Peritonsillar Abscess Drainage

Aka: Peritonsillar Abscess Drainage, Peritonsillar Abscess Needle Aspiration

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II. Indications

  1. Peritonsillar Abscess
    1. Alternatives: Incision and Drainage or Tonsillectomy by ENT

III. Precautions

  1. Carotid Artery runs 2 cm posterolateral to the Tonsillar Pillar
  2. Do not insert aspiration needle more than 8 mm

IV. Management: Primary Anesthetic

  1. Step 1: Spray with Topical Anesthetic
    1. Lidocaine 1% with Epinephrine via MADD atomizer (author preference) OR
    2. Benzalkonium 0.5% spray (Cetacaine)
  2. Step 2: Gargle 1-2% Lidocaine with Epinephrine
  3. Alternative Anesthetic
    1. Sphenopalatine block
      1. Lidocaine or Cocaine soaked pledget
      2. Place under posterior aspect of middle turbinate
    2. Local Anesthetic injection
      1. Inject into mucosa overlying region of fluctuance using 25-27 g 1.5 inch needle OR
      2. Inject Lidocaine 1% with Epinephrine into mucosa with aspiration needle and then aspirate

V. Technique: Preparation

  1. Be prepared for airway emergency (e.g. bleeding)
  2. Suction with Yanker tip
  3. Light source: Direct Laryngoscope with curved blade (Macintosh Blade)
    1. Position overlying the Tongue, lighting the posterior pharynx, but not so deep as to trigger a Gag Reflex
  4. Patient as assistant (if sufficiently calm)
    1. Patient may hold shallowly placed Laryngoscope Blade in place with one of their hands
    2. Patient may hold the suction catheter with their opposite hand
  5. Patient positioning
    1. Patients sits forward, at eye level to examiner
  6. Ultrasound with endocavitary probe
    1. Helps to guide needle towards largest abscess pocket
    2. Trismus may limit use
  7. References
    1. Lin in Herbert (2014) EM:Rap 14(4): 5-7

VI. Technique: Needle Aspiration

  1. Images
    1. entPeritonsillarAbscessNeedleAspiration.png
  2. Retract Tongue
    1. Tongue blade or
    2. Laryngoscope Blade (consider having patient hold this, see above)
  3. Needle 18 gauge on 3 cc syringe
    1. Consider longer needle (e.g. spinal needle) obstructs view less
    2. Smaller syringe requires less force to withdraw plunger
  4. Use a needle guard
    1. Prevents entrance into Carotid Artery
    2. Cut off distal 0.5 to 1 cm of plastic needle cover
    3. Needle should protrude only 0.5 to 1 cm beyond guard
    4. Tape needle cover to syringe to secure
  5. Avoid lateral margin of Tonsil
    1. Carotid Artery is 2 to 2.5 cm posterolateral to Tonsil
    2. Keep needle in sagittal plane
  6. Aspirate most fluctuant area
    1. Superior pole of Tonsil most commonly affected
    2. Aspirate peritonsillar space (medial Soft Palate)
      1. Tonsil itself is not aspirated
  7. Failed aspiration
    1. Move the needle inferolaterally along the Soft Palate and reattempt aspiration up to twice more
    2. Exercise caution, as carotid puncture increases in risk with inferior needle placement

VII. Complications

  1. Patient aspiration of pus or blood
  2. Hemorrhage from puncture of Carotid Artery
  3. Failed Needle Aspiration
  4. Peritonsillar Abscess recurrence (10%)

VIII. References

  1. Warrington (2017) Crit Dec Emerg Med 31(4): 17

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