Peritonsillar cellulitis

Background

Anatomy of the posterior pharynx.

• Peritonsillar cellulitis- inflammatory reaction between palatine tonsil and pharyngeal muscle with no discrete collection of pus.
• Peritonsillar abscess - collection of pus located between palatine tonsil and pharyngeal muscle.

Clinical Features

• Sore throat, odynophagia
• +/- fever
• +/- exudates, lymphadenopathy

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
• Laryngitis
• Acute Bronchitis
• Rhinovirus
• Coronavirus
• Adenovirus
• Herpesvirus
• Influenza virus
• Coxsackie virus
  • Herpangina
  • Hand-foot-and-mouth disease
• HIV (Acute Retroviral Syndrome)

Noninfectious

• Stevens-Johnson Syndrome
• Pemphigus
• Angioedema

Other

• Deep neck space infection
  • Retropharyngeal abscess
  • Ludwig's angina
  • Parapharyngeal 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

Evaluation

• Imaging may be necessary to differentiate peritonsillar abscess (PTA) from peritonsillar cellulitis, epiglottitis, deep space neck infection
• Intraoral or submandibular ultrasound distinguish PTA from cellulitis and guide needle aspiration
  • Submandibular ultrasound may be superior to intraoral ultrasound when limited by trismus or pain.
  • PTA will have echo-free cavity with irregular border
  • Peritonsillar cellulitis appears as homogenous area with no fluid collection
• Do not recommend CT to differentiate PTA from cellulitis
  • Recommend CT with IV contrast to identify deep space neck infection

Management

• Antibiotic therapy
  • Oral
    • Amoxicillin-clavulanate (45mg/kg per dose [max 875mg single dose]) x 12 hours in children; 875 mg x 12 hours in adults
    • Clindamycin (10mg/kg [max 600mg single dose]) x8 hours in children; 300-450mg x 6 hours in adults
  • Parenteral
    • Ampicillin-sulbactam (no MRSA coverage) IV (50mg/kg per dose [max 3g single dose]) x 6 hours children; 3g x6 hours adults
    • Clindamycin IV (13mg/kg per dose [max 900mg single dose]) x8 hours children; 600mg x6-8 hours adults
    • If moderate to severe disease (toxic, temp>39C, drooling, respiratory distress) add IV vancomycin or linezolid to ampicillin-sulbactam or clindamycin

Disposition

• Usually discharge

See Also

• PTA
• Pharyngitis