Peritonsillar abscess: Difference between revisions
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#No difference in outcome when comparing needle aspiration with I&D | #No difference in outcome when comparing needle aspiration with I&D | ||
#Needle Aspiration | #Needle Aspiration | ||
# | #*Apply anesthetic spray to overlying mucosa | ||
# | #*Have pt hold suction, and use as needed | ||
# | #*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 2.5 cm posterolateral) | ||
# | #**May require multiple aspirations to find the abscess (first try superior then middle then inferior poles) | ||
# | #**Consider spinal needle if pt has significant trismus. | ||
#I&D | #I&D | ||
# | #* 11 or 15 blade scalpel | ||
# | #* Do not penetrate more than 1cm | ||
# | #* May be indicated if significant pus with needle aspiration | ||
# | #[[Antibiotics]] | ||
# | #*Outpatient | ||
# | #**[[Clindamycin]] 300mg PO Q6hrs x7-10d OR | ||
# | #**[[Amoxicillin/Clavulanate]] 875 mg PO BID x 7-10d OR | ||
# | #**[[Penicillin V]] 500mg PO + flagyl 500mg QID | ||
# | #*Inpatient | ||
# | #**[[Ampicillin/Sulbactam]] 3 gm (75mg/kg) IV QID OR | ||
# | #**[[Pipericillin/Tazobactam]] 4.5 gm IV TID OR | ||
# | #**[[Ticarcillin/Clavulanate]] 3.1 g IV QID OR | ||
# | #**[[Clindamycin]] 600-900mg IV TID | ||
#Steroids | #Steroids | ||
# | #*Improves duration and severity of pain | ||
# | #*[[Methylprednisolone]] 125mg IV x1 OR [[dexamethasone]] 10mg PO/IM x1 | ||
#Indications for tonsillectomy: | #Indications for tonsillectomy: | ||
# | #*Airway obstruction | ||
# | #*Recurrent severe pharyngitis or PTA | ||
# | #*Failure of abscess resolution with drainage | ||
==Complications== | ==Complications== | ||
Revision as of 20:34, 10 March 2015
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
Differential Diagnosis
Acute Sore Throat
Bacterial infections
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [1]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Noninfectious
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
Diagnosis
- Ultrasound
- Differentiates cellulitis from abscess
- Can identify neck vasculature prior to aspiration
- CT w/ IV contrast
- Differentiates PTA from parapharyngeal or retropharyngeal space infection
Treatment
- No difference in outcome when comparing needle aspiration with I&D
- Needle Aspiration
- Apply anesthetic spray to overlying mucosa
- Have pt hold suction, and use as needed
- 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 2.5 cm posterolateral)
- May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
- Consider spinal needle if pt has significant trismus.
- I&D
- 11 or 15 blade scalpel
- Do not penetrate more than 1cm
- May be indicated if significant pus with needle aspiration
- Antibiotics
- Outpatient
- Clindamycin 300mg PO Q6hrs x7-10d OR
- Amoxicillin/Clavulanate 875 mg PO BID x 7-10d OR
- Penicillin V 500mg PO + flagyl 500mg QID
- Inpatient
- Ampicillin/Sulbactam 3 gm (75mg/kg) IV QID OR
- Pipericillin/Tazobactam 4.5 gm IV TID OR
- Ticarcillin/Clavulanate 3.1 g IV QID OR
- Clindamycin 600-900mg IV TID
- Outpatient
- Steroids
- Improves duration and severity of pain
- Methylprednisolone 125mg IV x1 OR dexamethasone 10mg PO/IM x1
- Indications for tonsillectomy:
- Airway obstruction
- Recurrent severe pharyngitis or PTA
- 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
- Recurrence occurs in 10-15% of patients
- Lemierre's syndrome
- Iatrogenic laceration of carotid artery
- Carotid artery is 2.5 cm behind and lateral to tonsil
Disposition
- F/u in 2-3 days
- Return Precautions:
- SOB
- Worsening throat or neck pain
- Enlarging mass
- Bleeding
- Neck stiffness
See Also
Source
- Tintinalli
- UpToDate
- Roberts & Hedges
- ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.