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Peritonsillar Abscess
Aka: Peritonsillar Abscess, Peritonsillitis, Peritonsillar Cellulitis, Quinsy Sore Throat
- See Also
- Pharyngitis
- Pharyngitis Causes
- Dysphagia
- Tonsillitis
- Group A Streptococcal Pharyngitis
- Retropharyngeal Abscess
- Lemierre Syndrome
- Diphtheria
- Chronic Pharyngeal Carriage of Streptococcus pyogenes
- Tonsillectomy Indications
- Epidemiology
- Highest Incidence ages 20-40 years old
- Accounts for 30% of head and neck abscesses
- Pathophysiology
- Sequelae of Acute Tonsillitis or Tonsillopharyngitis
- Abscess forms between lateral Tonsil and pharyngeal constrictor muscles
- Progression from exudative Tonsillitis to Peritonsillar Cellulitis to Peritonsillar Abscess
- Weber's Glands (mucous Salivary Glands within Soft Palate)
- Reside in Soft Palate, superior to Tonsil
- Duct between Weber Gland and Tonsil
- Cellulitis develops within the Weber Gland
- Weber Gland duct obstructs and abscess forms
- Risk Factors
- Exudative Tonsillitis
- Periodontal Disease
- Tobacco Abuse
- Causes
- Group A Streptococcal Pharyngitis complication
- Streptococcus Pyogenes (most common aerobic organism)
- Mixed oropharyngeal flora
- Staphylococcus aureus
- Corynebacterium
- Streptococcus milleri (S. intermedius, S. anginosus, S. constellatus)
- HaemophilusInfluenzae
- Neisseria
- Anaerobic Bacteria
- Fusobacterium
- Peptostreptococcus
- Prevotella
- Bacteroides
- Porphyromonas
- Symptoms
- Fever
- Temp over 39.4 F suggests more serious infection (Parapharyngeal Space Infection, Sepsis)
- Severe, unilateral throat pain
- Dysphagia and Odynophagia (difficult and painful swallowing)
- Malaise
- Otalgia (ipsilateral to abscess)
- Signs
- General
- Ill appearance
- Muffled ("hot potato") voice
- Trismus
- Drooling
- Tender Cervical Lymphadenopathy
- Oropharynx
- Uvula deviates away from abscess to the opposite side
- Localized swelling of Soft Palate over affected Tonsil
- Swollen Tonsil (usually superior pole)
- Indurated, fluctuant mass
- Exudate may be present
- Erythematous peritonsillar area
- Usually unilateral
- Labs
- Complete Blood Count (CBC)
- Throat Culture
- Streptococcal Rapid Antigen Test
- Monospot
- Imaging
- Indications
- Confirm Peritonsillar Abscess
- Diagnosis is uncertain
- Failed aspiration (Ultrasound)
- Evaluate contiguous soft tissues and vessels (CT or MRI)
- Significant Trismus
- Suspected deep space infection
- Neck Ultrasound
- Preferred imaging modality for diagnosis and aspiration guidance
- Endocavitary probe transducer intraoral (preferred)
- Alternatively, may attempt visualization over Submandibular Gland
- Abscess is echo-free with irregular border
- CT Neck with contrast
- Abscess appears with low attenuation
- High False Positive Rate for Peritonsillar Abscess
- Shows contiguous spread of infection to deep neck tissue
- MRI neck
- Evaluate for deep neck infections (better than CT)
- Evaluate internal Jugular Vein thrombosis and Carotid Artery sheath erosion
- Differential Diagnosis
- Peritonsillar Cellulitis (no pus in capsule)
- Retropharygeal abscess
- Dental Infection (e.g abscessed tooth, Retromolar abscess)
- Epiglottitis
- Mononucleosis (up to 6% coinfection, esp. in teens and young adults)
- Cervical adenitis
- Sialolithiasis or Sialadenitis
- Mastoiditis
- Internal cartoid artery aneurysm
- Malignancy (e.g. Lymphoma)
- Management
- Needle aspiration
- See Needle Aspiration technique below
- Be prepared for airway emergency
- Observe patient for several hours after observation and confirm able to tolerate liquids
- Failed aspiration of pus
- May be consistent with Peritonsillar Cellulitis
- Consider imaging soft tissue for deep space infection
- If no serious findings, may discharge home with close follow-up on oral medications
- Disposition: Indications for inpatient management (typically 2-4 day stays)
- Children
- Dehydration
- Toxic appearance
- Persistent significant Trismus or Dysphagia (refractory to aspiration)
- Airway compromise risk (e.g. kissing Tonsils)
- Disposition: Outpatient Management
- Observe after aspiration for several hours before discharge (confirm tolerating liquids)
- Prescribe antibiotics, Corticosteroids (typically) and Analgesics
- Close interval follow-up at 24-36 hours
- Antibiotics for 10-14 days
- Broad spectrum antibiotics are typically needed (polymicrobial infections, often with resistance)
- May adjust antibiotic based on needle aspiration sample
- Parenteral
- Combination
- Penicillin G 10 MU IV every 6 hours and
- Metronidazole 1.0 g load, and then 500 mg IV every 6 hours
- Piperacillin/Tazobactam (Zosyn) 3.375 mg every 6 hours
- Ampicillin with Sulbactam (Unasyn) 3 grams every 6 hours
- Ceftriaxone 1 g every 12 hours AND Metronidazole
- Clindamycin 900 mg IV every 8 hours (if Penicillin allergic)
- Consider Vancomycin AND Flagyl if MRSA concern
- Oral agents
- Clindamycin 300 to 450 mg orally every 8 hours
- Cefdinir (Omnicef) 300 mg every 12 hours AND Metronidazole
- Augmentin 875 mg orally twice daily
- Combination
- Penicillin VK 500 mg orally every 6 hours AND
- Metronidazole 500 mg orally every 6 hours
- Corticosteroids as adjunct to antibiotics
- Dexamethasone 10 mg orally for 1 dose
- O'Brien (1993) Ann Emerg Med 22(2): 212-5 [PubMed]
- Depo Medrol 2-3 mg/kg up to 250 mg IV for 1 dose
- Patients improved faster when adjunctive steroids were used
- Ozbek (2004) J Laryngol Otol 118:439-42 [PubMed]
- Efficacy
- Decreased pain and improved oral intake within 12-24 hours
- Faster recovery and shorter hospital stays
- Lee (2016) Clin Exp Otorhinolaryngol 9(2): 89-97 [PubMed]
- Procedure: Needle Aspiration
- Precautions
- Carotid Artery runs 2 cm posterolateral to Tonsillar Pillar
- Do not insert aspiration needle more than 8 mm
- Primary Anesthetic
- Step 1: Spray with Topical Anesthetic
- Benzalkonium 0.5% spray (Cetacaine)
- Step 2: Gargle 2% Lidocaine with Epinephrine
- Alternative Anesthetic
- Sphenopalatine block
- Lidocaine or Cocaine soaked pledget
- Place under posterior aspect of middle turbinate
- Local Anesthetic injection
- Inject into mucosa overlying region of fluctuance using 25-27 g 1.5 inch needle OR
- Inject Lidocaine into mucosa with aspiration needle and then aspirate
- Preparation
- Be prepared for airway emergency (e.g. bleeding)
- Suction with Yanker tip
- Light source: Direct Laryngoscope with curved blade
- Position overlying the Tongue, lighting the posterior pharynx, but not so deep as to trigger a Gag Reflex
- Patient as assistant (if sufficiently calm)
- Patient may hold shallowly placed Laryngoscope Blade in place with one of their hands
- Patient may hold the suction catheter with their opposite hand
- Patient positioning
- Patients sits forward, at eye level to examiner
- Ultrasound with endocavitary probe
- Helps to guide needle towards largest abscess pocket
- Trismus may limit use
- References
- Lin in Herbert (2014) EM:Rap 14(4): 5-7
- Needle Aspiration Technique
- Retract Tongue
- Tongue blade or
- Laryngoscope Blade (consider having patient hold this, see above)
- Spinal needle 18 gauge on 3 cc syringe
- Longer spinal needle obstructs view less
- Smaller syringe requires less force to withdraw plunger
- Consider needle guard
- Prevents entrance into Carotid Artery
- Needle should protrude only 0.5 cm beyond guard
- Cut off distal 0.5 cm of plastic needle cover
- Tape needle cover to syringe to secure
- Avoid lateral margin of Tonsil
- Carotid Artery is 2 to 2.5 cm posterolateral to Tonsil
- Keep needle in sagittal plane
- Aspirate most fluctuant area
- Superior pole of Tonsil most commonly affected
- Aspirate peritonsillar space (medial Soft Palate)
- Tonsil itself is not aspirated
- Failed aspiration
- Move the needle inferolaterally along the Soft Palate and reattempt aspiration up to twice more
- Exercise caution, as carotid puncture increases in risk with inferior needle placement
- Complications
- Patient aspiration of pus or blood
- Hemorrhage from puncture of Carotid Artery
- Complications
- Airway obstruction
- Lung infection (Aspiration Pneumonia or Lung Abscess) from Peritonsillar Abscess rupture
- Erosion into Carotid Artery sheath (uniformly fatal)
- Internal jugular vein Thrombophlebitis
- Deep neck or mediastinal infection from contiguous spread
- Follow-up
- Consider Tonsillectomy 3-6 months after Peritonsillar Abscess (40% recurrence rate)
- References
- Anderson (2019) Crit Dec Emerg Med 33(9): 3-10
- Roberts (1998) Procedures Emergency Medicine, p. 1122-6
- Swadron and Finley in Herbert (2018) EM:Rap 18(7): 3-4
- Brook (2004) J Oral Maxillofac Surg 62:1545-50 [PubMed]
- Galioto (2017) Am Fam Physician 95(8): 501-6 [PubMed]
- Kieff (1999) Otolaryngol Head Neck Surg 120(1):57-61 [PubMed]
- Steyer (2002) Am Fam Physician 65(1):93-96 [PubMed]