Peritonsillar abscess

Background

• Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
• Microbiology
  • Polymicrobial: strep/staph, anaerobes, eikenella, haemophilus

Clinical Features

• Symptoms
  • Fever
  • Sore throat
  • Odynophagia/dysphagia
• Signs
  • Trismus
  • Muffled voice ("hot potato voice")
  • Contralateral deflection of swollen uvula

DDX

• Peritonsillar cellulitis
• Mono
• Lymphoma
• Herpes simplex tonsillitis
• Retropharyngeal Abscess
• Internal carotid artery aneurysm

Diagnosis

• Ultrasound
  • Differentiates cellulitis from abscess
• CT w/ IV contrast
  • Differentiates PTA from parapharyngeal or retropharyngeal space infection

Treatment

1. No difference in outcome when comparing needle aspiration with I&D
2. Needle Aspiration
   1. Apply anesthetic spray to overlying mucosa
   2. Have pt hold suction, and use as needed
   3. Use laryngoscope (miller 2) as tongue depressor and light source
   4. Inject 1-2mL of lidocaine with epi into mucosa of anterior tonsillar pillar using 25ga needle
   5. Cut distal tip off of needle sheath and place over 18ga needle to expose 1 cm of needle to prevent accidentally plunging deeper than desired
   6. Aspirate using 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery nearby)
      1. May require multiple aspirations to find the abscess
      2. Consider spinal needle if pt has significant trismus.
3. Abx
   1. Outpatient
      1. Amoxicillin/clavulanate 875 mg PO BID x 7-10d OR
      2. Clindamycin 300mg PO Q6hrs x7-10d OR
      3. Pen VK 500mg PO + flagyl 500mg QID
   2. Inpatient
      1. Ampicillin/Sulbactam 3 gm (75mg/kg) IV QID OR
      2. Pipericillin/Tazobactam 4.5 gm IV TID OR
      3. Ticarcillin/Clavulanate 3.1 g IV QID OR
      4. Clindamycin 600-900mg IV TID
4. Steroids
   1. Improves duration and severity of pain
   2. Methylprednisolone 125mg IV x1 OR dexamethasone 10mg PO/IM x1
5. Indications for tonsillectomy:
   1. Airway obstruction
   2. Recurrent severe pharyngitis or PTA
   3. Failure of abscess resolution with drainage

Complications

• Airway obstruction
• Rupture abscess with aspiration of contents
• Hemorrhage due to erosion of carotid sheath
• Retropharyngeal abscess
• Mediastinitis

See Also

• Pharyngitis

Source

Tintinalli