Peritonsillar abscess

Background
  • Abbreviation: PTA
  • Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
    • Location affected: superior > middle > inferior pole
  • Microbiology

Clinical Features
Right sided peritonsillar abscess

Symptoms

Signs
  • Trismus
  • Muffled voice ("hot potato voice")
  • Contralateral deflection of swollen uvula

Differential Diagnosis

Acute Sore Throat

Bacterial infections

Viral infections

Noninfectious

Other

Dentoalveolar Injuries

Odontogenic Infections

Other

Evaluation
Endocavitary probe shows hypoechoic circumscribed area consistent with abscess[2]
  • Ultrasound
    • Differentiates cellulitis from abscess
    • Can use an intraoral approach using a endocavitary probe or transcutaneous approach using a linear probe
    • Can identify depth of neck vasculature prior to aspiration
  • CT with IV contrast

Management

Drainage

Needle Aspiration
  1. Apply anesthetic spray to overlying mucosa
  2. Have patient hold suction and use as needed
  3. Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source
  4. Inject 1-2mL of lidocaine with epinephrine into mucosa of anterior tonsillar pillar using 25 gauge needle
  5. Cut distal tip off of needle sheath and place over 18ga needle to expose 1 cm of needle to prevent accidentally plunging deeper than desired
  6. Aspirate using 18 gauge needle just lateral to the tonsil
    • Use static ultrasound to determine depth of vasculature.
    • Though always a concern, carotid injury has not been clearly documented as a complications[5]
    • May require multiple aspirations to find the abscess
      • First try superior then middle then inferior poles
    • Consider spinal needle if patient has significant trismus

I&D
  1. #11 or #15 blade scalpel
  2. Do not penetrate more than 1cm
  3. Only advance posteriorly
  4. May be indicated if significant pus with needle aspiration

Antibiotics Alone
  • A 2018 paper showed that if pts were given abx/IVF/decadron and felt better (must improve clinically), similar results could be obtained compared to I&D[6]
  • Protocol includes the medications below and ED observation for 1-2 hours after, with liquid PO challenge
  • Pediatric protocol is the same, with weight based dosing
  • Medical therapy patients required less opioids, fewer sore throat days, required less days off from work

Antibiotics

Coverage for Streptococcus species, anerobes, Eikenella, H. influenza, S. auresus

Outpatient Options

Inpatient Options

Steroids

Decreases duration and severity of pain

Disposition
  • Generally may be discharged with ENT follow-up
  • If no pus can be obtained but there is high suspicion for a PTA, admit with IV antibiotics (30% neg aspiration still have PTA)
  • In pediatric patients 50% respond to med management[7]

Return Precautions

Prognosis

Complications

Indications for tonsillectomy
  • Airway obstruction
  • Recurrent severe pharyngitis or PTA
  • Failure of abscess resolution with drainage

See Also

References
  1. Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  2. http://www.thepocusatlas.com/soft-tissue-vascular/
  3. Johnson RF, Stewart MG. The contemporary approach to diagnosis and man- agement of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005;13:157
  4. Wolf M. Peritonsillar abscess: repeated needle aspiration versus incision and drainage. Ann Otol Rhinol Laryngol. 1994 Jul;103(7):554-7.
  5. Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep. 2006;8(3):196.
  6. Comparison Of Medical Therapy Alone To Medical Therapy With Surgical Treatment Of Peritonsillar Abscess Battaglia, A., et al, Otolaryngol Head Neck Surg 58(2):280, February 2018
  7. Blotter JW, Yin L, Glynn M, et al. Otolaryngology consultation for peritonsillar abscess in the pediatric population. Laryngoscope. 2000;110(10 Patient 1):1698.
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