Author:
AlexaCamarena-Michel
Maria E.Moreira
Description
- Suppurative complication of tonsillitis where infection spreads outside the tonsillar capsule between the palatine tonsil and pharyngeal muscles
- Most common deep infection of the head and neck (incidence of 30/100,000 per year)
- In the U.S., 45,000 cases annually
- Occurs in all ages, more commonly in young adults (mean age 20-40 yr)
- Occurs most commonly November-December, April-May (coincides with highest incidence rates of streptococcal pharyngitis)
- Complications:
- Airway compromise (uncommon)
- Sepsis (uncommon)
- Recurrence (12-15%)
- Extension to lateral neck or mediastinum
- Spontaneous perforation and aspiration pneumonitis
- Jugular vein thrombosis (Lemierre syndrome)
- Poststreptococcal sequelae (glomerulonephritis, rheumatic fever)
- Hemorrhage from extension and erosion into carotid sheath
- Severe dehydration
- Intracranial extension (meningitis, cavernous sinus thrombosis, cerebral abscess)
- Dural sinus thrombosis
Etiology
- 2 theories explain the development of peritonsillar abscess (PTA):
- Direct bacterial invasion into deeper tissues in the patient with acute pharyngitis
- Acute obstruction and bacterial infection of small salivary gland s (Weber gland s) in the superior tonsil
- Smoking may be a risk factor
- Most common pathogens:
- Group-A Streptococcus
- Staphylococcal species, including methicillin-resistant Staphylococcus aureus (MRSA)
- Anaerobes (Prevotella, Peptostreptococcus, Fusobacterium)
- Polymicrobial
Signs and Symptoms
History
- Sore throat
- Fever
- Voice change
- Odynophagia (difficulty swallowing)
- Drooling
- Headache
- Pain radiating to the ear
- Decreased PO intake
- Malaise
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:
- Stridor
- Tripod position
- Inability to hand le secretions
- Definitive management with either needle aspiration or incision and drainage (I&D), followed by a course of antibiotics
Diagnostic 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 US 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
- CXR:
- 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
- Peritonsillar cellulitis
- Epiglottitis
- Retropharyngeal abscess
- Peripharyngeal abscess
- Tracheitis
- Meningitis
- Retropharyngeal hemorrhage
- Cervical osteomyelitis
- Cervical adenitis
- Epidural abscess
- Infectious mononucleosis
- Internal carotid artery aneurysm
- Lymphoma
- Foreign body
- Other deep space infections of the neck
Prehospital
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 prehospital
- 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:
- Benzocaine spray
- Lidocaine, 1% with 1:100,000 epinephrine
- 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 stand point 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 d (<10-dtreatment course may be associated with recurrence)
- Adjunct with steroids can improve symptoms
Oral Antibiotics
- Amoxicillin/clavulanic acid (Augmentin), 875 mg b.i.d (peds: 45 mg/kg/d divided b.i.d, max: 4 g/d)
- Clindamycin, 600 mg b.i.d or 300 mg q6h (peds: 10-30 mg/kg/d divided q8h, max. 450 mg/dose)
- If suspect MRSA infection, linezolid, 600 mg b.i.d (peds: <12 yr 30 mg/kg/d divided q8h or >12 yr 20 mg/kg/d divided b.i.d, max. 1,200 mg/d)
- Penicillin VK, 500 mg q6h plus metronidazole (Flagyl), 500 mg q6h
Steroids
- Dexamethasone, 10 mg IV/IM/PO single dose (peds: 0.6 mg/kg; max. 10 mg)
- Methylprednisolone 125 mg IV single dose (peds: 2 mg/kg/dose, max. 125 mg/dose)
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
- BattagliaA, BurchetteR, HussmanJ, et al. Comparison of medical therapy alone to medical therapy with surgical treatent of peritonsillar abscess . Otolaryngol Head Neck Surg. 2018;158:280-286.
- BrookI. Pediatric peritonsillar abscess . Medscape. Retrieved January 4, 2018 from http://emedicine.medscape.com/article/970260-overview.
- ChangBA, ThambooA, BurtonMJ, et al. Needle aspiration versus incision and drainage for the treatment of peritonsillar abscess . Cochrane Database Syst Rev. 2016;12:CD006287.
- ChungJH, LeeYC, ShinSY, et al. Risk factors for recurrence of peritonsillar abscess . J Laryngol Otol. 2014;128:1084-1088.
- GosselinBJ. Peritonsillar abscess . Medscape. Retrieved January 4, 2018 from http://emedicine.medscape.com/article/194863-overview.
- HerzonFS, MeiklejohnDA, HobbsEA. What antibiotic should be used in the management of an otherwise healthy adult with a peritonsillar abscess?Laryngoscope. 2018;128:783-784.
- HurK, ZhouS, KyshL. Adjunct steroids in the treatment of peritonsillar abscess: A systematic review . Laryngoscope. 2018;128:72-77.
- KimDK, LeeJW, NaYS, et al. Clinical factor for successful nonsurgical treatment of pediatric peritonsillar abscess . Laryngoscope. 2015;125:2608-2611.
- WallsRM, HockbergerRS, Gausche-HillM, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed.Philadelphia, PA: Elsevier; 2018.
See Also (Topic, Algorithm, Electronic Media Element)
ICD9
475 Peritonsillar abscess
ICD10
J36 Peritonsillar abscess
SNOMED