Difference between revisions of "Peritonsillar abscess"

(Disposition)
(I&D)
 
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*Abbreviation: PTA
 
*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 influenzae]]
+
**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]]
 
==Clinical Features==
 
 
===Symptoms===
 
===Symptoms===
 
*[[Fever]]
 
*[[Fever]]
 
*[[Sore throat]]
 
*[[Sore throat]]
*Odynophagia/dysphagia
+
*Odynophagia/[[dysphagia]]
  
 
===Signs===
 
===Signs===
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{{Sore throat DDX}}
 
{{Sore throat DDX}}
  
==Diagnosis==
+
{{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 w/ IV contrast
+
*[[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 pain meds, sedation or procedural sedation (midazolam, ketamine, glycopyrrolate can reduce secretions)
+
*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, and use as needed
+
#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 epi into mucosa of anterior tonsillar pillar using 25ga needle
+
#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 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery 2.5 cm posterolateral)
+
#Aspirate using 18 gauge needle just lateral to the tonsil
#*May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
+
#*Use static ultrasound to determine depth of vasculature.
#*Consider spinal needle if pt has significant trismus.
+
#*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. Do not advance laterally (carotid).
+
#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 fora PTA, admit with IV abx (30% neg aspiration still have PTA).
+
*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 peds, some advocate for medical management. 50% respond to med management. Requires admission given lack of response necessitates drainage.
+
*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===
*[[SOB]]
+
*[[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==

Latest 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

Clinical Features

Right sided peritonsillar abscess

Symptoms

Signs

  • Trismus
  • Muffled voice ("hot potato voice")
  • Contralateral deflection of swollen uvula

Differential Diagnosis

Acute Sore Throat

Bacterial infections

Viral infections

Noninfectious

Other

Dentoalveolar Injuries

Odontogenic Infections

Other

Evaluation

Endocavitary probe shows hypoechoic circumscribed area consistent with abscess[2]

Management

Drainage

Needle Aspiration

  1. Apply anesthetic spray to overlying mucosa
  2. Have patient hold suction and use as needed
  3. Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source
  4. Inject 1-2mL of lidocaine with epinephrine into mucosa of anterior tonsillar pillar using 25 gauge needle
  5. 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
  6. 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

  1. #11 or #15 blade scalpel
  2. Do not penetrate more than 1cm
  3. Only advance posteriorly
  4. May be indicated if significant pus with needle aspiration
  5. 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
  • 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

Inpatient Options

Steroids

Decreases duration and severity of pain

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

Prognosis

Complications

Indications for tonsillectomy

  • Airway obstruction
  • Recurrent severe pharyngitis or PTA
  • Failure of abscess resolution with drainage

See Also

References

  1. Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  2. http://www.thepocusatlas.com/soft-tissue-vascular/
  3. Johnson RF, Stewart MG. The contemporary approach to diagnosis and man- agement of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005;13:157
  4. Wolf M. Peritonsillar abscess: repeated needle aspiration versus incision and drainage. Ann Otol Rhinol Laryngol. 1994 Jul;103(7):554-7.
  5. Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep. 2006;8(3):196.
  6. Ballew JD. Unlocking Common ED Procedures – Peritonsillar Abscess Drainage. Arp 4, 2019. http://www.emdocs.net/unlocking-common-ed-procedures-peritonsillar-abscess-drainage/.
  7. 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
  8. Blotter JW, Yin L, Glynn M, et al. Otolaryngology consultation for peritonsillar abscess in the pediatric population. Laryngoscope. 2000;110(10 Patient 1):1698.