Difference between revisions of "Peritonsillar abscess"

(Disposition)
(Treatment)
Line 25: Line 25:
  
 
==Treatment==
 
==Treatment==
#No difference in outcome when comparing needle aspiration with I&D  
+
#Drainage (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
 
#[[Antibiotics]]
 
#[[Antibiotics]]
 
#*Outpatient
 
#*Outpatient
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#*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:
+
 
#*Airway obstruction
+
===Indications for tonsillectomy===
#*Recurrent severe pharyngitis or PTA
+
*Airway obstruction
#*Failure of abscess resolution with drainage
+
*Recurrent severe [[pharyngitis]] or PTA
 +
*Failure of abscess resolution with drainage
  
 
==Complications==
 
==Complications==

Revision as of 20:37, 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. Drainage (no difference in outcome when comparing needle aspiration with I&D)
    • 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.
    • I&D
      • 11 or 15 blade scalpel
      • Do not penetrate more than 1cm
      • May be indicated if significant pus with needle aspiration
  2. Antibiotics
  3. Steroids

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

  • Follow up 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.