Case 37

77 yo female pmhx HTN, DM presents for evaluation of left ear pain x4 days worsening over the past two days. Patient also complains of sore throat and dizziness. 

Vital signs: T 99.3F BP 147/87 HR 82 O2 100% RA

On physical exam you note an uncomfortable appearing elderly female. She is able to speak in complete sentences but complains of severe pain to her throat with decreased mouth opening. On physical exam of her mouth you note swelling and erythema to the left tonsillar area. 

You decide to ultrasound the area for possible abscess formation and obtain IMAGE 1 below.

IMAGE 1

IMAGE 1

QUESTIONS:

  1. What transducer do you use for this study and why?
  2. How do you identify a PTA on an ultrasound?
  3. What do you need to be careful of when draining a PTA?
  4. What is the treatment for a PTA?

ANSWERS:

  1. The high frequency endocavitary probe. Its shape allows for placement in the posterior pharyngeal space and the high frequency is good for superficial structures.
  2. The abscess is identified as a hypoechoic space over the area of maximal swelling; they are visibly fluctuant when compressed with the probe. Scan the normal tonsil first and compare it to the affected side.
  3. The carotid artery is located posterior and lateral to the PTA. You can use color doppler to identify its location and measure to determine the depth. 
  4. Drainage of the abscess followed by a course of antibiotics, Clindamycin or Augmentin would be possible choices.