Bilateral peritonsillar abscess complicated with bilateral submandibular

abscess, cervical cellulitis and acute respiratory failure

Authors: Prof. univ Dr. Marginean Emil

Assistant Prof. Mohan Aurel ( Neurosurgeon)
Coautors: Dr. Venter Ciprian, Dr. Sorban Ildiko, Dr. Domuta Maria, Dr. Oana Valenas, Dr.
Alina Pantis
ENT Department and Toracic Surgery, Emergency Clinical Hospital Oradea
Str. Gheorghe Doja nr 65
Univesity of Medicine and Pharmacy Oradea

Contact Addres
Profesor Universitar Dr. Marginean Emil- Emergency Clinical Hospital Oradea, Str. Gheorghe
Doja nr. 65
e-mail: clinicaorloradea@yahoo.ro

ABSTRACT

The peritonsillar abscess represents the common form of pharyngeal infections. As a

pathogenic entity, the abscess is a purulent collection formed around an infected tissue. The
infection starts at the level of the tonsil and spreads succesively to the deeper layers of the
pharyngeal wall, the collection being localized between the tonsillar capsula and the superior
constrictor faringeal muscle.
The peritonsillar abscess is considered to be the complication of the acute tonsilitis.
At the present the frecyuency of the peritonsillar abscess shows an increasing trend
because the microorganisms have become resistant to the antibiotics.
The etiology is polimicrobian envolving aerobic and anaerobic bacteria as well, the most
frecyuently encountered being Streptococcus pyogenes ( Streptococcus β hemoliticus group A).
Usually streptococcus causes the unilateral inflamation of the tonsil and the peritonsillar
tissue, creating proper conditions for developing anaerobic flora.
Other aerobic bacilli found in purulent secretions are Staphylococcus aureus and
Haemophilus influenzae, while from anaerobic flora- Fusobacterium.
Rarely, the abscess can appear as a complication of mononucleosis infectiosa or “de
novo” without any previous infection.

RESUME
L'abces periamigdalien est une forme commune d'infection localisee au niveau de la
region cervicale et qui englobe toute la zone adjacente des amigdales.Comme entite patologique
on considere que c'est une collection purulente qiu est formee autour d'une zone infectee.
 C'est une infection qui debute dans les couches superficialles qui englobe successivement
le tissu sousadjacent,le pus etant localise plus exactement entre la capsule amygdalienne et le
pilier pharingien laterale et on le considere comme etant une complication de l'amigdalite
aigue(celle ci etant en realise l'inflammation des amygdales palatines).

A present on a remarque que l'incidence de l'abces periamygdalienest en croussance,les

germes incrimines dans l'apparition de l'amygdalite aigue sont d'habitude les memes qui
declanchent le processus infectieux pharingien et sont devenus resistents au traitement avec des
antibiotiques.

En general,l'etiologie est polymicrobienne impliquant auusi bien les germes aerobies que
ceux anaerobies.L'aerob le plus frequement impliquee c'est le Streptococcus Pyogenes(le
steptococcus beta hemoliticus de groupe A).

D'autres microorganismes aerobies troves dans le pus des patientes sont Stapylococcus
Aureus,Haemophilus Influenzae.

D'habitude,le streptocoque determine l'inflammation unilaterale des amygdales eu du

tissu periamygdalienne et cree une ambiance infectieuse propice au developpement des bacteries
anaerobies.Le frequemment cite des germes anaerobiesc'est Fusobacterium.

L'abces periamygdaliene peut aussi apparaitre tele une complication de la mononucleose

infectieuse ou"de novo" dans l'absence d'une processus infectieux.

MATERIAL AND METHOD

The authors present a case of a young patient, 23 y. o., transferred from Beius County
Hospital where he was treated with antibiotics for acute tonsillitis. He presented unfavorable
evolution developing bilateral peritonsillar abscess, bilateral submandibular abscess and cervical
cellulitis.
Individualized medical and surgical treatment were performed for any specific condition.
Key words: periamigdalian abscess, submandibular abscess, cervical cellulitis, acute
respiratory failure.

INTRODUCTION
The peritonsillar space communicates with the submandibullar space which is connected
to the sublingual space, the parotid gland lodge, lateropharyngian and pterygomandibular space.
The submandibular space communicates with sublingual space, parotid gland lodge,
lateropharyngian space, pterygomandibular space and is limited by:
- superior and medial- the mylohyoidian muscle, the masseter, styloglos muscle, mandibula
- inferior- hyoid bone
- lateral- the internal face of the mandibula
 - anterior- the anterior face of the digastricus muscle
- posterior- the posterior face of the digastricus muscle and the stylohioidian muscle
This space contains the submandibular gland, nodi lymfatici, the hypoglos nerve the
lingual nerve, the arteria and vena facialis.
The mylohyoid muscle divides the submandibular space into sublingual space situated
superior and submaxilar space situated inferior.
The relationship between the mylohyoid muscle and the apex of the teeth explains the
spreading of the odontogenic infection ( from the II, III-rd molars) to the submandibular space.

CLINICAL CASE
23 y.o. male patient shows up in the Emergency Unit with fever, altered general status,
trismus, odynofagia, dysphagia, hot potato voice, halena, dental septicity, massive left
submandibular induration, sensitive on palpation.
ENT physical examination: the bucopharyngoscopy ( which was difficult because of the trismus)
revealed multiple dental cavities, salivary stasis with sialorheea, halena, the induration and
congestion of the palate predominantely on the left, edem of the lueta, induration of the anterior
palatinal arch bilaterally, indurated tonsils, pushed medially and down, massive submandibular
induration on the left associated with Celsian signs.
Blood tests revealed leucocytosis (28.000) with neutrophylia, culture was positive for
Enterococcus faecalis sensitive to Teicoplanin, Vancomicin, Biseptol, Ofloxacin, Clyndamicin,
Tazobactam.
The treatment was with :Clindamicin 3x600 mg/zi, Tazobactam 3x3gr/zi,Ampi-
Sulbactam 4x1,5 gr/zi.
©
Surgical treatment was provided by transoral drainage on the left side. Aproximately 50
ml of purulent secretion under pression was drained. Another incision was made submandibulary
at the level of the digastric muscle and a big amount of yellow, green, fetid pus was found. The
wound was washed and a drain was placed in the submandibulary lodge. Immediately
postoperatory the patient status improved but later it became worse. Raising leucocytosis, fever
and cervical induration appeared which extinded until the incisura sternalis. Also, the patient
presented symptoms of acute respiratory failure and disphonia.
CT (native +i.v contrast) revealed blurry contured hipodense collection with multiple air
inclusions extended from the right submandibular space through the masticator, parapharyngyan
and carotid space reaching the epiglottis. Even in the preepiglottic space and close to the thyroid
cartilage was present a small amount of collection. In the left peritonsillar and submandibular
lodge there was a multiseptate, imprecise contured collection with fluid purulent content sized
6.5/3.6 cm. Submandibular and bilateral cervical inflammatory adenopathy with 1.3/1 cm
maximal diameters on the left was present.
At bucopharyngoscopy we observed the extention of the induration to the left palate and
peritonsillar regions, also to the left submandibular space.
 We provided transoral incision at the level of the left palate, draining pus in an appreciable
quantity. Also the left submandibular space was opened, draining purulent secretion under
pressure. The wound was washed and a drain was left inside.
Because the respiratory failure the patient was strictly monitorised considering that tracheostomy
could be necessary. Finally, because of the favorable evolution of the patient condition we
abandoned it.
The management of the case has respected the following strategy:
1.securize the airways- the acute respiratory failure required strict monitorization
2.rehydration to avoid dehydration caused by the severe dysphagia
3.i.v. broad spectrum antibiotics.
The peritonsillar and submandibular drainage was mentained for two weeks, the wound
being washed every day with desinfectants and betadine.
For five days around 20-30 ml of purulent secretion was drained daily.
The patient was externed after 14 days released from hospital.
In the literature, the bilateral peritonsillar and submandibular abcess complicated with
cervical cellulitis is rarely mentioned and usually has an unfavorable prognosis.

CONCLUSION:
Setting up a Multidisciplinary team ENT-IMAGISTIC DEPARTMENT improved for the
prognosis of complicated neck infections.
The correct surgical and medical management, also the strict monitorization of the patient
helped to avoid tracheostomy.
The combined surgical and medical treatment is the gold standard in the management of
the complicated peritonsillar abcess.

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