Difference between revisions of "Peritonsillar abscess"
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===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> | ||
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====Needle Aspiration==== | ====Needle Aspiration==== | ||
#Apply anesthetic spray to overlying mucosa | #Apply anesthetic spray to overlying mucosa | ||
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#*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. | ||
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====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 | ||
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===[[Antibiotics]]=== | ===[[Antibiotics]]=== | ||
{{PTA Antibiotics}} | {{PTA Antibiotics}} | ||
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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 | ||
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==Disposition== | ==Disposition== | ||
Revision as of 08:14, 19 August 2015
Contents
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
- 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
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
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 [2][3]
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 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
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
Return Precautions
- SOB
- Worsening throat or neck pain
- Enlarging mass
- Bleeding
- Neck stiffness
See Also
References
- ↑ 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.