Mouth
Peritonsillar Abscess
search
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
Tonsil
lopharyngitis
Abscess forms between lateral
Tonsil
and pharyngeal constrictor muscles
Progression from exudative
Tonsillitis
to Peritonsillar Cellulitis to Peritonsillar Abscess
Weber's Gland
s (mucous
Salivary Gland
s 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)
Haemophilus
Influenza
e
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
Gene
ral
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
Tonsil
s)
Disposition: Outpatient Management
Observe after aspiration for several hours before discharge (confirm tolerating liquids)
Prescribe antibiotics,
Corticosteroid
s (typically) and
Analgesic
s
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
Corticosteroid
s 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]
Type your search phrase here