Difference between revisions of "Peritonsillar abscess"

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#No difference in outcome when comparing needle aspiration with I&D  
 
#No difference in outcome when comparing needle aspiration with I&D  
 
#Needle Aspiration
 
#Needle Aspiration
##Apply anesthetic spray to overlying mucosa  
+
#*Apply anesthetic spray to overlying mucosa  
##Have pt hold suction, and use as needed
+
#*Have pt 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 epi into mucosa of anterior tonsillar pillar using 25ga 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 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery 2.5 cm posterolateral)
###May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
+
#**May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
###Consider spinal needle if pt has significant trismus.
+
#**Consider spinal needle if pt 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
## May be indicated if significant pus with needle aspiration
+
#* May be indicated if significant pus with needle aspiration
#Abx
+
#[[Antibiotics]]
##Outpatient
+
#*Outpatient
###[[Clindamycin]] 300mg PO Q6hrs x7-10d OR
+
#**[[Clindamycin]] 300mg PO Q6hrs x7-10d OR
###[[Amoxicillin/Clavulanate]] 875 mg PO BID x 7-10d OR
+
#**[[Amoxicillin/Clavulanate]] 875 mg PO BID x 7-10d OR
###[[Penicillin V]] 500mg PO + flagyl 500mg QID
+
#**[[Penicillin V]] 500mg PO + flagyl 500mg QID
##Inpatient
+
#*Inpatient
###[[Ampicillin/Sulbactam]] 3 gm (75mg/kg) IV QID OR
+
#**[[Ampicillin/Sulbactam]] 3 gm (75mg/kg) IV QID OR
###[[Pipericillin/Tazobactam]] 4.5 gm IV TID OR
+
#**[[Pipericillin/Tazobactam]] 4.5 gm IV TID OR
###[[Ticarcillin/Clavulanate]] 3.1 g IV QID OR
+
#**[[Ticarcillin/Clavulanate]] 3.1 g IV QID OR
###[[Clindamycin]] 600-900mg IV TID
+
#**[[Clindamycin]] 600-900mg IV TID
 
#Steroids
 
#Steroids
##Improves duration and severity of pain
+
#*Improves 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
 
#Indications for tonsillectomy:
 
#Indications for tonsillectomy:
##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
  
 
==Complications==
 
==Complications==

Revision as of 20:34, 10 March 2015

Background

  • Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
  • Microbiology
    • Polymicrobial: 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

Differential Diagnosis

Acute Sore Throat

Bacterial infections

Viral infections

Noninfectious

Other

Diagnosis

  • Ultrasound
    • Differentiates cellulitis from abscess
    • Can identify neck vasculature prior to aspiration
  • 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
    • Apply anesthetic spray to overlying mucosa
    • Have pt 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 epi into mucosa of anterior tonsillar pillar using 25ga 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 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery 2.5 cm posterolateral)
      • May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
      • Consider spinal needle if pt has significant trismus.
  3. I&D
    • 11 or 15 blade scalpel
    • Do not penetrate more than 1cm
    • May be indicated if significant pus with needle aspiration
  4. Antibiotics
  5. Steroids
  6. Indications for tonsillectomy:
    • Airway obstruction
    • Recurrent severe pharyngitis or PTA
    • Failure of abscess resolution with drainage

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

Disposition

  • F/u in 2-3 days
  • Return Precautions:
    • SOB
    • Worsening throat or neck pain
    • Enlarging mass
    • Bleeding
    • Neck stiffness

See Also

Source

  • Tintinalli
  • UpToDate
  • Roberts & Hedges
  • Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.