SIGNS AND SYMPTOMS 
History
Physical Exam
- Fever
- Trismus
- "Hot potato" voice
- Erythematous tonsils/soft palate
- Inferior and medial displacement of superior pole of tonsil on affected side
- Uvular deviation away from affected side
- Halitosis
- Cervical lymphadenitis
- Tenderness on ipsilateral side of neck at the angle of the jaw
ESSENTIAL WORKUP
- Evaluation for deep space infections beyond the PTA, either with additional imaging or physical exam that may require admission and surgery
- Evaluate and ensure airway patency: Look for stridor, tripod position, or inability to handle secretions
- Definitive management with either needle aspiration or incision and drainage (I&D), followed by a course of antibiotics
DIAGNOSIS TESTS & INTERPRETATION
- Usually a clinical diagnosis made by visually examining oropharynx
- May be difficult with severe trismus
Lab
- Throat culture and monospot (20% incidence of mononucleosis with PTA)
- CBC and culture of the abscess contents may be useful in some cases
- Basic metabolic panel may be useful in patients with decreased oral intake and clinical signs of dehydration
Imaging
- Bedside intraoral US:
- Using the high-frequency intracavitary US transducer with a lubricated latex cover can aid in identification and localization of the abscess
- A cooperative patient can place the transducer at the point of maximum tenderness
- Transcutaneous cervical ultrasound is an option when the patient has too much trismus to use an intracavitary probe
- Soft-tissue lateral neck:
- If suspicion for epiglottitis or retropharyngeal abscess exists
- Chest radiograph:
- With severe respiratory symptoms or draining abscess
- CT scan of neck:
- If suspicion exists for other deep space infection of the neck, CT may be indicated
- CT also may be indicated if unable to obtain a good exam secondary to trismus
- CT may locate abscess pocket after failed needle aspiration
- MRI may be useful to evaluate for complications of deep space infections (internal jugular vein thrombosis or erosion into the carotid sheath)
Diagnostic Procedures/Surgery
- Needle aspiration is diagnostic and often curative
- Bedside I&D
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
Rarely associated with airway emergencies, but diagnosis is likely to be uncertain in transport, so suction and intubation equipment should be at the bedside:
- Pulse oximetry, supplemental oxygen
- Cardiac monitor
- IV access
Pediatric Considerations
- PTA occurs in children (< 18 yr) in 25–30% of reported cases (14 cases per 100,000 population)
- Young children may need sedation or general anesthesia if I&D or aspiration of the abscess is attempted
- Obtain soft-tissue lateral neck radiograph before oral exam in young children with symptoms of upper airway obstruction
INITIAL STABILIZATION/THERAPY
- Same as for pre-hospital
- Airway management may be necessary
- Equipment for intubation and cricothyroidotomy should be available
ED TREATMENT/PROCEDURES
- Antibiotics should be administered
- IV fluid should be given for dehydration
- Pain control is important
- A single dose of steroids may improve symptoms
- Adequate anesthesia prior to aspiration or I&D procedures is important:
- No clear benefit for one drainage technique over another:
- Needle drainage:
- Successful 87–94%
- Should be performed by a person experienced in drainage procedure and adept at advanced airway techniques
- Less painful, less invasive than I&D
- The internal carotid artery lies ~2.5 cm posterolaterally to the tonsil; sheathing the aspiration needle to prevent introduction of the needle to < 0.5 cm is prudent
- The superior pole of the tonsil is the most common place for maximal fluctuance (followed by the middle pole and then the inferior pole)
- Repeat aspiration is necessary in 10%
- I&D:
- Successful 90–92%
- An 11- or 15-blade scalpel is used to make stab incision to area of fluctuance
- Guard scalpel with trimmed plastic sheath leaving 1 cm of blade exposed
- Avoid > 0.5 cm depth
- Medial and superior incisions are safer from the standpoint of potential injury to the carotid artery
- Incision typically made superior to tonsil in area of soft palate. Incision in the tonsil itself causes excessive bleeding and may miss the abscess, which is located in the peritonsillar soft tissue of the soft palate.
- Suction should be ready to remove purulent drainage and blood
- Packing is not used
- Tonsillectomy (indications in children):
- Upper airway obstruction
- Previous episodes of severe recurrent pharyngitis or PTA
- Failure of abscess resolution with other drainage techniques
- Can be performed immediately or after resolution of acute infection
MEDICATION
- Length of antibiotic treatment should be 14 days (< 10 day treatment course may be associated with recurrence)
- Adjunct with steroids can improve symptoms
Intravenous Antibiotics
Oral Antibiotics
Steroids
[Outline]
DISPOSITION
Admission Criteria
- Airway compromise
- Sepsis
- Altered mental status
- Dehydration and inadequate PO intake
- Extension of infection beyond the PTA (i.e., deep space neck infections)
Discharge Criteria
- Most patients with PTA can be discharged home on oral antibiotics after abscess drainage
- Must be able to tolerate sufficient oral intake and antibiotics
Issues for Referral
- Referral to an otolaryngologist or surgeon should be provided
- Tonsillectomy is recommended 6–8 wk following treatment of the abscess
FOLLOW-UP RECOMMENDATIONS
Close follow-up recommended in 24–48 hr:
- Treatment failures and recurrences are relatively common
[Outline]
ICD9
475 Peritonsillar abscess
ICD10
J36 Peritonsillar abscess
[Outline]