Abstract

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Introduction: A peri – tonsilar abscess, also known as quincy, is a condition which can present as a sore throat and represents collection of pus in the peri – tonsilar space. Treatment involves drainage of the abscess and completing a course of antibiotics. We describe a novel case whereby a patient diagnosed with quincy also suffered with complete heart block and non sustained ventricular tachycardia. The rhythm disturbances observed resolved once the quincy was treated.
Case presentation: We present a case of an 89 year old caucasain lady who presented to hospital and diagnosed with a peri – tonsillar abscess. She was found to be in complete heart block that degenerated in runs of non sustained ventricular tachycardia. The non sustained ventricular tachycardia was associated with haemodynamic compromise and therefore a temporary pacing wire was inserted in addition to loading with intravenous amiodarone. The ears, nose, and throat team (ENT) drained the abscess and prescribed a course of antibiotics. Following treatment of the abscess the heart rhythm problems resolved and the patient was discharged home.
Conclusion: A clear temporal relationship was observed between the onset of the quincy and the rhythm disturbances. We conclude the peri – tonsillar abscess had a local effect on the vagus nerve and resulted in complete heart block which in turn degenerated into runs of non sustained ventricular tachycardia. This is a rare but important phenomenon as it can have life threatening implications.

Introduction

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Peri-tonsilar abscess, also known as quincy, is a complication of tonsillitis with an incidence of 30,000 cases per 100,000 people per year in the United States (1). Quincy occurs if tonsillitis progresses to a collection of pus in the peri-tonsilar space.
The symptoms associated with a quincy can start several days prior to the abscess formation. A unilateral sore throat, fever, malaise, headache and a ‘hot potatoe voice’ are commonly described symptoms. Odynophagia and ipsilateral earache have also been presenting features.
Physical signs include erythema, oedema in the tonsillar region of the affected side and swelling of the jugulodigastric lymph nodes. The uvula may be displaced towards the contralateral side as a result of physical compression.
Aerobic and anaerobic bacteria can be involved but commonly group A beta-hemolytic streptococcus, staphylococci, or haemophilus are the culprit organisms (2).
Treatment involves drainage of the pus via either a needle or surgical incision and drainage (3). Concomitant antibiotics, usually penicillin, are also used.
We present a life threatening case of complete heart block and polymorphic ventricular tachycardia in a patient acutely admitted to hospital with a diagnosis of quincy.
Complete heart block (CHB), also known as third degree heart block, is a condition whereby the sino – atrial (SA) node in the atrium does not lead to coordinated ventricular activity. Instead, the atria and ventricles contract independent of each other at different rates. This manifests itself on an ECG as there being no relationship between the P waves (atrial activity) and the QRS complexes (ventricular activity). Coronary ischaemia is a common cause of CHB. Typically involvement of the right coronary artery is the culprit as this artery supplies the AV node. Autoimmune phenomenon and lymes disease have also been implicated.
CHB will usually require insertion of a permanent pacemaker but in the acute setting temporary pacing is required as a bridging measure if haemodynamic instability occurs; transcutaneous pacing or the insertion of a temporary pacing wire into the right ventricle are all possible strategies.
CHB can sometimes lead to a very malignant arrhythmia called ventricular tachycardia (VT). VT is a life threatening arrhythmia requiring urgent attention.

 

 

Case Report

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We present a case of an 89 year old Caucasian lady seen by her general practitioner (GP) and diagnosed with a peri - tonsillar abscess. She was therefore referred to ENT for drainage of the quincy and antibiotics. Whilst being assessed in the accident and emergency department the ENT team confirmed the diagnosis of quinsy but also noted a heart rate of 31 beats per minute and therefore requested a cardiology opinion.
Whilst being assessed the heart rate on the cardiac monitor fluctuated between 30 and 180 beats per minute. The cardiac monitor revealed asymptomatic intermittent CHB and also non sustained VT with an associated fluctuating level of consciousness.
There was no history of chest pain or shortness of breath. A bolus of magnesium sulphate was administered and the patient transferred to the coronary care unit for insertion of a temporary pacing wire and administration of intravenous amiodarone through a central line. Intermittent pacing was required for the next 18-24 hours and the frequency of non sustained VT decreased over this interval also.
A CT scan of the neck was performed with the following result: ‘There is a significant soft tissue swelling in the right peri - tonsillar region consistent with the clinical diagnosis of quincy. The left tonsil is normal. The swelling in the right para – tonsillar region crosses the midline.’
The ENT team then aspirated the abscess and recommended a course of antibiotics. Two days later the patient was much improved and the temporary pacing wire was removed along with amiodarone being discontinued.
An ECG (figure 3) returned to normal and a 24 hour tape did not reveal any rhythm disturbance.

Discussion

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The CT of the neck confirmed a right peri - tonsillar soft tissue swelling that crossed the midline and was therefore of a significant size. The parapharyngeal space houses the vagus nerve and we postulate the CHB was induced by the effect of the peri - tonsillar abscess on the vagus nerve. The CHB then degenerated into runs of NSVT.
An argument could be made the CHB and NSVT was due to coronary ischaemia. The patient did go on to have a nuclear medicine myoview scan two weeks later to exclude an ischaemic component to her aetiology of CHB and VT. No electrolyte imbalance was identified on the blood tests and therefore excluded as a precipitant to the VT.
The nuclear medicine cardiac adenosine stress report is as follows: ‘No scintigraphic evidence of ischaemia or infarction. Left ventricular function is preserved’.
In view of the scan being normal and the existence of a clear temporal relationship between the onset of the peri – tonsilar abscess and the rhythm disturbance we strongly feel the two are linked. Also, the rhythm disturbance improved following aspiration of the quinsy and a course of antibiotics. The raised troponin I of 0.5, mentioned above, was attributed to sepsis and multiple runs of non sustained VT.

Conclusion

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A peri tonsilar abscess can lead to local effects on surrounding structures, in this case the vagus nerve, and lead to sinister heart rhythms. In this particular case complete heart block degenerating into intermittent non sustained VT was observed. There is very limited literature and no other case reports which have demonstrated a link between quinsy and complete heart block with VT. Admittedly, although a rare phenomenon, we feel an increased awareness amongst general practitioners, ENT, and cardiology doctors would improve our understanding and knowledge base. Ultimately, this would lead to an improvement in the quality of care provided to patients and also patient safety.

References

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1. Ola Sunnergren, Jonas Swanberg and Sigvard Mölstad:  Incidence, microbiology and clinical history of peritonsillar abscesses. Scandinavian Journal of Infectious Disease 2008, Vol. 40, No. 9, Pages 752-755
2. Klug TE, Henriksen JJ, Fuursted K, Ovesen T:  Significant pathogens in peri - tonsillar abscesses. European Journal Clinical Microbiology Infectious Disease. 2011 May; 30(5):619-27
3. Papacharalampous GX, Vlastarakos PV, Kotsis G, Davilis D, Manolopoulos L: Bilateral Peritonsillar Abscesses: A Case Presentation and Review of the Current Literature with regard to the Controversies in Diagnosis and Treatment. Case Reports in Medicine. Volume 011. Article ID 981924.

Source(s) of Funding

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none

Competing Interests

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none

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