Peritonsillar abscess: Difference between revisions
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==Background== | ==Background== | ||
*Abbreviation: PTA | |||
*Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles | *Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles | ||
** Location affected: superior > middle > inferior pole | |||
*Microbiology | *Microbiology | ||
**Polymicrobial: strep/staph, anaerobes, eikenella, haemophilus | **Polymicrobial: [[strep]]/[[staph]], [[anaerobes]], [[eikenella]], [[haemophilus influenzae]], Fusobacterium necrophorum | ||
==Clinical Features== | |||
[[File:PeritonsilarAbsess.jpg|thumb|Right sided peritonsillar abscess]] | [[File:PeritonsilarAbsess.jpg|thumb|Right sided peritonsillar abscess]] | ||
===Symptoms=== | ===Symptoms=== | ||
*[[Fever]] | *[[Fever]] | ||
*[[Sore throat]] | *[[Sore throat]] | ||
*Odynophagia/dysphagia | *Odynophagia/[[dysphagia]] | ||
===Signs=== | ===Signs=== | ||
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{{Sore throat DDX}} | {{Sore throat DDX}} | ||
== | {{Dental Problems DDX}} | ||
*Ultrasound | |||
**Differentiates cellulitis from abscess | ==Evaluation== | ||
**Can identify neck vasculature prior to aspiration | [[File:PTA Singh.gif|thumbnail|Endocavitary probe shows hypoechoic circumscribed area consistent with abscess<ref>http://www.thepocusatlas.com/soft-tissue-vascular/</ref>]] | ||
*CT | *[[Ultrasound]] | ||
**Differentiates PTA from parapharyngeal or retropharyngeal space infection | **Differentiates [[peritonsillar cellulitis|cellulitis]] from abscess | ||
**Can use an intraoral approach using a endocavitary probe or transcutaneous approach using a linear probe | |||
**Can identify depth of neck vasculature prior to aspiration | |||
*CT with IV contrast | |||
**Differentiates PTA from [[parapharyngeal space infection|parapharyngeal]] or [[retropharyngeal abscess|retropharyngeal space infection]] | |||
==Management== | ==Management== | ||
===Drainage=== | ===Drainage=== | ||
*The recurrence rate after aspiration is 10% and the cure rate is 93% to 95%. Recurrence rate for aspiration alone may be higher than I&D <ref>Johnson RF, Stewart MG. The contemporary approach to diagnosis and man- agement of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005;13:157 </ref><ref>Wolf M. Peritonsillar abscess: repeated needle aspiration versus incision and drainage. Ann Otol Rhinol Laryngol. 1994 Jul;103(7):554-7.</ref> | *The recurrence rate after aspiration is 10% and the cure rate is 93% to 95%. Recurrence rate for aspiration alone may be higher than I&D <ref>Johnson RF, Stewart MG. The contemporary approach to diagnosis and man- agement of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005;13:157 </ref><ref>Wolf M. Peritonsillar abscess: repeated needle aspiration versus incision and drainage. Ann Otol Rhinol Laryngol. 1994 Jul;103(7):554-7.</ref> | ||
*May need IV [[analgesia|pain meds]], [[sedation]] or [[procedural sedation]] | |||
**[[Glycopyrrolate]] can reduce secretions | |||
====Needle Aspiration==== | ====Needle Aspiration==== | ||
#Apply anesthetic spray to overlying mucosa | #Apply anesthetic spray to overlying mucosa | ||
#Have patient hold suction | #Have patient hold suction and use as needed | ||
#Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source | #Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source | ||
#Inject 1-2mL of lidocaine with | #Inject 1-2mL of lidocaine with epinephrine into mucosa of anterior tonsillar pillar using 25 gauge needle | ||
#Cut distal tip off of needle sheath and place over 18ga needle to expose 1 cm of needle to prevent accidentally plunging deeper than desired | #Cut distal tip off of needle sheath and place over 18ga needle to expose 1 cm of needle to prevent accidentally plunging deeper than desired | ||
#Aspirate using | #Aspirate using 18 gauge needle just lateral to the tonsil | ||
#*May require multiple aspirations to find the abscess | #*Use static ultrasound to determine depth of vasculature. | ||
#*Consider spinal needle if | #*Though always a concern, carotid injury has not been clearly documented as a complications<ref>Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep. 2006;8(3):196.</ref> | ||
#*May require multiple aspirations to find the abscess | |||
#**First try superior then middle then inferior poles | |||
#*Consider spinal needle if patient has significant trismus | |||
====I&D==== | ====[[I&D]]==== | ||
# #11 or #15 blade scalpel | # #11 or #15 blade scalpel | ||
#Do not penetrate more than 1cm | #Do not penetrate more than 1cm | ||
#Only advance posteriorly | |||
#May be indicated if significant pus with needle aspiration | #May be indicated if significant pus with needle aspiration | ||
#Macintosh size 3 or 4 with handle in a "tomahawk" position provides visualization with lighting<ref>Ballew JD. Unlocking Common ED Procedures – Peritonsillar Abscess Drainage. Arp 4, 2019. http://www.emdocs.net/unlocking-common-ed-procedures-peritonsillar-abscess-drainage/.</ref> | |||
====Antibiotics Alone==== | |||
*A 2018 paper showed that if pts were given abx/IVF/decadron and felt better (must improve clinically), similar results could be obtained compared to I&D<ref>Comparison Of Medical Therapy Alone To Medical Therapy With Surgical Treatment Of Peritonsillar Abscess Battaglia, A., et al, Otolaryngol Head Neck Surg 58(2):280, February 2018</ref> | |||
*Protocol includes the medications below and ED observation for 1-2 hours after, with liquid PO challenge | |||
**D5-1/2 NS, 1 L bolus | |||
**[[Dexamethasone]] 10 mg IV | |||
**[[Ceftriaxone]] 2 g IV | |||
**[[Clindamycin]] 600 mg IV | |||
**Upon discharge, [[Clindamycin]] 300 mg PO QID x10 days | |||
*Pediatric protocol is the same, with weight based dosing | |||
*Medical therapy patients required less opioids, fewer sore throat days, required less days off from work | |||
===[[Antibiotics]]=== | ===[[Antibiotics]]=== | ||
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===Steroids=== | ===Steroids=== | ||
Decreases duration and severity of pain | Decreases duration and severity of pain | ||
*[[Methylprednisolone]] 125mg IV x1 OR [[dexamethasone]] 10mg PO/IM x1 | *[[Methylprednisolone]] 125mg IV x1 '''OR''' [[dexamethasone]] 10mg PO/IM x1 | ||
==Disposition== | ==Disposition== | ||
*Generally may be discharged with ENT follow-up | *Generally may be discharged with ENT follow-up | ||
*If no pus can be obtained but there is high suspicion for a PTA, admit with IV antibiotics (30% neg aspiration still have PTA) | |||
*In pediatric patients 50% respond to med management<ref>Blotter JW, Yin L, Glynn M, et al. Otolaryngology consultation for peritonsillar [[abscess]] in the pediatric population. Laryngoscope. 2000;110(10 Patient 1):1698.</ref> | |||
===Return Precautions=== | ===Return Precautions=== | ||
*[[ | *[[shortness of breath]] | ||
*Worsening throat or neck pain | *Worsening throat or neck pain | ||
*Enlarging mass | *Enlarging mass | ||
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===Complications=== | ===Complications=== | ||
*Airway obstruction | *Airway obstruction | ||
*Rupture abscess with aspiration of contents | *Rupture [[abscess]] with aspiration of contents | ||
*Hemorrhage due to erosion of carotid sheath | *[[Hemorrhage]] due to erosion of carotid sheath | ||
*[[Retropharyngeal abscess]] | *[[Retropharyngeal abscess]] | ||
*[[Mediastinitis]] | *[[Mediastinitis]] | ||
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*Airway obstruction | *Airway obstruction | ||
*Recurrent severe [[pharyngitis]] or PTA | *Recurrent severe [[pharyngitis]] or PTA | ||
*Failure of abscess resolution with drainage | *Failure of [[abscess]] resolution with drainage | ||
==See Also== | ==See Also== |
Revision as of 05:52, 26 September 2020
Background
- Abbreviation: PTA
- Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
- Location affected: superior > middle > inferior pole
- Microbiology
- Polymicrobial: strep/staph, anaerobes, eikenella, haemophilus influenzae, Fusobacterium necrophorum
Clinical Features
Symptoms
- Fever
- Sore throat
- Odynophagia/dysphagia
Signs
- Trismus
- Muffled voice ("hot potato voice")
- Contralateral deflection of swollen uvula
Differential Diagnosis
Acute Sore Throat
Bacterial infections
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [1]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Noninfectious
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
Dentoalveolar Injuries
Odontogenic Infections
- Acute alveolar osteitis (dry socket)
- Acute necrotizing ulcerative gingivitis (trench mouth)
- Dental abscess
- Periapical abscess
- Periodontal abscess
- Ludwig's angina
- Pulpitis (dental caries)
- Pericoronitis
- Peritonsillar abscess (PTA)
- Retropharyngeal abscess
- Vincent's angina - tonsillitis and pharyngitis
Other
Evaluation
- Ultrasound
- Differentiates cellulitis from abscess
- Can use an intraoral approach using a endocavitary probe or transcutaneous approach using a linear probe
- Can identify depth of neck vasculature prior to aspiration
- CT with IV contrast
- Differentiates PTA from parapharyngeal or retropharyngeal space infection
Management
Drainage
- The recurrence rate after aspiration is 10% and the cure rate is 93% to 95%. Recurrence rate for aspiration alone may be higher than I&D [3][4]
- May need IV pain meds, sedation or procedural sedation
- Glycopyrrolate can reduce secretions
Needle Aspiration
- Apply anesthetic spray to overlying mucosa
- Have patient hold suction and use as needed
- Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source
- Inject 1-2mL of lidocaine with epinephrine into mucosa of anterior tonsillar pillar using 25 gauge needle
- Cut distal tip off of needle sheath and place over 18ga needle to expose 1 cm of needle to prevent accidentally plunging deeper than desired
- Aspirate using 18 gauge needle just lateral to the tonsil
- Use static ultrasound to determine depth of vasculature.
- Though always a concern, carotid injury has not been clearly documented as a complications[5]
- May require multiple aspirations to find the abscess
- First try superior then middle then inferior poles
- Consider spinal needle if patient has significant trismus
I&D
- #11 or #15 blade scalpel
- Do not penetrate more than 1cm
- Only advance posteriorly
- May be indicated if significant pus with needle aspiration
- Macintosh size 3 or 4 with handle in a "tomahawk" position provides visualization with lighting[6]
Antibiotics Alone
- A 2018 paper showed that if pts were given abx/IVF/decadron and felt better (must improve clinically), similar results could be obtained compared to I&D[7]
- Protocol includes the medications below and ED observation for 1-2 hours after, with liquid PO challenge
- D5-1/2 NS, 1 L bolus
- Dexamethasone 10 mg IV
- Ceftriaxone 2 g IV
- Clindamycin 600 mg IV
- Upon discharge, Clindamycin 300 mg PO QID x10 days
- Pediatric protocol is the same, with weight based dosing
- Medical therapy patients required less opioids, fewer sore throat days, required less days off from work
Antibiotics
Coverage for Streptococcus species, anerobes, Eikenella, H. influenza, S. auresus
Outpatient Options
- Clindamycin 300mg PO Q6hrs x7-10d
- Amoxicillin/Clavulanate 875 mg PO BID x 7-10d
- Penicillin V 500mg PO + Metronidazole 500mg QID
Inpatient Options
- Ampicillin/Sulbactam 3 gm (75mg/kg) IV four times daily
- Pipericillin/Tazobactam 4.5 gm IV TID
- Ticarcillin/Clavulanate 3.1 g IV QID
- Clindamycin 600-900mg IV TID
- Penicillin G 4 million units (50,000 units/kg) IV four times daily + Metronidazole 500mg IV three times daily
Steroids
Decreases duration and severity of pain
- Methylprednisolone 125mg IV x1 OR dexamethasone 10mg PO/IM x1
Disposition
- Generally may be discharged with ENT follow-up
- If no pus can be obtained but there is high suspicion for a PTA, admit with IV antibiotics (30% neg aspiration still have PTA)
- In pediatric patients 50% respond to med management[8]
Return Precautions
- shortness of breath
- Worsening throat or neck pain
- Enlarging mass
- Bleeding
- Neck stiffness
Prognosis
Complications
- Airway obstruction
- Rupture abscess with aspiration of contents
- Hemorrhage due to erosion of carotid sheath
- Retropharyngeal abscess
- Mediastinitis
- Recurrence occurs in 10-15% of patients
- Lemierre's syndrome
- Iatrogenic laceration of carotid artery
- Carotid artery is 2.5 cm behind and lateral to tonsil
Indications for tonsillectomy
- Airway obstruction
- Recurrent severe pharyngitis or PTA
- Failure of abscess resolution with drainage
See Also
References
- ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
- ↑ http://www.thepocusatlas.com/soft-tissue-vascular/
- ↑ Johnson RF, Stewart MG. The contemporary approach to diagnosis and man- agement of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005;13:157
- ↑ Wolf M. Peritonsillar abscess: repeated needle aspiration versus incision and drainage. Ann Otol Rhinol Laryngol. 1994 Jul;103(7):554-7.
- ↑ Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep. 2006;8(3):196.
- ↑ Ballew JD. Unlocking Common ED Procedures – Peritonsillar Abscess Drainage. Arp 4, 2019. http://www.emdocs.net/unlocking-common-ed-procedures-peritonsillar-abscess-drainage/.
- ↑ Comparison Of Medical Therapy Alone To Medical Therapy With Surgical Treatment Of Peritonsillar Abscess Battaglia, A., et al, Otolaryngol Head Neck Surg 58(2):280, February 2018
- ↑ Blotter JW, Yin L, Glynn M, et al. Otolaryngology consultation for peritonsillar abscess in the pediatric population. Laryngoscope. 2000;110(10 Patient 1):1698.