Peritonsillar abscess: Difference between revisions
 
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==Background==
==Background==
[[File:Gray1014.png|thumb|Anatomy of the posterior pharynx.]]
[[File:Infrahyoid deep neck spaces.png|thumb|Infrahyoid deep neck spaces]]
[[File:EB1911 - Tongue.png|thumb|Neck anatomy at the level of the tongue.]]
[[File:Human anatomy, including structure and development and practical considerations (1911) (14594049867).jpg|thumb|Midline neck anatomy on lateral view.]]
*Abbreviation: PTA
*Abbreviation: PTA
*Most common deep head and neck infection in all populations
*Generally preceded by pharyngitis, tonsillitis, or peritonsillar cellulitis
*Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
*Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
** Location affected: superior > middle > inferior pole
** Location affected: superior > middle > inferior pole of tonsil
*Variable presentation, may range from minimal sore throat to sepsis and airway obstruction
*Microbiology
*Microbiology
**Polymicrobial: [[strep]]/[[staph]], [[anaerobes]], [[eikenella]], [[haemophilus influenzae]], Fusobacterium necrophorum
**Polymicrobial: [[strep]]/[[staph]], [[anaerobes]], [[eikenella]], [[haemophilus influenzae]], Fusobacterium necrophorum
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[[File:PeritonsilarAbsess.jpg|thumb|Right sided peritonsillar abscess]]
[[File:PeritonsilarAbsess.jpg|thumb|Right sided peritonsillar abscess]]
===Symptoms===
===Symptoms===
*[[Fever]]
*[[Sore throat]]
*[[Sore throat]]
*[[Fever]], chills
*Odynophagia/[[dysphagia]]
*Odynophagia/[[dysphagia]]
*May have neck or ear pain


===Signs===
===Signs===
*Trismus
*Trismus, drooling, or saliva pooling
*Muffled voice ("hot potato voice")
*Muffled voice ("hot potato voice")
*Contralateral deflection of swollen uvula
*Peritonsillar edema/fluctuance and contralateral deflection of swollen uvula
*Cervical lymphadenopathy


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
[[File:PTA Singh.gif|thumbnail|Endocavitary probe shows hypoechoic circumscribed area consistent with abscess<ref>http://www.thepocusatlas.com/soft-tissue-vascular/</ref>]]
[[File:PTA Singh.gif|thumbnail|Endocavitary probe shows hypoechoic circumscribed area consistent with abscess<ref>http://www.thepocusatlas.com/soft-tissue-vascular/</ref>]]
[[File:Peritonsilarabs.png|thumb|Right sided peritonsillar abscess on CT imaging.]]
[[File:PeritonsilarAbsMark.png|thumb|Peritonsilar abscess (arrow) on CT.]]
*Primarily a clinical diagnosis, though diagnostic uncertainty and assessment of the size/nature requires imaging
*Labs
**CBC
**CMP
**Blood cultures or culture/sensitivity of abscess fluid
*[[Ultrasound]]
*[[Ultrasound]]
**Differentiates [[peritonsillar cellulitis|cellulitis]] from abscess
**Differentiates [[peritonsillar cellulitis|cellulitis]] from abscess
**Can use an intraoral approach using a endocavitary probe or transcutaneous approach using a linear probe
**Can use an intraoral approach using a endocavitary probe or transcutaneous approach using a linear probe
**Can identify depth of neck vasculature prior to aspiration
**Can identify depth of neck vasculature prior to aspiration
**May be limited by trismus, gag reflex, and operator technique
*CT with IV contrast
*CT with IV contrast
**Appears as ring-enhancing hypodense mass
**Differentiates PTA from [[parapharyngeal space infection|parapharyngeal]] or [[retropharyngeal abscess|retropharyngeal space infection]]
**Differentiates PTA from [[parapharyngeal space infection|parapharyngeal]] or [[retropharyngeal abscess|retropharyngeal space infection]]


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#Apply anesthetic spray to overlying mucosa  
#Apply anesthetic spray to overlying mucosa  
#Have patient hold suction and use as needed
#Have patient hold suction and use as needed
#Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source
#Use [[direct laryngoscopy|laryngoscope]] or disassembled vaginal speculum with wand as tongue depressor and light source
#Inject 1-2mL of lidocaine with epinephrine into mucosa of anterior tonsillar pillar using 25 gauge needle
#Inject 1-2mL of lidocaine with epinephrine into mucosa of anterior tonsillar pillar using 25 gauge 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
#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
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====Antibiotics Alone====
====Antibiotics Alone====
*A 2018 paper showed that if pts were given abx/IVF/decadron and felt better (must improve clinically), similar results could be obtained compared to I&D<ref>Comparison Of Medical Therapy Alone To Medical Therapy With Surgical Treatment Of Peritonsillar Abscess Battaglia, A., et al, Otolaryngol Head Neck Surg 58(2):280, February 2018</ref>
''Caution: No prospective, controlled studies are currently available to support this approach. The most recent review with meta analysis (2020) found only low-quality data.<ref>Medical Intervention Alone vs Surgical Drainage for Treatment of Peritonsillar Abscess: A Systematic Review and Meta-analysis. Forner D., et al, Otolaryngology–Head and Neck Surgery 2020, Vol. 163(5) 915–922</ref>''
*Protocol includes the medications below and ED observation for 1-2 hours after, with liquid PO challenge
*The medications below and ED observation for 1-2 hours after, with liquid PO challenge:
**D5-1/2 NS, 1 L bolus
**D5-1/2 NS, 1 L bolus
**IV NSAIDs, antipyretics
**[[Dexamethasone]] 10 mg IV
**[[Dexamethasone]] 10 mg IV
**[[Ceftriaxone]] 2 g IV
**[[Ceftriaxone]] 2 g IV, [[Ampicillin/Sulbactam]] 3 g IV, or [[Clindamycin]] 600 mg IV
**[[Clindamycin]] 600 mg IV
**Upon discharge, [[Clindamycin]] 300 mg PO QID x10-14 days vs [[Amoxicillin/Clavulanate]] 875mg PO BID x10-14 days
**Upon discharge, [[Clindamycin]] 300 mg PO QID x10 days
**Pediatric protocol is the same, with weight based dosing
*Pediatric protocol is the same, with weight based dosing
*Medical therapy patients required less opioids, fewer sore throat days, required less days off from work


===[[Antibiotics]]===
===[[Antibiotics]]===
{{PTA Antibiotics}}
{{PTA Antibiotics}}
===Steroids===
===Steroids===
Decreases duration and severity of pain
Decreases duration and severity of pain<ref>Hur, K., Zhou, S., & Kysh, L. (2018). Adjunct steroids in the treatment of peritonsillar abscess: A systematic review. The Laryngoscope, 128(1), 72–77. https://doi.org/10.1002/lary.26672</ref>
*[[Methylprednisolone]] 125mg IV x1 '''OR''' [[dexamethasone]] 10mg PO/IM x1
*[[Methylprednisolone]] 125mg IV x1 '''OR''' [[dexamethasone]] 10mg PO/IM x1


==Disposition==
==Disposition==
*Generally may be discharged with ENT follow-up  
*Generally may be discharged with ENT follow-up and PO antibiotics
**Weight PO tolerance, probability of follow-up failure, antibiotics adherence in deciding disposition
*If no pus can be obtained but there is high suspicion for a PTA, admit with IV antibiotics (30% neg aspiration still have PTA)
*If no pus can be obtained but there is high suspicion for a PTA, admit with IV antibiotics (30% neg aspiration still have PTA)
*In pediatric patients 50% respond to med management<ref>Blotter JW, Yin L, Glynn M, et al. Otolaryngology consultation for peritonsillar [[abscess]] in the pediatric population. Laryngoscope. 2000;110(10 Patient 1):1698.</ref>
*In pediatric patients 50% respond to med management<ref>Blotter JW, Yin L, Glynn M, et al. Otolaryngology consultation for peritonsillar [[abscess]] in the pediatric population. Laryngoscope. 2000;110(10 Patient 1):1698.</ref>
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==See Also==
==See Also==
*[[Pharyngitis]]
*[[Pharyngitis]]
==External Links==


==References==
==References==

Latest revision as of 16:48, 16 April 2025

Background

Anatomy of the posterior pharynx.
Infrahyoid deep neck spaces
Neck anatomy at the level of the tongue.
Midline neck anatomy on lateral view.
  • Abbreviation: PTA
  • Most common deep head and neck infection in all populations
  • Generally preceded by pharyngitis, tonsillitis, or peritonsillar cellulitis
  • Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
    • Location affected: superior > middle > inferior pole of tonsil
  • Variable presentation, may range from minimal sore throat to sepsis and airway obstruction
  • Microbiology

Clinical Features

Right sided peritonsillar abscess

Symptoms

Signs

  • Trismus, drooling, or saliva pooling
  • Muffled voice ("hot potato voice")
  • Peritonsillar edema/fluctuance and contralateral deflection of swollen uvula
  • Cervical lymphadenopathy

Differential Diagnosis

Acute Sore Throat

Bacterial infections

Viral infections

Noninfectious

Other

Dentoalveolar Injuries

Odontogenic Infections

Other

Evaluation

Endocavitary probe shows hypoechoic circumscribed area consistent with abscess[2]
Right sided peritonsillar abscess on CT imaging.
Peritonsilar abscess (arrow) on CT.
  • Primarily a clinical diagnosis, though diagnostic uncertainty and assessment of the size/nature requires imaging
  • Labs
    • CBC
    • CMP
    • Blood cultures or culture/sensitivity of abscess fluid
  • Ultrasound
    • Differentiates cellulitis from abscess
    • Can use an intraoral approach using a endocavitary probe or transcutaneous approach using a linear probe
    • Can identify depth of neck vasculature prior to aspiration
    • May be limited by trismus, gag reflex, and operator technique
  • CT with IV contrast

Management

Drainage

Needle Aspiration

  1. Apply anesthetic spray to overlying mucosa
  2. Have patient 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 epinephrine into mucosa of anterior tonsillar pillar using 25 gauge 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 18 gauge needle just lateral to the tonsil
    • Use static ultrasound to determine depth of vasculature.
    • Though always a concern, carotid injury has not been clearly documented as a complications[5]
    • May require multiple aspirations to find the abscess
      • First try superior then middle then inferior poles
    • Consider spinal needle if patient has significant trismus

I&D

  1. #11 or #15 blade scalpel
  2. Do not penetrate more than 1cm
  3. Only advance posteriorly
  4. May be indicated if significant pus with needle aspiration
  5. Macintosh size 3 or 4 with handle in a "tomahawk" position provides visualization with lighting[6]

Antibiotics Alone

Caution: No prospective, controlled studies are currently available to support this approach. The most recent review with meta analysis (2020) found only low-quality data.[7]

Antibiotics

Coverage for Streptococcus species, anerobes, Eikenella, H. influenza, S. auresus

Outpatient Options

Inpatient Options

Steroids

Decreases duration and severity of pain[8]

Disposition

  • Generally may be discharged with ENT follow-up and PO antibiotics
    • Weight PO tolerance, probability of follow-up failure, antibiotics adherence in deciding disposition
  • If no pus can be obtained but there is high suspicion for a PTA, admit with IV antibiotics (30% neg aspiration still have PTA)
  • In pediatric patients 50% respond to med management[9]

Return Precautions

Prognosis

Complications

  • Airway obstruction
  • Rupture abscess with aspiration of contents
  • Hemorrhage due to erosion of carotid sheath
  • Retropharyngeal abscess
  • Mediastinitis
  • Recurrence occurs in 10-15% of patients
  • Lemierre's syndrome
  • Iatrogenic laceration of carotid artery
    • Carotid artery is 2.5 cm posterior and lateral to tonsil
    • Should limit depth of needle insertion to <10mm during aspiration

Indications for tonsillectomy

  • Airway obstruction
  • Recurrent severe pharyngitis or PTA
  • Failure of abscess resolution with drainage

See Also

External Links

References

  1. ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  2. ↑ http://www.thepocusatlas.com/soft-tissue-vascular/
  3. ↑ Johnson RF, Stewart MG. The contemporary approach to diagnosis and man- agement of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005;13:157
  4. ↑ Wolf M. Peritonsillar abscess: repeated needle aspiration versus incision and drainage. Ann Otol Rhinol Laryngol. 1994 Jul;103(7):554-7.
  5. ↑ Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep. 2006;8(3):196.
  6. ↑ Ballew JD. Unlocking Common ED Procedures – Peritonsillar Abscess Drainage. Arp 4, 2019. http://www.emdocs.net/unlocking-common-ed-procedures-peritonsillar-abscess-drainage/.
  7. ↑ Medical Intervention Alone vs Surgical Drainage for Treatment of Peritonsillar Abscess: A Systematic Review and Meta-analysis. Forner D., et al, Otolaryngology–Head and Neck Surgery 2020, Vol. 163(5) 915–922
  8. ↑ Hur, K., Zhou, S., & Kysh, L. (2018). Adjunct steroids in the treatment of peritonsillar abscess: A systematic review. The Laryngoscope, 128(1), 72–77. https://doi.org/10.1002/lary.26672
  9. ↑ Blotter JW, Yin L, Glynn M, et al. Otolaryngology consultation for peritonsillar abscess in the pediatric population. Laryngoscope. 2000;110(10 Patient 1):1698.
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