Paratonsillar abscess (paratonsillitis) - Diagnosis

Physical examination

Mesopharyngoscopy in a patient with paratonsillitis is often significantly complicated, since due to severe trismus the patient opens his mouth no more than 1-3 cm. The picture observed in this case depends on the localization of paratonsillitis.

In case of anterior superior or anterior paratonsillitis, a sharp bulging of the upper pole of the tonsil together with the palatine arches and soft palate towards the midline is noted.

When an abscess is forming, usually by the 3rd to 5th day, a fluctuation is observed at the site of the greatest protrusion, and spontaneous opening of the abscess often occurs, most often through the anterior arch or supratindalar fossa. Posterior paratonsillitis is localized in the tissue between the posterior palatine arch and the tonsil: the inflammatory process can spread to the posterior arch and tissues of the lateral pharyngeal ridge. Collateral edema may spread to the upper part of the larynx, which can lead to its stenosis and scarring. Lower paratonsillitis is characterized by less pronounced pharyngoscopic signs: edema and infiltration of the lower part of the anterior palatine arch. Sharp pain when pressing on the area of the tongue close to the infiltrated arch attracts attention. When examining with a laryngeal mirror, swelling of the lower pole of the tonsil is determined; Often hyperemia and infiltration spread to the lateral surface of the root of the tongue; collateral edema of the lingual surface of the epiglottis is possible.

External, or lateral, paratonsillitis is observed less frequently than other forms, but it is considered to be one of the most severe in terms of prognosis. The process develops in the tissue filling the tonsillar niche outside the tonsil, so the conditions for spontaneous opening with a breakthrough of pus into the pharyngeal cavity are the least favorable here.

Inflammatory changes in the pharynx are less pronounced, with only a slight medial protrusion of the tonsil. Pain in the throat when swallowing is usually mild, but trismus of the masticatory muscle develops earlier than in other localizations of paratonsillitis. and is pronounced. At the same time, swelling and infiltration of the soft tissues of the neck on the affected side, severe cervical lymphadenitis, and torticollis develop.

Laboratory research

Leukocytosis is observed in the blood (10-15x10 ⁹ /l), the blood formula is shifted to the left; ESR is significantly increased. It is necessary to conduct a microbiological study of the pathological discharge for flora and sensitivity to antibiotics.

Instrumental research

Ultrasound, CT.

Differential diagnostics

Unilateral swelling in the pharynx, with bright hyperemia and edema of the mucous membrane, similar to paratonsillitis, can be observed in diphtheria and scarlet fever, with which differential diagnostics are carried out. In diphtheria, as a rule, there are plaques in the pharynx and no trismus, and Corynobacterium diphtheriae are determined in the smear. Scarlet fever is characterized by a rash and certain epidemiological data. Sometimes it is necessary to differentiate paratonsillitis and erysipelas of the pharynx, in which characteristic diffuse hyperemia and edema of the mucous membrane can be observed, which appears shiny and tense. However, erysipelas is characterized by a course without trismus and the absence of the characteristic forced position of the head; sore throat is usually less intense; erysipelas of the face often occurs simultaneously with erysipelas.

To a certain extent, tumor diseases are similar to paratonsillitis - cancer, sarcoma, lymphoepithelioma of the pharyngeal ring, glomus tumor, etc. Slow progression, absence of temperature reaction and severe pain in the throat, as well as pronounced pain during palpation of regional lymph nodes allow to differentiate tumors of the pharynx from paratonsillitis. In rare cases, swelling in the pharynx can be associated with the close location of the carotid artery or its aneurysm from the surface. The presence of pulsation, determined visually and by palpation, allows to make the correct diagnosis.

Indications for consultation with other specialists

• Surgeon - if phlegmon, mediastinitis is suspected; for differential diagnosis and surgical treatment.
• Infectious disease specialist - when conducting differential diagnostics with diphtheria, scarlet fever, erysipelas,
• Oncologist - if there is a suspicion of a malignant neoplasm of the pharynx.
• Endocrinologist - in case of paratonsillitis combined with diabetes mellitus and other metabolic disorders.

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