0:00

Number four,

0:02

which is another patient who had fever and

0:07

left-sided throat pain.

0:10

So this is incredibly common in the emergency

0:15

department for us to be doing an evaluation for this.

0:20

Um,

0:22

my shift that I work is four 30 to 11:00 PM

0:28

at night, and therefore,

0:32

I'd say about two thirds of what I do is emergency room. And about one third is,

0:36

uh, inpatient studies.

0:39

And not a night goes by that I don't see R O P T

0:44

a rule out peron or abscess.

0:47

So we know that clinically the patient's complaining about a sore throat,

0:50

they look in there with a tongue depressor, they see enlarged tonsils,

0:54

and there's some narrowing of the airway, and they say,

0:56

rule out p t a rule out a peritoneal abscess. So,

1:02

um, very frequent contrast enhanced examination.

1:09

And in this, uh, case,

1:12

what we are looking for is the low density that's associated with

1:17

the tonsil. Uh,

1:20

and we want to see a well-defined collection,

1:24

and we define well-defined often with a peripheral

1:30

rim of contrast enhancement that is well-defined,

1:34

not indistinct. So for example,

1:37

the previous case where we had that rim of enhancement, we would say, oh,

1:41

that's an abscess that someone could put a needle in and drain cure material.

1:46

Here we have a case where we do see low

1:51

density on the left side,

1:55

and it looks like there may be a little bit of peripheral enhancement,

1:58

but it's not well defined.

2:03

It does have mass effect on the airway,

2:10

but it's not a well-defined collection.

2:17

Now, if we look at the full extent of the abnormality,

2:21

what we see is that even at the nasopharyngeal level,

2:24

there's some blunting of the SMU and some thickening Here.

2:29

Here is our palatine tonsil and soft palate level where it's thick.

2:33

Here's our lower density area, which is

2:38

we're extending laterally.

2:40

Here is our para pharyngeal space bat. Here's the normal side.

2:45

We can see that it's grayer brighter rather than black,

2:49

and so there is edema in the paranal space.

2:53

As we continue lower down,

2:57

we come to the epiglottis.

2:59

The epi gloss allows us to say that what's above it is

3:04

oropharynx and what's below it is hypo pharynx.

3:07

So now we have hypo pharyngeal edema coming down.

3:11

We're at the level of the area epiglottic fold here. Here's our piriform sinus.

3:16

It's still low density and still even paralytic.

3:19

There's some swelling here in the paralytic space.

3:23

Here's the normal fat of the paralytic space.

3:26

Here's our area epiglottic folder epiglottis.

3:29

And as we come down to the level of the false focal cords,

3:34

again, it's still swollen in the hypo pharynx.

3:37

When we get to the true vocal cord level, here's our laryngeal ventricle,

3:41

we're out of it. Subglottic looks good. Trachea esophagus looks good.

3:46

So the full extent of this does go into the hypo

3:51

pharynx and sup gods,

3:53

and it starts at the nasal pharyngeal level. So,

3:59

uh, at this point I'm going shift to a, a article I'd like to share with you.

4:06

It's not exactly the article we want to

4:13

have, but it's a good article from the standpoint of

4:19

that this is a, an issue that we raise quite frequently.

4:24

When do we use the term edema?

4:28

When do we use the term separative tonsillitis?

4:33

When do we use the term flagman and when do we use the term

4:39

abscess? In this case,

4:41

Jenny Hung's article is about the retro pharyngeal space,

4:44

but it asks how do you decide whether something's an abscess?

4:47

And she talks about the,

4:50

the fluid distribution and how in the retro pharyngeal space it's an

4:54

abscess when often when you see it crossing the midline.

4:57

So it's not just necrotizing ATUs.

5:00

So separative lymph node usually unilateral the

5:05

configuration bow tie edema, rounded,

5:10

rounded with mass effect, thick enhancing wall, no,

5:15

maybe in the lymph node must have an enhancing wall for us to call it an

5:19

abscess. And then ancillary findings, your primary infectious source. So,

5:26

uh, although this is a different location,

5:31

this low density without any enhancement was what we might suggest would be

5:35

called tonsillitis. And then low density

5:41

that has a little bit of mass effect. Maybe, you know, sive tonsilitis,

5:46

the peripheral rim of enhancement is

5:51

going to be when we start calling it an abscess.

5:54

Here's this big abscess here, not too subtle.

6:01

So in this situation,

6:03

when it does not meet our criteria for an

6:08

abscess with a well-defined wall and enhancement

6:13

around the periodontal collection,

6:18

we would call it a flagg mon.

6:22

If it was just the tonsils that had

6:27

little low density within it,

6:30

we usually just call that sive tonsils. This is extending too far laterally,

6:35

and it has associated pararenal space fat edema.

6:38

So we're going say that this is in the peritoneal space.

6:42

Suffice it to say that tonsil abscesses are very

6:48

uncommon.

6:48

Almost everything that looks like it's a tonsil abscesses is actually not in the

6:53

tonsil itself, but in the peritoneal space, which is defined by the, uh,

6:57

the fascia that is outside of it. So,

7:03

um, in this situation, um,

7:07

flagman is a good, uh, name. Now

7:13

what, why, what's in the name? Well,

7:16

it used to be that people would operate on,

7:22

um,

7:24

peri tonsil abscesses and take out the tonsil acutely.

7:28

And with the infection that's,

7:31

that approach is no longer valid. It's not been valid for years.

7:35

What what we learn is that many of these quote unquote abscesses

7:40

are readily treatable with antibiotics. It,

7:44

it may require some IV antibiotics, but they do get better with antibiotics.

7:49

Um, the the old adage was, oh, it's walled off. It's not going get,

7:54

um, cured by antibiotics. But that's not been the case.

8:00

Oftentimes, when there is a well-defined collection or abscess,

8:05

the surgeons will do a percutaneous, uh,

8:10

aspiration with a needle in the,

8:14

in the emergency department, um, just put a needle in aspirate,

8:19

suck them as much of it out, out as they can,

8:21

and then put the patient on antibiotics and see over the course of time whether

8:25

they improve often as an inpatient.

8:27

So this is inpatient antibiotics operating in this mucky stuff with

8:32

all this infection is not so easy.

8:34

And so that's why there's more of a reluctance to

8:39

acutely operate for a peron or abscess than there has been.

8:43

So at Hopkins, when we say, call them up and say, Hey,

8:47

I'm seeing a two centimeter by three centimeter well-defined collection with

8:50

peripheral rim, there's an, you know,

8:53

inter compatible with a peritoneal abscess, um,

8:57

it usually will elicit an E M T referral by the ed doc and an

9:02

aspiration through the mouth percutaneously.

9:05

And then in antibiotics it does, it's not, uh,

9:09

we're taking the patient to the or.

9:11

Now if you have all those complications of potential, you know,

9:14

ludwig's angina or, or larome, uh, Lumiere syndrome,

9:18

then obviously that's a little bit different.

9:21

Airway compromise is taken care of, um, more aggressively.

9:26

So it is common to say peritoneal abscess rather than tons abscess.

9:31

Yeah, we hardly ever say tonsil abscess. Okay. When in, when,

9:36

when you see low density within the tonsil,

9:39

what you're actually seeing is, um,

9:42

purulent material in the crips of the tonsil in,

9:46

in those crevices of the tonsils. That's not really an abscess,

9:49

that's just a pus among the fluffy

9:54

lymphoid tissue. So a tons abscess is incredibly uncommon.

9:59

What we're usually seeing off to the side associated with some para

10:04

pharyngeal space fat edema is a peri consular abscess,

10:09

which is access through the time. So, or you know,

10:13

if you have to go through the phase, but is, um,

10:18

defined by outside the pharyngeal musculature and still by the

10:22

pharyngeal. Um, ba pharyngeal, uh,

10:27

basar, fascial.