Lingual tonsil abscess: a rare, life-threatening cause of acute sore throat

Description

A previously fit and well 48-year-old woman presented to her emergency department with a 4-day history of sore throat. Over the past 24 hours her symptoms had progressed rapidly with associated fevers, and she had become unable to tolerate liquids or food. She had no significant medical history, took no regular medications and suffered from no allergies. On clinical review she was dysphonic and demonstrating early signs of sepsis, with a low grade temperature of 37.9°C and mild tachycardia. External examination revealed tender cervical lymphadenopathy more marked on the right and reduced range of neck movement. Examination of the oropharynx revealed marked trismus and a raised tongue, but no peritonsillar swelling or asymmetry, and normal dentition. Flexible nasendoscopy revealed inflammation and swelling of the right pharyngeal wall and tongue base, with no airway compromise. Blood tests demonstrated leucocytosis and raised C reactive protein levels of 173.2 mg/L.

The patient was admitted to hospital and received intravenous antibiotics, intravenous dexamethasone 6.6 mg two times per day, fluids and analgesia, and was kept nil by mouth for a suspected parapharyngeal abscess, with Ludwig’s angina a differential diagnosis. An urgent contrast CT scan of the neck was performed, which revealed a 6 mm abscess in the right aspect of the lingual tonsil with associated localised inflammatory changes (figure 1). Following diagnosis, a decision was made to continue on medical management, and she was encouraged to eat and drink as tolerated. After 48 hours her pain was well controlled, she remained haemodynamically stable and was achieving adequate oral intake. Her dysphonia had significantly improved and repeat flexible nasendoscopy demonstrated a marked improvement in appearances of the oropharynx and tongue base. She was discharged with a 1-week course of oral antibiotics and on outpatient review at 4 weeks she had made a complete recovery, with normal appearances of the tongue base and oropharynx on flexible nasendoscopy.

Figure 1.

Coronal, sagittal and axial sections on CT demonstrating right lingual tonsil abscess.

Lingual tonsil abscess is an extremely rare but potentially life-threatening entity, with instances in the published literature limited to a small number of case reports. Identified precipitants include lingual tonsillitis (as in this case), trauma and infected thyroglossal cyst. Its occult location and non-specific examination findings present a diagnostic challenge, and urgent referral to ear nose and throat for flexible nasendoscopic assessment of the airway plus cross sectional imaging are essential. Airway protection is the first priority, and a low threshold for awake intubation or surgical tracheostomy is essential. In the most comprehensive review of the literature to date, Srivanitchapoom report 18 cases,¹ all of which underwent surgical procedures ranging from simple aspiration to incision and drainage, with two cases requiring tracheostomy. Our case is unique in that it is the only reported instance in the literature of medical management alone. The uncompromised airway on flexible nasendoscopy and the very small size of the collection on radiographic assessment were key factors in guiding our decision making towards an initial and successful trial of medical management.

Learning points.

• Lingual tonsil abscess is a rare condition with precipitants including lingual tonsillitis, trauma and infected thyroglossal cysts.

• Very small (subcentimetre) collections with no clinical evidence of associated airway compromise may respond successfully to a trial of medical therapy.

• There must however, be a low threshold for considering surgical drainage and concomitant airway protection.