Peritonsillar abscess: Difference between revisions

Revision as of 17:15, 21 May 2014

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

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

Ultrasound
- Differentiates cellulitis from abscess
- Can identify neck vasculature prior to aspiration
CT w/ IV contrast
- Differentiates PTA from parapharyngeal or retropharyngeal space infection

No difference in outcome when comparing needle aspiration with I&D
Needle Aspiration
1. Apply anesthetic spray to overlying mucosa
2. Have pt hold suction, and use as needed
3. Use laryngoscope or disassembled vaginal speculum with wand 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 2.5 cm posterolateral)
  1. May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
  2. Consider spinal needle if pt has significant trismus.
Abx
1. Outpatient
  1. Clindamycin 300mg PO Q6hrs x7-10d OR
  2. Amoxicillin/Clavulanate 875 mg PO BID x 7-10d OR
  3. Penicillin V 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
Steroids
1. Improves duration and severity of pain
2. Methylprednisolone 125mg IV x1 OR dexamethasone 10mg PO/IM x1
Indications for tonsillectomy:
1. Airway obstruction
2. Recurrent severe pharyngitis or PTA
3. Failure of abscess resolution with drainage

@@ Line 34: / Line 34: @@
 ##Apply anesthetic spray to overlying mucosa
 ##Have pt hold suction, and use as needed
-##Use laryngoscope (miller 2) as tongue depressor and light source
+##Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source
 ##Inject 1-2mL of lidocaine with epi into mucosa of anterior tonsillar pillar using 25ga needle
 ##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
-##Aspirate using 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery nearby)
+##Aspirate using 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery 2.5 cm posterolateral)
-###May require multiple aspirations to find the abscess
+###May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
 ###Consider spinal needle if pt has significant trismus.
 #Abx