Primary Care POCUS Fellow talk by Dr. JD Adame
So i’m going to be talking about harry tonsler abscesses and um um i i think there was an intro earlier but yeah i’m also one of the um primary care ultrasound fellows at um indiana university all right so this was a case that was um that was in our outpatient clinic i had with one of the residents um it was a an 18 year old male he came in with um for some
Recurrent visits um concerning some tonsil swelling and pain that he’s been having um when we examined him and took a look at him um he had this right-sided uh tonsiller swelling with some exeter eights he had left-sided uh uvila deviation he was non-toxic appearing he was under no distress but he did have some difficulty in swallowing um so we went ahead and
Did a a rapid strep test that actually came out negative um but over the previous eight months he has received a couple rounds of antibiotics and this is actually the third visit to the clinic so um with that i was thinking and the resident was thinking as well that this was most likely um an abscess but we just didn’t know we didn’t have the imaging um so
We were a little he was a little confused as far as where to go as far as the next step um so this is usually what you would see this was in our actual patient um but as you can see here uh you got this unilateral swelling over here you got some uv deviation um and then what you’re usually thinking is the difference between an abscess or um a cellulitis so
Because this is a ultrasound interest group i mean of course i’m a target on the ultrasound um but there are some other imaging modalities and some other physical exams um that people approach to actually draining some of these at times um so if you look at the bottom here i actually showed the sensitivities and specificities when it comes to a physical exam
When you’re able to actually diagnose and treat this in comparison to ct and then using an intraoral uh uh ultrasound probe or a transcutaneous approach um and as you can see just by physical exam the sensitivity of the specificity are rather low um ct is high but again with ct you got to think about the timing um how long the patient is going to be sitting in
The ed um also the radiation this is in the neck i mean so it’s a lot of radiation that you can be given there as well as the thyroid um and then for active imaging guidance um ultrasound is going to be there you can’t do this under uh ct imaging or any other imaging so that’s what also makes it that that much better um it helps expedite it so you can get the
Patient in and out um and then like i said the active guidance as well um and in one randomized prospective study actually um they were looking at clinicians diagnostic accuracy for a periodoncellar abscess using an intraoral probe because this is where most of these studies are actually done with versus the transcutaneous approach and they did that versus a
Clinician using landmarks and they actually found that the accuracy as far as the diagnosis in comparison to the two was a hundred percent for the intraoral use of the ultrasound versus about 64 um when it came to the physical exam um and with that um the ultrasound actually led to a sevenfold decrease in um subspecialty consultation and further imaging um
Versus the landmark based approach which required over 50 of their patients to either be further consulted down the line or have uh additional imaging including ct scans and like i said so although there are uh limited studies in terms of the the transcutaneous approach or transcutaneous diagnostics for this um there was also a few other studies that showed
That when a patient either has trismus or something and you’re unable to actually get the intraoral probe into the mouth the use of the transcutaneous ultrasound did diagnose 100 of cases so it shows its utility there so this is your intraoral versus a transcutaneous and i mean just by just by looking at this i mean you can it already seems pretty uncomfortable
Just to have that intraoral device in your mouth um these patients are sometimes in a lot of pain they’ve got trismas they’re unable to open their mouth very wide so the use of an endocavitary probe um is something that may not be so user friendly and and just one thing with the indo cabinetry probe always make sure that you’re saying endocavity and not like a
Transvaginal probe because a patient hearing transvaginal probe going into their mouth probably isn’t going to be the most um you know satisfying thing to hear for the patients um when you do these approaches um i just have a couple images that are comparing the normal anatomy versus what you would see for a cellulitis versus an abscess and so for the uh normal
Anatomy here of a tonsil they range anywhere from about 10 to 22 millimeters um they’re either triangular shaped or they’re oval in appearance and they’ve got this just homogeneous um like low-level echo texture where you can see maybe a little bit of something in there but the size of it is pretty good it’s pretty um uniform throughout um the entire structure
And so it’s comparing um a to b so this is as you can see the footprint here so this is going to be your endocapitary probe and then this probe here is going to be a linear probe that they used um and um and same thing on the linear probe side you can see this over here um as what the normal tonsil looks like and then i think they have it start over here just
For anatomical purposes this is the oropharyngeal cavity and then this i believe is going to be your submandibular gland and then this would be probably most likely your internal carotid now versus a a cellulitis that we have down here so for a cellulitic tonsil these are going to be enlarged um they’re going to be in excess of 20 millimeters um they’re going to
Have this homogeneous or sometimes you’ll have this striated texture within the tonsil itself and when you do see that likely it’s going to be considered a cellulitis over here for the linear probe um this one is comparing a normal tonsil to a tonsil um with cellulitis and as you can see here it’s got this little bit of echo texture in here um little stride
In appearance can be a little a little difficult to tell if it’s maybe your first or second one but um with a little bit of practice the identification of it is pretty easy afterwards then you have your uh perry consular abscess so for the the abscess again you’re gonna see an enlarged console over 20 millimeters um and these are going to have a heterogeneous
Echo texture or they’re going to have this cystic appearance and when you see that this is typically going to be what a uh peritonsillar abscess is going to look like and also it’s just something to be aware of um these abscesses can often kind of either distort or they can displace the tonsil either medially or cuddly um and regardless of what the echo texture
Really is um even if you’re seeing these little striated lines where you’re thinking oh maybe it’s a cellulitis but if you see any type of mass effect it’s usually always going to represent um an abscess in that location and one thing that you can always do too if you’re unsure with what you’re actually looking at always go over to the control lateral side of
The neck um and take a look there just for comparison purposes so i’m really going to kind of i guess focus in on the transcutaneous approach versus the intraoral approach because the intraoral is the one that’s pretty much been studied and been laid out there for a while this this transcutaneous approach um was kind of brought to uh brought to light i believe
It was back in 2018 it was a professor from mgh um that kind of came up with this approach um and so what you do here is you can either grab a linear curvilinear probe um the maker of it said he actually prefers the curvilinear which is what they have right here marker is going to be posterior and the transducer is going to be placed medial to the angle the
Mandible and you’re just going to direct it posterior superiorly towards that tonsiller fossa and what you can also do is just ask the patient um just to point specifically where they’re most tender or where the pain is most and um and then you can throw the probe onto that area and then kind of look around and then like i said it’s always good to kind of um
Evaluate both sides so go ahead and take a look at the contralateral side as well and here is kind of what you would see so i flip so the images are flipped here so what you see is what you would actually see on your ultrasound imaging um so in order to to actually locate this is something that that you’ve never done what you would likely do is go in put it to
The medial side of the mandible try to locate the vascular structures first most of the time we’re able to see those easily try to find your internal jugular vein and the carotid artery you want to go ahead and just fan um fan the probe upset a lot a bit and then you would see this uh structure that’s going to be just medial to the oropharyngeal cavity which is
Going to be this hyperechoic um structure that you’re going to be seeing here this is a tongue this is the air space and then i kind of just highlighted everything over here just for visual purposes so you can see the abscess over here you’ve got your oropharyngeal cavity and then you have your internal carotid artery right there which is probably i mean less
Than maybe half a centimeter um and so one thing when you do do these abscesses and this is just any abscess in general um you always want to throw color flow and you want to throw color flow one in this case because of how close these vascular structures are so you can identify them but then also um you want to do it because um you don’t want to accidentally
Diagnose a potential pseudoaneurysm as as an abscess and put a needle in there because that would not be a good idea so to kind of help with the procedural planning that you would do if you were to drain these abscesses um go ahead and obtain measurements you want to obtain measurements in three different orthogonal planes to help manage that and as you can
See here um the measurements that they got was about three 3.4 centimeters by three um by about another three centimeters and as far as the aspiration of the abscess one thing again the vascular structures are in very close proximity of of the the actual peritonsillar abscess that you’d be going for so ensuring safety um is of most importance for these for
These cases and there are several different uh approaches to this one um is what you can do is you can actually once you get the measurements you can figure out where you’re at and you can do this thing called a cap needle approach to where you would go ahead and take the the cap off the needle see the distance of the um peritoneal abscess itself and go ahead
And just snip off the top to where you know no matter how far you go if that end cap ends up going flush up against the abscess you’re not going to end up anywhere near these vascular structures there’s another alternative approach because sometimes some people say the these caps are actually pretty hard and sometimes when you do cut them they can actually be
Jagged um or there could be some kind of pieces hanging off a little bit and some of them can fall potential aspiration for the patients or just the jaggedness of itself can be very uncomfortable so an alternative approach is that you can grab one of these little pediatric vacutainers um cut off the cap probably right around here go take the cap off cut it off
It’s rather soft and pliable so you’d be able to insert the needle through the back side of it and then um this uh back side that would sit flush up against the abscess is smooth um and it’s not going to have any jackness or anything like that to to bother the patient any more than necessary and then when you do do these of course um anesthetic is something you
Do want to do i mean i’m not going through like the full um the full approach or the full absence of the aspiration itself more just the identification and and knowing kind of the setup for this um but uh good options for anesthesia you can either use just some localized like some benzocaine spray or you can also use some nebulized lidocaine and then you want
To put a little bit of um just local anesthetic lidocaine with some epi into that as well so they coined it as uh the telescopic submandibular approach is kind of what they’ve named it um i have a little video here so i’m just gonna play this you can watch it um so again this is dynamic so it’s kind of the only way that people can go from doing the needle in a
Different plane than what the ultrasound actually is so when you do have the ultrasound kind of set up up uh underneath the subman submandible you want to kind of imagine when you go into the oral cavity and when you keep the oral cavity open you can either use a a speculum or you can use a like a tongue depressor as well um with all with the light would also
Kind of help sometimes but when you do have the ultrasound in this place you’re imagining this plane that you’re going to be meeting both of them on so when the needle does come into the mouth you can kind of manipulate the probe itself and you’ll kind of find the plane and and match them up together um so i’m going to play this real quick and so what you can
See here is that right now he’s putting some lidocaine into um the abscess itself um he probably went a little too far um in that they wanted him to actually put kind of the lidocaine on the outer surface into the actual tissue than the abscess but you can see the abscess kind of swell up a little bit with some of that lidocaine and again you’re saying this
In live so you’re able to identify where the needle is you can see the vascular structures and so the lidocaine is in he used probably a 25 27 gauge needle pulled out put on a larger gauge needle most likely an 18 gauge because you never know just how viscous the material inside the abscess can be and now he went ahead and is actually going into the abscess
And you can see i mean the abscess is collapsing and you’re seeing this in live view um you’re able to watch all the contents of it come out you’re still visualizing the needle tip there you’ve got your vascular structures over here everything’s safe and that’s it i mean he the the needle tip still there i stopped the video but you can kind of see right there as
The entire capsule pretty much collapsed one thing that you can do also is um keep the needle capped don’t cut it yet at this point um and what what you can do is try to help set yourself up is by going in there and going and pressing right up against the abscess itself so you can see that in in real time and then you can go ahead and cap the needle and um do
The approach and here’s just some final tips um again the the whole thing with the transactional probe just trying to never say that when it comes to these type of um procedures always say endocapitary um and then if you’re able unable to distinguish um between like an abscess or the cellulitis when you are using the uh transcutaneous approach if you do have
An endocavity probe um it’s great for diagnostic purposes so you can go ahead and go in there um and you can use the endocafeteria probe to go right up against the abscess itself you can press on the abscess which we do for most abscesses in general and when you do press on the abscess you can get that swirl sign which kind of tells you hey this is definitely
An abscess and then at that point you can switch back to the uh trans uh cutaneous approach or the um curvilinear probe and then do the procedure that way and so like i said they coined this as the telescopic submandibular um you can use either a linear or curvilinear um likely you will need assistance with this you’ll need somebody in holding on the probe they
Did say that probably after a little bit of practice that you may be able to do it yourself but that’s if you don’t actually need um some other tools in order to help keep the mouth open or the tongue um out of the way while you’re inserting the needle uh for the aspiration um and then again regarding the vascular structures make sure to plan the approach with
That fully capped needle um because of the safetiness of that in terms of the vascular structures and then again you’re going into the mouth with a needle patients can either be cooperative patients can sometimes either syncopize on you they can um just have a knee-jerk reaction and end up either moving their head one way or the other and you don’t want the
Needle accidentally just going into areas it shouldn’t and then in general um again just regarding any abscess you you see always always use color um just in case there might be a pseudo abscess in that area and then communication is key uh in these type of things especially in the mouth where the patient isn’t going to be able to voice any type of concerns
Or anything so when the patient’s mouth is open in these cases um if they need a signal to you or they need to say something they do get like these secretions in their mouth you can give them a um like a suction they can have the suction where they can use that as needed you can also have them use that suction and maybe like raise it up as a signal instead of
Them trying to talk or them trying to move while you’re trying to insert a needle and that’s just just some tips just some safety things just to kind of be aware of and keep in mind when you’re doing these type of procedures you
Transcribed from video
Peri-tonsilar abscess diagnosis and treatment By Indiana University School of Medicine POCUS