Peritonsillar Abscess Management

Here’s Dr. Adal with today’s Morning Report!

Peritonsillar Abscess

Differential Diagnosis:

Tonsillitis, Pharyngitis, Epiglottitis, Paratonsillar Cellulitis, PTA, RPA, PPA, Diptheria, Ludwigs angina, Uvulitis, Mononucleosis, Acute HIV, Carotid Aneurysm.

Epidemiology: Most common deep space infection of the neck. Young adults in winter and early spring.

Pathogenesis: Polymicrobial infection, but GAS predominates. Progression of tonsillitis-cellulitis-abscess, or following inflammation of Weber glands. Can occur in patients with tonsillectomy. Complications if left untreated: airway obstruction, hemorrhage of carotid artery, extension of infection, aspiration, Pseudoaneurysm, CN IX,X,XII palsy.

Symptoms: Sore throat, odynophagia, fever, malaise, ipsilateral otalgia

Signs: Uvular deviation, muffled voice, trismus, foul smelling breath, lymphadenitis

Diagnosis: Clinical, needle aspiration, ultrasound, CT scan, lateral neck X-ray

Treatment: Steroids, Antibiotics (GAS, staph, resp anaerobes), Aspiration, I&D, tonsillectomy

Aspiration: Patient cooperative w/o severe trismus. Upright position. Topical and local anesthesia w/epi (25g needle), aspiration in sagittal plane with 18 gauge needle, 12ml syringe, suction.

I&D: No.11 blade with 0.5cm exposed, approach in sagittal plane, Kelly clamp –> loculations, no packing

Disposition: Observation of airway and ability to tolerate po . ENT consult if patient not improving. Admission if immunocompromised, septic, young child, severe trismus, complications, not able to tolerate po. If discharged, antibiotics for 10 days, with outpatient f/u in 24-36 hours. Recurrence 9-22%.

References:

Chapter 241. Infections and Disorders of the Neck and Upper Airway: Rupali N. Shah; Trinitia Y. Cannon; Carol G. Shores. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh edition.

Otolaryngologic Procedures Ralph J. Riviello. Roberts and Hedges’ Clinical Procedures in Emergency Medicine, Sixth edition. Chapter 63, 1298-1341

Powell, J., & Wilson, J. A. (2012). An evidence‐based review of peritonsillar abscess. Clinical Otolaryngology, 37(2), 136-145.

Lyon, M., & Blaivas, M. (2005). Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department. Academic emergency medicine, 12(1), 85-88.

Costantino, T. G., Satz, W. A., Dehnkamp, W., & Goett, H. (2012). Randomized Trial Comparing Intraoral Ultrasound to Landmark‐based Needle Aspiration in Patients with Suspected Peritonsillar Abscess. Academic Emergency Medicine, 19(6), 626-631.