Difference between revisions of "Peritonsillar abscess"

(Diagnosis)
(Treatment)
Line 26: Line 26:
  
 
==Treatment==
 
==Treatment==
#Drainage (no difference in outcome when comparing needle aspiration with I&D)
+
===Drainage===
#*Needle Aspiration
+
*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>
#**Apply anesthetic spray to overlying mucosa  
+
====Needle Aspiration====
#**Have pt hold suction, and use as needed
+
#Apply anesthetic spray to overlying mucosa  
#**Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source
+
#Have patient hold suction, and use as needed
#**Inject 1-2mL of lidocaine with epi into mucosa of anterior tonsillar pillar using 25ga needle
+
#Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source
#**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
+
#Inject 1-2mL of lidocaine with epi into mucosa of anterior tonsillar pillar using 25ga needle
#**Aspirate using 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery 2.5 cm posterolateral)
+
#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
#***May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
+
#Aspirate using 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery 2.5 cm posterolateral)
#***Consider spinal needle if pt has significant trismus.
+
#*May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
#*I&D  
+
#*Consider spinal needle if pt has significant trismus.
#** 11 or 15 blade scalpel
+
====I&D====
#** Do not penetrate more than 1cm
+
# #11 or #15 blade scalpel
#** May be indicated if significant pus with needle aspiration
+
#Do not penetrate more than 1cm
#[[Antibiotics]]
+
#May be indicated if significant pus with needle aspiration
#*Outpatient
+
===[[Antibiotics]]===
#**[[Clindamycin]] 300mg PO Q6hrs x7-10d OR
+
{{PTA Antibiotics}}
#**[[Amoxicillin/Clavulanate]] 875 mg PO BID x 7-10d OR
+
 
#**[[Penicillin V]] 500mg PO + flagyl 500mg QID
+
===Steroids===
#*Inpatient
+
Decreases duration and severity of pain
#**[[Ampicillin/Sulbactam]] 3 gm (75mg/kg) IV QID OR
+
*[[Methylprednisolone]] 125mg IV x1 OR [[dexamethasone]] 10mg PO/IM x1
#**[[Pipericillin/Tazobactam]] 4.5 gm IV TID OR
 
#**[[Ticarcillin/Clavulanate]] 3.1 g IV QID OR
 
#**[[Clindamycin]] 600-900mg IV TID
 
#Steroids
 
#*Improves duration and severity of pain
 
#*[[Methylprednisolone]] 125mg IV x1 OR [[dexamethasone]] 10mg PO/IM x1
 
  
 
===Indications for tonsillectomy===
 
===Indications for tonsillectomy===

Revision as of 13:53, 13 April 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

Right sided peritonsillar abscess
  • 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

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 [2][3]

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 epi into mucosa of anterior tonsillar pillar using 25ga 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 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

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

Antibiotics

Coverage for Streptococcus species, anerobes, Eikenella, H. influenza, S. auresus

Outpatient Options

Inpatient Options

Steroids

Decreases duration and severity of pain

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.
  • 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.