The theory of everything (tonsil)?
Reviewed by Rohit Verma

Tonsil sepsis can manifest as acute tonsillitis, a peritonsillar abscess (PTA) or rarely as an intra-tonsillar (ITA) abscess. Whilst the management of these conditions is familiar to ENT surgeons from early in training, perhaps little attention has been paid to how these conditions develop and how previous episodes of tonsil infection may precipitate different manifestations with subsequent infections. The authors performed histological analysis of pathological specimens of PTA, acute tonsillitis and ITA. In cases of tonsillitis, the surface epithelium was eroded with invasion of neutrophils. In cases of PTA, there was neutrophil infiltration, tissue necrosis and abscess formation between the fibrous tonsillar capsule and the skeletal muscle of the pharyngeal constrictor muscles. In ITA, there was erosion of the epithelium as in tonsillitis but this time deep infiltration of neutrophils into the crypts resulting in a circumscribed abscess surrounded by normal parenchyma. The authors suggest that a PTA is more likely to occur than the rare ITA as lymphatic drainage within the tonsil parenchyma itself is rapid and drains to the lymphatic channels of the fibrous capsule. Therefore, after inflammatory swelling of the tonsils of previous PTA, 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.

A unifying theory of tonsillitis, intratonsillar abscess and peritonsillar abscess.
Bair AB, Booth R, Baugh R.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY
2015;36(4):517-20.