Peritonsillar Abscess

Aka: Peritonsillar Abscess, Peritonsillitis, Peritonsillar Cellulitis, Quinsy Sore Throat

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II. Epidemiology

  1. Highest Incidence ages 20-40 years old
  2. Accounts for 30% of head and neck abscesses

III. Definitions

  1. Peritonsillar Abscess
    1. Suppurative fluid collection within the peritonsillar space (between Tonsillar capsule and superior constrictor Muscle)

IV. Pathophysiology

  1. Sequelae of Acute Tonsillitis or Tonsillopharyngitis
  2. Abscess forms between lateral Tonsil and pharyngeal constrictor Muscles
  3. Progression from exudative Tonsillitis to Peritonsillar Cellulitis to Peritonsillar Abscess
    1. Weber's Glands (mucous Salivary Glands within Soft Palate)
      1. Reside in Soft Palate, superior to Tonsil
      2. Duct between Weber Gland and Tonsil
    2. Cellulitis develops within the Weber Gland
    3. Weber Gland duct obstructs and abscess forms

V. Risk Factors

  1. Exudative Tonsillitis
  2. Periodontal Disease
  3. Tobacco Abuse

VI. Causes

  1. Group A Streptococcal Pharyngitis complication
    1. Streptococcus Pyogenes (most common aerobic organism)
  2. Mixed oropharyngeal flora
    1. Staphylococcus aureus
    2. Corynebacterium
    3. Streptococcus milleri (S. intermedius, S. anginosus, S. Constellatus)
    4. HaemophilusInfluenzae
    5. Neisseria
    6. Anaerobic Bacteria
      1. Fusobacterium
      2. Peptostreptococcus
      3. Prevotella
      4. Bacteroides
      5. Porphyromonas

VII. Symptoms

  1. Fever
    1. Temp over 39.4 F suggests more serious infection (Parapharyngeal Space Infection, Sepsis)
  2. Severe, unilateral throat pain
  3. Dysphagia and Odynophagia (difficult and painful Swallowing)
  4. Halitosis
  5. Malaise
  6. Otalgia (ipsilateral to abscess)

VIII. Signs

  1. General
    1. Ill appearance
    2. Muffled ("hot potato") voice
    3. Trismus
    4. Drooling
    5. Tender Cervical Lymphadenopathy
  2. Oropharynx
    1. Uvula deviates away from abscess to the opposite side
    2. Localized swelling of Soft Palate over affected Tonsil
  3. Swollen Tonsil (usually superior pole)
    1. Indurated, fluctuant mass
    2. Exudate may be present
    3. Erythematous peritonsillar area
    4. Usually unilateral

IX. Labs

  1. Complete Blood Count (CBC)
  2. Throat Culture
  3. Streptococcal Rapid Antigen Test
  4. Monospot

X. Imaging

  1. Indications
    1. Uncomplicated Peritonsillar Abscess is a clinical diagnosis that may often be managed without imaging
    2. Confirm Peritonsillar Abscess
      1. Diagnosis is uncertain
      2. Failed aspiration (Ultrasound)
    3. Evaluate contiguous soft tissues and vessels (CT or MRI)
      1. Significant Trismus
      2. Suspected deep space infection
  2. Neck Ultrasound
    1. Preferred imaging modality for diagnosis and aspiration guidance of Peritonsillar Abscess
    2. Endocavitary probe transducer intraoral (preferred)
      1. Alternatively, may attempt visualization over Submandibular Gland
    3. Abscess is echo-free with irregular border
  3. CT Neck with contrast
    1. Abscess appears with low attenuation
    2. High False Positive Rate for Peritonsillar Abscess
    3. Shows contiguous spread of infection to deep neck tissue
  4. MRI neck
    1. Evaluate for deep neck infections (better than CT without inonizing radiation)
    2. Evaluate Internal Jugular Vein Thrombosis and Carotid Artery sheath erosion

XI. Differential Diagnosis

  1. Peritonsillar Cellulitis (no pus in capsule)
  2. Retropharyngeal Abscess
  3. Dental Infection (e.g abscessed tooth, Retromolar abscess)
  4. Lemierre Syndrome
  5. Epiglottitis
  6. Mononucleosis (up to 6% coinfection, esp. in teens and young adults)
  7. Cervical adenitis
  8. Sialolithiasis or Sialadenitis
  9. Mastoiditis
  10. Internal cartoid artery aneurysm
  11. Malignancy (e.g. Lymphoma)

XII. Management

  1. Needle aspiration
    1. See Peritonsillar Abscess Needle Aspiration
    2. Be prepared for airway emergency
    3. Observe patient for several hours after observation and confirm able to tolerate liquids
    4. Failed aspiration of pus
      1. May be consistent with Peritonsillar Cellulitis
      2. Consider imaging soft tissue for deep space infection
      3. If no serious findings, may discharge home with close follow-up on oral Antibiotics and steroids
    5. Medical intervention (Antibiotics, steroids) alone without aspiration has similar outcomes in uncomplicated PTA
      1. Medical management without aspiration has a similar failure rate as with aspiration (5 to 8%)
      2. Forner (2020) Otolaryngol Head Neck Surg 163(5):915-922 +PMID: 32482146 [PubMed]
      3. Zebolsky (2021) Am J Otolaryngol 42(4):102954 +PMID: 33581462 [PubMed]
      4. Battaglia (2018) Otolaryngol Head Neck Surg 158(2):280-286 +PMID: 29110574 [PubMed]
  2. Disposition: Indications for inpatient management (typically 2-4 day stays)
    1. Children
    2. Dehydration
    3. Toxic appearance
    4. Persistent significant Trismus or Dysphagia (refractory to aspiration)
    5. Airway compromise risk (e.g. "kissing" Tonsils)
  3. Disposition: Outpatient Management
    1. Observe after aspiration for several hours before discharge (confirm tolerating liquids)
    2. Prescribe Antibiotics, Corticosteroids (typically) and Analgesics
    3. Close interval follow-up at 24-36 hours
  4. Antibiotics for 10-14 days
    1. Broad spectrum Antibiotics are typically needed (polymicrobial infections, often with resistance)
      1. May adjust Antibiotic based on needle aspiration sample
    2. Parenteral
      1. Combination
        1. Penicillin G 10 MU IV every 6 hours and
        2. Metronidazole 1.0 g load, and then 500 mg IV every 6 hours
      2. Piperacillin/Tazobactam (Zosyn) 3.375 mg every 6 hours
      3. Ampicillin with Sulbactam (Unasyn) 3 grams every 6 hours
      4. Ceftriaxone 1 g every 12 hours AND Metronidazole
      5. Clindamycin 900 mg IV every 8 hours (if Penicillin allergic)
      6. Consider Vancomycin AND Flagyl if MRSA concern
    3. Oral agents
      1. Clindamycin 300 to 450 mg orally every 8 hours
      2. Cefdinir (Omnicef) 300 mg every 12 hours AND Metronidazole
      3. Augmentin 875 mg orally twice daily
      4. Combination
        1. Penicillin VK 500 mg orally every 6 hours AND
        2. Metronidazole 500 mg orally every 6 hours
  5. Corticosteroids as adjunct to Antibiotics
    1. Dexamethasone 10 mg orally for 1 dose
      1. O`Brien (1993) Ann Emerg Med 22(2): 212-5 [PubMed]
    2. Depo Medrol 2-3 mg/kg up to 250 mg IV for 1 dose
      1. Patients improved faster when adjunctive steroids were used
      2. Ozbek (2004) J Laryngol Otol 118:439-42 [PubMed]
    3. Efficacy
      1. Decreased pain and improved oral intake within 12-24 hours
      2. Faster recovery and shorter hospital stays
      3. Lee (2016) Clin Exp Otorhinolaryngol 9(2): 89-97 [PubMed]

XIII. Complications

  1. Airway obstruction
  2. Lung infection (Aspiration Pneumonia or Lung Abscess) from Peritonsillar Abscess rupture
  3. Erosion into Carotid Artery sheath (uniformly fatal)
  4. Internal jugular vein Thrombophlebitis
  5. Deep neck or mediastinal infection from contiguous spread
  6. Lemierre Syndrome

XIV. Follow-up

  1. Consider Tonsillectomy 3-6 months after Peritonsillar Abscess (40% recurrence rate)

XV. References

  1. Anderson (2019) Crit Dec Emerg Med 33(9): 3-10
  2. Guess and Pittman (2022) Crit Dec Emerg Med 36(7): 12-4
  3. Roberts (1998) Procedures Emergency Medicine, p. 1122-6
  4. Swadron and Finley in Herbert (2018) EM:Rap 18(7): 3-4
  5. Brook (2004) J Oral Maxillofac Surg 62:1545-50 [PubMed]
  6. Galioto (2017) Am Fam Physician 95(8): 501-6 [PubMed]
  7. Kieff (1999) Otolaryngol Head Neck Surg 120(1):57-61 [PubMed]
  8. Steyer (2002) Am Fam Physician 65(1):93-96 [PubMed]

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