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Peritonsillar Abscess View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by University of Missouri: MOspace Peritonsillar Abscess Background 1. Definition o Extension of tonsillar infection beyond the capsule with abscess formation usually above and behind the tonsil 2. Almost always a complication of acute tonsillitis 3. Most common deep head/neck infection (50%) 4. Also known as "Quinsy" 5. Peritonsillar cellulitis o Extension of tonsillar infection beyond the capsule without abscess Pathophysiology 1. Pathology of disease o Infection that starts as acute tonsillitis and results in abscess o Most often Group A Strep1 o Cultures of abscesses often grow anaerobes (Fusobacterium, Prevotella, Veillonella spp)1 o H. flu, S. aureus occasionally cultured alone o Inflamed areas . Supratonsillar space of soft palate Just above superior pole of tonsil . Surrounding muscles Esp. internal pterygoids o Pus collects between fibrous capsule of tonsil and superior pharyngeal constrictor muscle 2. Incidence, prevalence o Most commonly seen in adults age 15-30 o Estimated incidence in USA: 30/ 100,000 people/ year 3. Risk factors o Tonsillitis o Acute or chronic oropharyngeal infection o 15% with antecedent Infectious Mono, seen by monospot test2 o Prior tonsillar infection 36% o Smoking 4. Morbidity/ mortality o Airway obstruction o Septicemia o Thrombophlebitis (Lemierre's Syndrome) - spread of infection to carotid sheath which may lead to spread of infection to lungs, mediastinum o Aspiration pneumonia subsequent to rupture of abscess into an airway Diagnosis 1. History o Headache, malaise o Severe sore throat . Worsens, becomes unilateral o Dysphagia Peritonsillar Abscess Page 1 of 6 10.26.09 o "Hot potato" muffled voice o Trouble fully opening mouth o Neck pain / swelling . Due to lymphadenopathy Jugulodigastric area of affected side o May complain of ear pain (referred) 2. Physical exam o Fever, tachycardia, dehydration o Throat / pharynx exam . Involved tonsil displaced anterior / medially . Uvula displaced AWAY from abscess side . Tissues around tonsil swollen . Tonsil may be red, enlarged, have exudates . Very painful . Bulging peritonsillar mass o Trismus (2/3 of cases) . Due to internal pterygoid muscle inflammation o May drool (hard to handle secretions) o Anterior cervical lymphadenopathy o Bad breath o If impending airway compromise (very rare) . Anxious, agitated, severe distress 3. Diagnostic testing o CBC with differential (SOR:C ) o Culture / sensitivity of aspirate (SOR:C) . Gives definitive Dx of pathogen 4. Diagnostic imaging o Usually no imaging necessary o X-ray (SOR:C) . "Perfect lateral" with widened retropharyngeal space >7 mm at C2 or 14 mm at C6 suggestive of PTA . Can help Dx epiglottitis . May be technically difficult to perform o Intraoral ultrasound (SOR:C)3 . Very accurate, inexpensive . Can confirm abscess, exclude cellulitis & retropharyngeal abscess . Can determine volume and position of abscess . Also shows position of carotid artery in relation to abscess o CT of neck (SOR:C) . If patient unable to open mouth . Excellent visualization of tissues . Distinguish between abscess and cellulitis . Detect spread of abscess to contiguous spaces in deep neck Treatment 1. Depends on age, cooperativeness, condition of patient4 2. Important step is to differentiate cellulitis from abscess o Symptoms are identical to abscess Peritonsillar Abscess Page 2 of 6 10.26.09 o Abscess formation usually 5 days after onset of peritonsillar cellulitis 3. Conservative treatment o Consider if cellulitis probable o May be appropriate for small abscess, no respiratory compromise, no trismus, no septicemia o Fluids, analgesia, antibiotics o Reassess in 12-24 hours- if not improved in 24 hours consider surgical drainage 4. Antibiotic treatment o Sufficient by itself to treat cellulitis o One small study of 98 patients treated strictly as outpatients with antibiotics alone showed complete resolution of symptoms at 10 days provided that there was improvement within 48-72 hrs (95.9% success rate)5 SOR:C o Must be combined with aspiration / drainage to treat abscess if no initial improvement of symptoms with antibiotics alone (within 48-72 hrs) o Studies show that treatment with penicillin alone (clindamycin as alternative for penicillin allergy) is just as effective as broad spectrum antibiotics even when cultures show polymicrobial infection including anaerobes (SOR:C)6 o Penicillin G . Adults 600 mg (1 million U) IV for 24 hr . Peds 12,500-25,000 U/kg IV q6hr o Amp/ sulbactam . Adults 2 g IV q4hr . Children 50 mg/ kg IV q6hr o Clindamycin . Adults 600 mg IV q6hr . Children 13 mg/ kg IV q8hr o Alternatives: . Penicillin and metronidazole . Cefoxitin . Cefotaxime . Ceftizoxime . Imipenem . Piperacillin/ tazobactam o Continue IV antibiotics until patient afebrile and improved, then switch to oral antibiotics . Amoxicillin/clavulanate (or clindamycin) x14d 5. Needle aspiration o Prepare equipment . 18-19 G needle + 10cc syringe . Cut plastic needle cover in half . Slide proximal (open) 1/2 of cover back over needle . Tape cover to syringe . Functions as a "depth gauge" . Prevents deep tissue penetration o Place patient in Trendelenburg position Peritonsillar Abscess Page 3 of 6 10.26.09 o Anesthetize area . Cetacaine spray or other topical anesthetic first . Follow with 2-4 cc lidocaine + epi Small study suggests needle infiltration with anesthetic superior to spray alone)6 o Aspirate abscess . Point of maximal bulging . Usually near top of tonsil, lateral to uvula About 10-11 o'clock position . Aspirate as much pus as possible May be up to 20cc . If no pus, can try again 1 cm lower down . Inability to get pus may indicate peritonsillar cellulitis only Does NOT fully R/O abscess 6. Surgical drainage o Indications . Conservative tx failure . Large abscesses . Airway compromise . Septicemia . Severe trismus . Young, uncooperative patients o Requires experienced practitioner o When surgical drainage indicated, studies suggest no significant difference in outcome between needle aspiration, incision and drainage, and Quinsy Tonsillectomy (all with success rate >90%) (SOR:C )6-8 o Formal incision/ exploration . Associated with increased pain compared with needle aspiration, but possibly slightly lower failure rate o Quinsy tonsillectomy . Recommended by some for recurrent pharyngitis (SOR:C)8 7. Steroids o Randomized trial suggests that parenteral steroids in conjunction with abscess drainage may speed resolution of fever and resumption of swallowing (SOR:C)6,7,8,9 Follow Up 1. Return to office o 24 hr if conservative treatment with antibiotics only o Within 48 hr after needle aspiration if . No improvement or worsening of symptoms . Inability to swallow . Worsening trismus . Worsening pain 2. Refer to specialist o More invasive drainage required beyond level of training or comfort level of provider o Lack of facilities to adequately protect airway during drainage Peritonsillar Abscess Page 4 of 6 10.26.09 3. Admit to hospital o If toxic, severe trismus, airway compromise, dehydration . IV antibiotics . Surgical drainage may be required 4. Discharge home o Patient must be . Non-toxic . Able to take meds/handle secretions o Discharge with antibiotic coverage o Return if worse pain, trismus, unable to swallow o Patient likely to need elective tonsillectomy Prognosis 1. Excellent prognosis for full recovery without complications, especially with initiation of therapy within 48-72 hr of symptom onset Prevention 1. Primary prevention o See Prevention of GAS infection 2. Secondary infection o Quinsy tonsillectomy- consider for recurrent pharyngitis o Studies show immediate tonsillectomy to be as safe as delayed Patient Education 1. http://www.aafp.org/afp/20080115/209ph.html References 1. Brook, I. Microbiology and Management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg 2004;62:1545. 2. Goldstein, NA. Hammerschlag, MR. Peritonsillar, retropharyngeal, and parapharyngeal abscesses. In: Textbook of Pediatric Infectious Diseases, 5th ed, Feigin, RD, Cherry, JD, Demmler, GJ, Kaplan, SL (Eds), Saunders, Philidelphia, 2004. p. 178. 3. Scott, PM, Loftus, WK, Kew, J, et al. Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. J Laryngol Otol 1999; 113:229. 4. Schraff, S, McGinn, JD, Derkay, CS. Peritonsillar abscess in children: a 10-year review of diagnosis and management. Int J Pediatr Otorhinolaryngol 2001; 57:213 5. Lamkin, RH, Portt, J. An outpatient medical treatment protocol for peritonsillar abscess. Ear Nose Throat J 2006; 85:658. 6. Herzon, FS, Martin, AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep 2006; 8:196. 7. Galioto, NJ. Peritonsillar abscess. Am Fam Physician 2008; 77:199. 8. Johnson, R, Stewert MG; Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg 2003; 128:332. 9. Johnson, RF, Stewert MG. The contemporary approach to diagnosis and management of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg 2005; 13:157. Peritonsillar Abscess Page 5 of 6 10.26.09 Author: Jacob Jackson, MD, Kaiser Permanete Medical Center FPRP, Riverside, CA Editor: Brett White, MD, Oregon Health & Sciences University Peritonsillar Abscess Page 6 of 6 10.26.09 .
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