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A case of suppurative mediastinitis
secondary to acute bacterial tonsillitis
D Micallef1, V Bugeja2, N Aquilina3, G Borg1, C Zahra1
1. Mater Dei Hospital, 2. Saint Vincent de Paul Residence, 3. Rehabilitation Hospital Karin Grech
A case report of suppurative mediastinitis as a complication of
acute bacterial tonsillitis, with the aim of raising awareness of this
uncommon complication of a relatively common ENT condition.
Background
A 78 year old gentleman presented with sore throat, odynophagia,
and epigastric discomfort. On examination he was found to be
febrile. The uvula was deviated to the right with a visible collection
of pus, which was sampled and sent for MC&S (microscopy, culture
and sensitivity). The patient was admitted and started on
intravenous broad-spectrum antibiotics (co-amoxiclav and
metronidazole).
Further Investigations
A CT (Computed Tomography) scan of the neck and thorax
revealed peritonsillar cellulitis which was tracking in the
parapharyngeal space down to the mediastinum, associated with
an air-fluid level (indicative of a gas-forming organism). MC&S
results showed growth of Peptostreptococcus species organism.
Cardiothoracic surgical consultation was performed, and it was
agreed that surgical intervention was not required.
Outcome
After three weeks of intravenous antibiotics the patient recovered
fully.
Suppurative infections of the neck are uncommon. However, they
are potentially very serious.
Peritonsillar cellulitis is an inflammatory reaction of the tissue
between the capsule of the palatine tonsil and the pharyngeal
muscles that is caused by infection, but not associated with a
discrete collection of pus.
Peritonsillar abscess (PTA) is a collection of pus located between
the capsule of the palatine tonsil and the pharyngeal muscles.
Peritonsillar abscesses are often polymicrobial. The predominant
bacterial species are Streptococcus pyogenes, Streptococcus
anginosus, Staphylococcus aureus, and respiratory anaerobes
(including Peptostreptococcus, Fusobacteria, Prevotella, and
Veillonella species)
Peritonsillar infection generally is preceded by tonsillitis or
pharyngitis and progresses from cellulitis to phlegmon to abscess.
PTA also may occur without preceding infection; such cases are
thought to be caused by obstruction of the Weber glands (a group
of salivary glands in the soft palate just superior to the tonsil and
connected to the surface of the tonsil by a duct).
Examination findings consistent with PTA include an extremely
swollen and/or fluctuant tonsil with deviation of the uvula to the
opposite side. Alternatively, there may be fullness or bulging of
the posterior soft palate near the tonsil with palpable fluctuance.
Diagnosing Peritonsillar Infection
The diagnosis of PTA can usually be made clinically without
laboratory data or imaging of any kind in the patient with medial
displacement of the tonsil and deviation of the uvula. Suggested
investigations include:
Radiological evidence of gas in the retropharyngeal space and mediastinum
A large unilateral abscess is visible in the pharynx.
Prominent swelling of the anterior pillar and soft palate is present.
Serology
Elevated WBC
Serum Electrolytes (decreased oral intake)
Microbiology
Throat swab for MC&S
Aspiration of abscess for cytology
Intraoral or submandibular ultrasonography to
distinguish cellulitis from abscess
Imaging CT with IV contrast for identifying deep space
neck infections such as retro- or parapharyngeal
abscess
References
Tebruegge M, Curtis N. Principles and Practice of Pediatric Infectious Diseases, 4th ed, Elsevier Saunders, New York
2012. p.205
Brook, I. Journal of Oral and Maxillofacial Surgery (2004), 62(12), pp.1545-1550
Herzon, F. and Martin, A. Current Infectious Disease Reports (2006), 8(3), pp.196-202
Scott, P., Loftus, W., Kew, J., et al. The Journal of Laryngology & Otology (1999), 113(03)
Ungkanont, K., Yellon, R., Weissman, J., et al. Otolaryngology - Head and Neck Surgery (1995), 112(3), pp.375-382.
Presentation of Case Discussion