, including anaerobes, in their pus and the resistance to penicillin was low. Only the bacteroides species were generally penicillin resistant. The vast majority of patients made a good recovery following needle drainage of the abscess and treatment with parenteral penicillin. The patients with a mixture of penicillin sensitive and penicillin resistant organisms also made a good clinical recovery following needle drainage and administration of parenteral penicillin. The relevance of these findings in the pathogenesis and management of peritonsillar sepsis is discussed.
Quinsies (peritonsillar abscesses) are routinely treated in all ENT departments. This paper outlines a technique for safe aspiration of a quinsy, which minimizes the risk to adjacent structures.
Tonsillectomy (TE) is one of the most frequent as well as one of the most controversial surgical interventions. The objective of this paper was to assess the evidence of the most common indications for TE. For this purpose the literature of the past 25 years was analysed using the criteria of evidence based medicine. In children seventy-five percent of TEs are performed because of recurrent tonsillitis. Several randomised clinical trials (RCTs) have demonstrated the efficacy of TE in this disease. This indication is based on evidence grade I-II. No consensus has yet been reached, however, about the number of annual episodes that justify TE. The remaining paediatric TEs are performed to relieve symptoms of airway obstruction. TE has been shown to improve obstructive symptoms in up to 100% of patients. It is the accepted treatment of paediatric obstructive sleep apnoea, although the evidence is not based on major RCTs. In adults, too, the majority of TEs are performed for recurrent or chronic tonsillitis. There are no good RCTs, but the indication can be based on a series of well controlled studies (evidence grade III). Obviously, TE is indicated if there is suspicion of neoplasm. Peritonsillar abscess per se is no indication for TE, unless the abscess cannot be drained otherwise. TE plays no role in the standard management of OSAS and mononucleosis.
From 1989 to 1991, 126 tonsils were prospectively studied in cadavers, volunteers and patients by B-scan ultrasonography. The transducer was positioned just medial of the mandibular angle. The submandibular gland, M. digastricus, M. stylohyoideus and the tongue proved to be suitable landmarks. Normal and chronically inflamed tonsils both presented as oval structures with weak echos. Peritonsillar abscess could not be sonographically defined in 13/15 cases. Squamous cell carcinoma presented with random echos and indistinct borders. Infiltration of the base of the tongue could be safely confirmed.
The major advantages of immediate tonsillectomy in the treatment of peritonsillar abscess include rapid relief of symptoms, a short hospital stay, and elimination of a subsequent interval tonsillectomy. The procedure performed 26 times under routine general anesthesia with intubation over a two year period proved safe and effective.
Bilateral peritonsillar abscesses are rare and often not diagnosed until tonsillectomy. As the condition may create diagnostic problems and serious complications, a case history is presented. The importance of rapid otorhinolaryngological examination and treatment is stressed.
A Fifteen years girl belonging to a low socioeconomic status was admitted with peritonsillar abscess caused by methicillin resistant Staphylococcus aureus (MRSA), high fever, diarrhoea and septicaemic shock. Initial blood cultures and widal test, stool cultures and routine stool examination were non-contributory to the diagnosis. A bone marrow culture in the second week confirmed the diagnosis of Salmonella typhi infection. Examination of a fresh stool sample showed cysts of Entamoeba histolytica. She was treated with ciprofloxacin, metronidazole, augmentin and ceftriaxone. She had no clinical evidence of immunosuppression prior to this episode and her HIV test was negative. This case report highlights the presence of community acquired MRSA infection causing perititonsillar abscess, and the diagnostic dilemma of fever and diarrhoea due to coinfection with Salmonella typhi and Entamobea histolytica.
We became aware that a range of antibiotics were being used in our unit to treat patients suffering from tonsillitis or peritonsillar abscess (quinsy). There appeared to be no rationale to determine which antibiotics were used, and we felt that we were possibly using expensive antibiotics when cheaper equally effective ones were available. An audit project was therefore devised to establish the current practice in the ENT Unit at the City Hospital at Edinburgh. Following a six-month prospective pilot study, a protocol for the treatment of tonsillar and peritonsillar sepsis was drawn up and subsequent practice and outcome was then audited, thus completing the audit cycle. As a result substantial savings in the cost of prescribed antibiotics have been made without compromising patient care.
Eucalyptus-based drug eucalymine made in Russia has been tried in children with acute maxillary sinusitis, exacerbation of chronic purulent maxillary sinusitis and peritonsillar abscess. The findings indicate a good antiinflammatory effect of eucalymine which can be used as a treatment of choice in children with ENT diseases.
Twenty-four children with severe peritonsillar infections, subjected to unilateral tonsillectomies were studied with regards to the incidence of late infections in the remaining tonsil. Unilateral immediate tonsillectomy is an effective and sufficient treatment for unilateral peritonsillar abscesses in children or adolescents. The removal of the opposite uninvolved tonsil is not justified for it increases the risk of surgical morbidity, deprives the individual of an immunocompetent organ and does not result in demonstrable clinical benefit.
OBJECTIVE: To review recent clinical trials that provide a foundation on which clinicians can base decisions regarding adenotonsillar surgery for their patients. STUDY DESIGN: Review. METHODS: An evidence-based approach was used to review recent clinical trials addressing indications for adenotonsillectomy, tonsillectomy, and adenoidectomy. RESULTS: Absolute indications for tonsillectomy and adenoidectomy include adenotonsillar hyperplasia with obstructive sleep apnea, failure to thrive, or abnormal dentofacial growth; suspicion of malignant disease; and (for tonsillectomy) hemorrhagic tonsillitis. Relative indications for both procedures are adenotonsillar hyperplasia with upper airway obstruction, dysphagia, or speech impairment, and halitosis. Otitis media and recurrent or chronic rhinosinusitis or adenoiditis are relative indications for adenoidectomy but not tonsillectomy. Recurrent or chronic pharyngotonsillitis, peritonsillar abscess, and streptococcal carriage are relative indications for tonsillectomy but not adenoidectomy. CONCLUSION: Good clinical evidence regarding indications for tonsillectomy and adenoidectomy is available. Clinicians should make recommendations for surgery on the basis of this evidence.
Solitary fibrous tumors are rare tumors originating from the mesenchymal tissue. In most cases they arise from the subpleural tissue but have also been described in other locations in the body. Most such tumors in the head and neck region occur in the orbit. Although malignant tumors can occur, benign tumors are far more common. The therapy is surgical excision. For a conclusive diagnosis, a typical morphology and immunohistochemistry are required. The tumor is strongly positive for CD34 and vimentin. This report describes the clinical appearance and treatment of a solitary fibrous tumor of the parapharyngeal space in a female patient. The symptoms were similar to those in a peritonsillar abscess, one of the more common ear-nose-throat dysfunctions. Fewer than 10 cases of a solitary fibrous tumor of the parapharyngeal space have been described in the literature.