Peritonsillar abscess: Difference between revisions

Revision as of 05:48, 22 June 2011

Background

Abscess between tonsillar capsule and superior constrictor muscle
Etiology
- Strep/staph, anaerobes, eikenella, haemophilus
<10% bilateral

Diagnosis

Presentation

Sore throat, fever trismus, voice change, uvular devation (away from abscess)

Imaging

May be needed to differentiate tonsillitis from abscess
CT
- Consider if:
  - I&D failed
  - Pt uncooperative (trismus, peds)
Ultrasound
- Sn 95.2%, Sp 78.5%

Treatment

Needle aspiration versus I&D
Abx
1. Outpatient
  1. Amoxicillin/clavulanate 875 mg PO BID x 7-10d OR
  2. Clindamycin 600-900 mg PO TID x7-10d OR
2. Inpatient
  1. Ampicillin/Sulbactam 3 gm (75mg/kg) IV QID OR
  2. Pipericillin/Tazobactam 4.5 gm IV TID OR
  3. Ticarcillin/Clavulanate 3.1 g IV QID OR
  4. Clindamycin 600-900mg IV TID
Steroids
1. Dexamethasone 10mg PO/IM x1

@@ Line 1: / Line 1: @@
 ==Background==
-Common Organisms: Streptococcus spp, Anaerobes, Eikenella Corrodens, Haemophilis spp, S. Aureus
+*Abscess between tonsillar capsule and superior constrictor muscle
+*Etiology
+**Strep/staph, anaerobes, eikenella, haemophilus
+*<10% bilateral
 ==Diagnosis==
 ===Presentation===
-* Fever, hot-potato voice, trismus, exudate and uvular devation (away from abscess)
+*Sore throat, fever trismus, voice change, uvular devation (away from abscess)
-* If unclear, can attempt to digitally palpate posterior oropharynx for fluctuance
+===Imaging===
+*May be needed to differentiate tonsillitis from abscess
-===Imaging Studies===
+*CT
-* Radiography: Lateral soft tissue neck radiographs may help rule out other causes. The anteroposterior (AP) view of the neck may demonstrate distortion of soft tissue.
+**Consider if:
-* CT scan: Head and neck scan with intravenous (IV) contrast is useful if incision and drainage (I&D) is failed, if the patient cannot open his or her mouth, or if the patient is young (<7 y). A hypodense fluid collection with rim enhancement may be seen in the affected tonsil. Foreign bodies such as fish or chicken bones may also be found as an inciting factor.
+***I&D failed
-* Ultrasonography: Intraoral ultrasonography (use vaginal probe with condom!) has a sensitivity of 95.2% and specificity of 78.5%. Transcutaneous ultrasonography has a sensitivity of 80% and specificity of 92.8%. This method is cost-effective and fast.
+***Pt uncooperative (trismus, peds)
+*Ultrasound
-===Work-Up===
+**Sn 95.2%, Sp 78.5%
-* Needle aspiration is used for symptom relief and is the criterion standard for diagnosis
 ==Treatment==
-#Needle aspiration
+#Needle aspiration versus I&D
-#Abscess I&D: After lidocaine with epinephrine local infiltration, a No. 11 blade scalpel may be used to incise a very large PTA, allowing the purulent drainage to flow freely as the abscess cavity decompresses. Allow the patient to hold the Yankauer catheter tip and to suction the pus, rather than swallow it.
+#Abx
-#Tonsillectomy: for recurrent or emergent PTA (i.e. not protecting airway)
+##Outpatient
-#Hydrate as most patients often not tolerating adequate amount of fluid
+###Amoxicillin/clavulanate 875 mg PO BID x 7-10d OR
-#Pain and antipyretics prn
+###Clindamycin 600-900 mg PO TID x7-10d OR
+##Inpatient
-==Antibiotics==
+###Ampicillin/Sulbactam 3 gm (75mg/kg) IV QID  OR
-===Outpatient===
+###Pipericillin/Tazobactam 4.5 gm IV TID OR
-* Amoxicillin/Clavulanate 875 mg PO BID for 7-10 days
+###Ticarcillin/Clavulanate 3.1 g IV QID OR
-* Clindamycin 600-900 mg IV/PO TID (7.5 mg/kg IV QID) for 7-10 days
+###Clindamycin 600-900mg IV TID
-* Penicillin G 4 million units IV/PO (50,00 units/kg) four times daily AND Metronidazole 500 mg IV/PO (7.5 mg/kg) four time daily 7-10 days
+#Steroids
-===Inpatient===
+##Dexamethasone 10mg PO/IM x1
-* Ampicillin/Sulbactam 3 gm (75mg/kg) IV four times daily
-* Pipericillin/Tazobactam 4.5 gm IV three times daily
-* Ticarcillin/Clavulanate 3.1 g IV four time daily
-==Steroids==
-The addition of a single dose of intravenous dexamethasone to parenteral antibiotics has been found to significantly lessen the variables of hours hospitalized, throat pain, fever, and trismus compared with a group of patients who were only treated with parenteral antibiotics.
-* Dexamethasone 10mg PO/IM once
 [[Category:ENT]]
 [[Category:ID]]