Peritonsillar abscess

Presentation

Fever, hot-potato voice, trismus, exudate and uvular devation (away from abscess)
If unclear, can attempt to digitally palpate posterior oropharynx for fluctuance

Diagnosis

Needle aspiration is used for symptom relief and is the criterion standard for diagnosis

Imaging Studies

Radiography: Lateral soft tissue neck radiographs may help rule out other causes. The anteroposterior (AP) view of the neck may demonstrate distortion of soft tissue.
CT scan: Head and neck scan with intravenous (IV) contrast is useful if incision and drainage (I&D) is failed, if the patient cannot open his or her mouth, or if the patient is young (<7 y). A hypodense fluid collection with rim enhancement may be seen in the affected tonsil. Foreign bodies such as fish or chicken bones may also be found as an inciting factor.
Ultrasonography: Intraoral ultrasonography (use vaginal probe with condom!) has a sensitivity of 95.2% and specificity of 78.5%. Transcutaneous ultrasonography has a sensitivity of 80% and specificity of 92.8%. This method is cost-effective and fast.

Treatment

Needle aspiration
Abscess I&D: After lidocaine with epinephrine local infiltration, a No. 11 blade scalpel may be used to incise a very large PTA, allowing the purulent drainage to flow freely as the abscess cavity decompresses. Allow the patient to hold the Yankauer catheter tip and to suction the pus, rather than swallow it.
Tonsillectomy: for recurrent or emergent PTA (i.e. not protecting airway)
Hydrate as most patients often not tolerating adequate amount of fluid
Pain and antipyretics prn

Antibiotics

Common Organisms: Streptococcus spp, Anaerobes, Eikenella Corrodens, Haemophilis spp, S. Aureus

Outpatient

Amoxicillin/Clavulanate 875 mg PO BID for 7-10 days
Clindamycin 600-900 mg IV/PO TID (7.5 mg/kg IV QID) for 7-10 days
Penicillin G 4 million units IV/PO (50,00 units/kg) four times daily AND Metronidazole 500 mg IV/PO (7.5 mg/kg) four time daily 7-10 days

Inpatient

Ampicillin/Sulbactam 3 gm (75mg/kg) IV four times daily
Pipericillin/Tazobactam 4.5 gm IV three times daily
Ticarcillin/Clavulanate 3.1 g IV four time daily

Steroids

The addition of a single dose of intravenous dexamethasone to parenteral antibiotics has been found to significantly lessen the variables of hours hospitalized, throat pain, fever, and trismus compared with a group of patients who were only treated with parenteral antibiotics.

Dexamethasone 10mg PO/IM once