AM ER IC AN JOURNAL OF OT OLARYNGOLOGY–H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 5 17–5 2 0

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A unifying theory of tonsillitis, intratonsillar abscess

and peritonsillar abscess☆,☆☆

Alex B. Blair, MD a , Robert Booth, MD b , Reginald Baugh, MD c,⁎

a
Department of Surgery, University of Toledo, College of Medicine, Toledo, OH, USA
b
Department of Pathology, University of Toledo College of Medicine, Toledo, OH, USA
c
Department of Surgery, Division of Otolaryngology, University of Toledo College of Medicine, Toledo, OH, USA

ARTI CLE I NFO A BS TRACT

Article history: We review existing models of the pathogenesis of peritonsillar abscess (PTA) and intra-
Received 21 January 2014 tonsillar abscess (ITA) and present a novel pathophysiologic model based upon observed
histopathology in 2 ITAs and 10 PTAs and acute tonsillitis cases. ITA is rare, and prevailing
models are only able to account for a minority of cases. The tonsillar lymphatic
ultrastucture and the rapid nature of intratonsillar lymphatic transit, offer the framework
for a unifying model of the development and progression of tonsillitis, PTA and ITA.
© 2015 Elsevier Inc. All rights reserved.

1. Introduction are expelled by contraction of the tonsillopharyngeus muscle [1]. A

Tonsillitis is a common pharyngeal infection affecting young
adults and children. Peritonsillar abscess (PTA) is an occa-
sionally identified complication and intratonsillar abscess
(ITA) is rarely reported. Prevailing models of the reported
pathogenesis of tonsillitis, PTA and ITA are found to be
lacking, suggesting that these conditions are either unrelated
or the general conceptual framework is inadequate.
The palatine tonsils are located in the tonsillar fossa defined by
the palatoglossal muscle anteriorly and the palatopharyngeal
muscle posteriorly. Laterally the tonsil is covered by a fibrous
connective tissue capsule and medially the tonsillar crypts are
covered by nonkeratinized stratified squamous epithelium. Dis-
ruption in the crypt epithelium allows for interaction of antigenic
stimuli with tonsillar lymphocytes. Contents of the tonsillar crypts
virulent organism that enters the tonsillar crypt and fails to be
expelled can proliferate in the base and lead to localized edema
and influx of neutrophils: clinically presenting as a red swollen
tonsil with exudate [1].
A PTA is a collection of pus between the tonsil fibrous
capsule and the pharyngeal constrictor muscles. The true
pathophysiology of PTA formation is unclear. Authors have
proposed that drainage failure of suppurative inflammation
from crypt blockage in acute tonsillitis leads to coalescence by
extension into the peritonsillar space [1]. The collection of pus
in the loose areolar tissue behind the superior tonsillar pole
leads to tonsillar bulging and uvula and palate deviation.
Others have proposed that PTA formation may be a conse-
quence of abscess formation in a group of salivary glands
(Weber's glands) located in the supratonsillar space [2].

☆
Funding: N/A.
☆☆
Presentations: Poster presented at Triological Society, Annual meeting at Combined Otolaryngology Sections Meeting; Orlando FL.
April 12-13, 2013.
⁎ Corresponding author at: The University of Toledo, Department of Surgery, Division of Otolaryngology, 3000 Arlington Avenue, MS
#1095, Toledo, OH 43614. Tel.: + 1 419 383 6834; fax: + 1 419 383 3105.
E-mail address: reginald.baugh@utoledo.edu (R. Baugh).

http://dx.doi.org/10.1016/j.amjoto.2015.03.002
0196-0709/© 2015 Elsevier Inc. All rights reserved.
518 AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 5 17 –5 2 0

2. Case review

Two cases of ITA, and ten representative cases of PTA and

Fig. 1 – Human palatine tonsil in setting of tonsillitis:
Ulcerated surface epithelium with acute inflammation and
neutrophil invasion(10 ×).
An ITA is defined as focal areas of neutrophils and necrotic
debris within the parenchyma of the tonsil [3]. The pathogenesis
of this rare presentation is also uncertain. Two mechanisms of
ITA formation have been proposed: First, direct extension of acute
suppurative inflammation into the crypts is followed by enlarge-
ment of the inflamed tonsil, occluding the crypt and containing
the abscess. Second, it is proposed that ITA arises from bacterial
seeding via the bloodstream or lymphatic system [3].
acute tonsillitis cases were pulled from the pathology
department from The University of Toledo Medical Center by
a listed diagnosis of PTA or acute tonsillitis over the years
2007–2013. Institutional review board approval was obtained
and all slides were appropriately stripped of all identifiers.
The histopathology was then reviewed and classified.
Pathologic examination of acute tonsillitis specimen demon-
strated ulceration of the stratified squamous surface epithelium
with local invasion of neutrophils (PMN). This commonly
extended into the crypts but no inflammation or abscess
formation was observed deeper within the parenchyma (Fig. 1).
Microscopic examination of six PTA specimen revealed
erosion of the surface epithelium with PMN invasion, as observed
in the acute tonsillitis specimen. The tonsillar parenchyma was
observed to be uniformly unremarkable throughout, only with
hyperplasia of follicles. The PTA itself was represented by a
collection of PMN infiltration, tissue necrosis and abscess
formation deep between the fibrous tonsillar capsule and the
skeletal muscle of the pharyngeal wall (Fig. 2).
Pathologic examination of ITA specimen revealed a similar
erosion of stratified squamous surface epithelium, with sheets of

Fig. 2 – (A) PTA specimen: Ulcerated surface epithelium, acute inflammation, PMN invasion (10 ×). (B) PTA specimen: Normal
tonsillar parenchyma without inflammation or abscess (4 ×). (C) PTA specimen: Neutrophil collection in peritonsillar space with
presence of pharyngeal wall skeletal muscle fibers (sm) (40 ×).
 AM ER IC AN JOURNAL OF OT OLARYNGOLOGY–H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 5 17–5 2 0
Fig. 3 – (A) ITA: Abscess surrounded with normal tonsillar parenchyma (2 ×). (B) ITA: Gross collection of neutrophils within the
abscess (40 ×).
PMN extending into the tonsillar crypts. Deep into the epithelium,
within the parenchyma, a large abscess was found completely
surrounded within unremarkable appearing tonsillar tissue (Fig. 3).
A concomitant PTA with abscess collection between the tonsil and
pharyngeal skeletal muscle wall was also observed.
3. Discussion
Intratonsillar abscesses are a rare occurrence, with a review of
literature revealing 24 reported cases [3–7]. The true prevalence
may be underestimated because prevalence of ITA alone is
unknown [4]. Management strategies vary from incision and
drainage, needle aspiration and tonsillectomy [3–7]. A recent
review of 11 cases helped to better clarify clinical presentation
and treatment; reporting surgical drainage as the optimal option
in the presence of airway compromise, concomitant PTA or
medical treatment failure [7]. However, the pathogenesis re-
mains unclear and an adequate theory has not been proposed.
We postulate that acute tonsillitis represents a cellulitis of the
tonsil epithelium. The lack of subepithelial lymphatic channels
results in bacterial antigens, but not bacteria, transported to
lymph nodes for antigenic processing. A virulent organism may
start at the tonsillar crypt and penetrate the stratified squamous
epithelium into the core tonsillar lymphatics below, serving as a
route to the fibrous capsule. Fujisaka and Watanabe used
enzyme histochemistry and scanning electron microscopy to
analyze the distribution of lymphatics in human palatine tonsils.
519
Lymphatic distribution was detected to be absent in the
subepithelial area but existed in the parafollicular area forming
a three-dimensional network that drained to the connective
tissue septa and lastly lymphatic channels of the fibrous capsule,
which contain valves [8]. Previous study of dynamic magnetic
resonance lymphangiography reveals that lymphatic contrast
transport in the palatine tonsil is rapid; with an early enhance-
ment peak at less than 10 minutes and returning to near baseline
by 30–40 minutes [9]. The absence of lymphatic valves prior to
the capsule, as well as the suggested rapid lymphatic transit may
not allow adequate time for aggregation of bacteria within the
tonsillar parenchyma. This serves as a possible explanation for
the paucity of ITA and the subsequent more common PTA
presentation of surface ulceration with concomitant deep collec-
tion of pus between the capsule and the pharyngeal constrictors.
Dehydration, inflammatory swelling of tonsillar follicles and
previous history of PTA may further compromise lymphatic flow
within the tonsil predisposing the patient to bacterial aggregation
and ITA development. Bacterial virulence may also play a role in
the necessary speed of parenchymal abscess formation. The
specimen in this study was obtained from an individual with
previous history of drained PTA.
4. Conclusion
The lymphatic ultrastructure and suggested rapid physiologic
transit may serve as a unifying means to explain association
520 AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 5 17 –5 2 0
of acute tonsillitis, PTA and ITA. Both start with a surface
ulceration and lymphatic transit of the bacteria toward the
fibrous capsule. Alteration of lymphatic flow may allow
adequate time for accumulation of virulent bacteria within
the tonsillar parenchyma leading to ITA instead of the more
common presentation of deep abscess between the capsule
and pharyngeal muscles.
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