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I’m afraid to do this…

September 8, 2018

A young woman presented with four days of a sore throat. Her voice was muffled. She couldn’t open her mouth very wide. She had trouble swallowing her own spit. She had had strep throat a few times. She also had two episodes of peritonsillar abscess in the last two years, one of which required drainage. She was eating and drinking less due to the pain. She was also sore all over. Past history also included some substance abuse issues. Her vitals were normal except for a heart rate of 102. Physical examination revealed 2-finger trismus. There was swelling in the left tonsillar area. She had tender left tonsillar lymph nodes but there was no evidence of Ludwig’s angina. Here is her EDE/POCUS scan:

One of the reasons that we are posting this case is because abscess fluid in a peritonsillar abscess is usually black. But in this case, it is fairly isoechoic with the surrounding tonsillar tissue. This is less common. But can you see the difference in the echogenicity of the thick abscess fluid versus the tonsillar tissue? Towards the end of the video, we pressed down with the probe to confirm that the pus was jiggling a bit, to distinguish it from tonsillar tissue. Here is an image first without then with labels.

It looked like a sizable abscess so the decision was made to go ahead and drain it. The patient’s throat was sprayed up with lidocaine and we were able to drain 10 mL of pus, as shown in this image. As you can see, tape was placed around the proximal end of the needle to ensure not going too far.

Having had so much pus drained, the patient felt quite a bit better. She was given a dose of IV clindamycin and dexamethasone as well as IV fluids. She was discharged after a few hours of observation. She was seen the next day for another dose of IV clindamycin. She felt a bit better and the swelling was significantly improved. She was converted to PO clindamycin and did well thereafter. Given the recurrent nature of her presentations, an ENT referral was made.

As I like to point out at EDE 2, I only drained a peritonsillar abscess once during my training. It was during medical school with an ENT staff holding my hand. I went through five years of residency and a few years of practice in Sudbury before I attempted another one. Why? Because, like most people, I was afraid of hitting the carotid artery. But with bedside ultrasound, the procedure became not scary at all. In fact, it could be described as “idiot-proof”. As I pointed out in a post last year, most of the procedures that I have done for the first time have come after residency. POCUS is a big reason for that.

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