Peritonsillar abscess

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Background

Right sided peritonsillar abscess

Clinical Features

Symptoms

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

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

  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 because the carotid lies posterior
  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

Disposition

  • Generally may be discharged with ENT follow-up
  • In order, some advocate for medical management. 50% respond to med management. Requires admission given lack of response necessitates drainage.

Return Precautions

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

Prognosis

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

Indications for tonsillectomy

  • Airway obstruction
  • Recurrent severe pharyngitis or PTA
  • Failure of abscess resolution with drainage

See Also

References

  1. Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  2. Johnson RF, Stewart MG. The contemporary approach to diagnosis and man- agement of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005;13:157
  3. Wolf M. Peritonsillar abscess: repeated needle aspiration versus incision and drainage. Ann Otol Rhinol Laryngol. 1994 Jul;103(7):554-7.