Peritonsillar abscess

Revision as of 20:35, 10 March 2015 by Rossdonaldson1 (talk | contribs) (Disposition)


  • 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




  • Ultrasound
    • Differentiates cellulitis from abscess
    • Can identify neck vasculature prior to aspiration
  • CT w/ IV contrast
    • Differentiates PTA from parapharyngeal or retropharyngeal space infection


  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


  • 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


  • Follow up in 2-3 days

Return Precautions

  • SOB
  • Worsening throat or neck pain
  • Enlarging mass
  • Bleeding
  • Neck stiffness

See Also


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