Peritonsillar abscess

Background

• Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
• Etiology
  • Strep/staph, anaerobes, eikenella, haemophilus

Clinical Features

• Symptoms
  • Fever
  • Sore throat
  • Odynophagia/dysphagia
• Signs
  • Trismus
  • Muffled voice ("hot potato voice")
  • Contralateral deflection of swollen uvula

DDX

• Peritonsillar cellulitis
• Mono
• Lymphoma
• Herpes simplex tonsillitis
• Retropharyngeal abscess
• Internal carotid artery aneurysm

Diagnosis

• Ultrasound
  • Differentiates cellulitis from abscess
• CT w/ IV contrast
  • Differentiates PTA from parapharyngeal or retropharyngeal space infection

Treatment

1. No difference in outcome when comparing needle aspiration with I&D
2. Needle Aspiration
   1. Apply anesthetic spray to overlying mucosa
   2. Inject 1-2mL of lidocaine with epi into mucosa of anterior tonsillar pillar using 25ga needle
   3. Aspirate using 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery nearby)
      1. May require multiple aspirations to find the abscess
3. Abx
   1. Outpatient
      1. Amoxicillin/clavulanate 875 mg PO BID x 7-10d OR
      2. Clindamycin 600mg 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
4. Steroids
   1. Improves duration and severity of pain
   2. Methylprednisolone 125mg IV x1 OR
   3. Dexamethasone 10mg PO/IM x1

Complications

• Airway obstruction
• Rupture abscess with aspiration of contents
• Hemorrhage d/t erosion of carotid sheath
• Retropharyngeal abscess
• Mediastinitis

Source

Tintinalli