Failure to Diagnose Peritonsillar Abscess Leads to Patient Death

Case Summary

This case involves an elderly female who presented to the emergency room with shortness of breath and fever and said she had been feeling unwell for the past week. The patient was evaluated by the emergency room physician who noticed swelling of the left pharynx. A CT scan of the neck was ordered by the ED physician. While the patient was in transit to the CT scan, her lab results showed an elevated creatinine blood level, and the scan was canceled. The patient was returned to the emergency department.

Soon after, the patient experienced worsening shortness of breath, a syncopal episode, and became unresponsive, resulting in a Code Blue. Intubation attempts by the ED physician failed. Anesthesia was called and intubation was again unsuccessful. An Otolaryngologist (ENT) was called in and performed an emergency tracheotomy. Despite attempts to revive the patient, she remained unresponsive and was transferred to the intensive care unit. It was discovered that the patient had a peritonsillar abscess. A brain MRI revealed extensive hypoxic-ischemic encephalopathy. Several weeks later, the patient died.

Case Theory

Peritonsillar abscess (PTA) is an infection of the head and neck caused by pus accumulation between the palatine tonsils and the superior pharyngeal constrictor muscles. A deep neck infection (DNI) is caused by bacteria invading the deep neck space and can be fatal. Incision and drainage plus antibiotic therapy, tonsillectomy à chaud, or interval tonsillectomy is recommended for PTA. PTA is typically caused by recurrent tonsillitis. The parapharyngeal space can be affected by severe PTA, resulting in a DNI. It is recommended to administer empiric antibiotics. Often, steroids are used as an adjunctive treatment.

It is common for patients with PTA to present to the emergency department with fever, severe sore throat, odynophagia, dysphagia, trismus, and even respiratory distress, and they will often require pus drainage, antibiotic therapy, and supportive therapy. Creatinine levels in the blood may be abnormal. An elevated temperature requires antipyretics as well as adequate analgesia for pain.

It is important to pay attention to the patient’s airway when evaluating peritonsillar abscesses. Immediate endotracheal intubation is necessary if the patient’s airway is compromised. It may be necessary to perform a STAT cricothyroidotomy or a tracheostomy if this is not possible. An alternative method, if resources are available, is awake fiberoptic bronchoscopy for intubating patients with significant pharyngeal edema. In this case, the negligent failure to diagnose a peritonsillar abscess and delay in intubation led to the patient’s death.

Expert Witness Specialties

Emergency Room Physician

An expert in Emergency Medicine can opine on the standard of care for a similar patient and speak to necessary steps for an elderly patient with signs and symptoms of infection.

Otolaryngologist

Swollen tissues can block the airway. This is a life-threatening medical emergency. An abscess can rupture into the throat if it breaks open. Pneumonia can be caused by the contents of an abscess traveling into the lungs. An ENT specialist can opine on the standard of care for treating a peritonsillar abscess.

Neurologist

An expert neurologist can speak to the importance of time in restoring an airway in a non-responsive patient and the effects of hypoxic brain injury.

Questions for the Expert Witnesses

• How might airway obstruction and failure to timely intubate lead to neurologic damage?
• What is the standard of care for an elderly patient presenting with swollen lymph nodes, shortness of breath, and fever?
• Is a CT scan the first step in evaluating a similar patient?
• What is the standard of care for restoring an airway in a non-responsive patient with multiple failed intubation attempts in the ED?

Expert Witness Involvement

Here is what an intensive care neurologist had to say about this case:

Expert Witness Response E-197416

I frequently treat patients with hypoxic brain injury. As an intensive care neurologist, I typically see 1-2 of these types of patients per week. I see patients post-cardiac arrest, post-surgical complications, and post-traumatic injuries and many of these patients have a hypoxic injury. The brain is a very sensitive organ and it is highly dependent on blood and oxygen delivery. Even a few minutes of oxygen deprivation may lead to hypoxic brain injury. A patient with an airway obstruction, such as an abscess, may be deprived of oxygen because of the mass effect of the abscess. Throughout the time physicians were unable to intubate the patient, she continued to suffer from low oxygen levels and resultant brain injury. I have reviewed two cases of traumatic brain injury, both resulted in permanent and lasting damage and I am interested in reviewing this case further.