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

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
• Laryngitis
• Acute Bronchitis
• Rhinovirus
• Coronavirus
• Adenovirus
• Herpesvirus
• Influenza virus
• Coxsackie virus
  • Herpangina
  • Hand-foot-and-mouth disease
• HIV (Acute Retroviral Syndrome)

Noninfectious

• Stevens-Johnson Syndrome
• Pemphigus
• Angioedema

Other

• Deep neck space infection
  • Retropharyngeal abscess
  • Ludwig's angina
  • Parapharyngeal 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

1. No difference in outcome when comparing needle aspiration with I&D
2. 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.
3. I&D
   • 11 or 15 blade scalpel
   • Do not penetrate more than 1cm
   • May be indicated if significant pus with needle aspiration
4. 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
5. Steroids
   • Improves duration and severity of pain
   • Methylprednisolone 125mg IV x1 OR dexamethasone 10mg PO/IM x1
6. 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

• Follow up in 2-3 days

Return Precautions

• SOB
• Worsening throat or neck pain
• Enlarging mass
• Bleeding
• Neck stiffness

See Also

• Pharyngitis

Source

• Tintinalli
• UpToDate
• Roberts & Hedges