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Peritonsillar Abscess

Celina Martinez, MSIII April 25, 2006. Peritonsillar Abscess. Clinical Presentation of A.E. 47 y.o. AAF c/o “sore throat” and difficulty swallowing for 4 days PMH None Meds None SH Current cigarette use with 20 pack-year history Moderate EtOH use, current heroin use ROS

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Peritonsillar Abscess

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  1. Celina Martinez, MSIII April 25, 2006 Peritonsillar Abscess

  2. Clinical Presentation of A.E. • 47 y.o. AAF c/o “sore throat” and difficulty swallowing for 4 days • PMH • None • Meds • None • SH • Current cigarette use with 20 pack-year history • Moderate EtOH use, current heroin use • ROS • + fever, throat pain, cough, wheezing, dysphagia • Throat pain is 7/10

  3. Physical Exam VS: 137/86 HR 103 T 100.8 98-100% RA HEENT: • + lymphadenopathy bilaterally • Unable to visualize oropharynx, patient cannot fully open mouth Repeat exam of oropharynx • L tonsil swollen, with exudate • Uvula midline

  4. Labs 9.0 6.9 0.6 17 3.8 11 Alk Phos – 69 144 105 11 3.1 29 0.6 Glucose – 98 • 11.8 • 13,460264 • 35.2 • P =82% • L =14% • M = 4%

  5. Anatomically related conditions Epiglottitis Peritonsillar abscess Retropharyngeal abscess Candidal pharyngitis Apthous stomatitis Thyroiditis Bullous erythema multiforme Differential Diagnosis • Viral • Rhinovirus, coronavirus, adenovirus • Influenza • Parainfluenza • Coxsackie virus • HSV • CMV • HIV • Bacterial • GAβS • Gonococci • Chlamydia • Diphtheria • Legionella • Mycoplasma

  6. Imaging • Neck CT with Contrast • L tonsillar enlargement with 2 rim-enhancing peritonsillar hypodensities • Oropharyngeal narrowing at level of tonsillar enlargement • Swelling of adjacent soft palate with hypodensity compatible with fluid that crosses the midline • Impression • Enlargement of the left palatine tonsil with cystic/necrotic change and marked swelling of adjacent structures

  7. Peritonsillar cellulitis • Tonsillar abscess • Mononucleosis • FB aspiration • Cervical adenitis • Neoplasm • Dental infection • Salivary gland tumor • Aneurysm of internal carotid artery Peritonsillar Abscess Background • 30 cases per 100,000 people per year • 45,000 US cases annually • Highest incidence in 3rd and 4th decades of life Differential Diagnosis

  8. Peritonsillar Abscess Pathophysiology - Progression of tonsillitis Tonsillitis  Peritonsilar Inflammation  Abscess • Inflammation of supratonsillar soft palate and surrounding muscle • Pus collects between fibrous capsule and superior constrictor muscle of the pharynx • Common infectious agents • Common aerobes • Streptococcus pyogenes in 30% • H. influenzae, S. aureus, neisseria species • Common anaerobes • Fusobacterium, peptostreptococcus, prevotella, bacteroides

  9. Signs Fever Trismus Drooling, salivation Lymphadenopathy Dehydration Signs of airway compromise (rare) Oropharyngeal exam Peritonsillar Abscess Symptoms • Sore throat • Dysphagia • Difficulty opening mouth • “Hot potato voice” • Headache • Neck pain • Referred ear pain • General malaise

  10. Oropharyngeal Exam • Edema of tissues lateral and superior to the involved tonsil • Medial and/or anterior displacement of the involved tonsil • Displacement of the uvula to the contralateral side of the pharynx • Possibly erythematous, enlarged, or exudate-covered tonsil

  11. Peritonsillar Abscess Diagnosis is usually clinical! Other Tests • Intraoral ultrasound • Rule out retropharyngeal abscess and peritonsillar cellulitis • CT scan • Trismus, suspicion of invasion into deep neck tissue

  12. Peritonsillar Abscess Treatment • IV hydration • IV steroids • IV pain control • Antibiotics • Penicillin V 500 mg TID for 10-14 days • Metronidazole 500 mg BID for 10-14 days OR • Clindamycin 300 mg QID for 10 days

  13. Peritonsillar Abscess Treatment • Needle aspiration • Anesthetic spray, 2-4 cc of lidocaine w/epi • 19-gauge needle; keep proximal half covered w/cap • Point needle medially, keep medial to molars to avoid vessels! • Needle can be inserted 1-2 cm safely • Culture aspirate and gram stain aspirate

  14. Peritonsillar Abscess • When to defer to otolaryngology • Marked trismus • Unsuccessful aspiration • Deep neck invasion

  15. Current Literature • Losanoff JE, Missavage AE. Neglected peritonsillar abscess resulting in necrotizing soft tissue infection of the neck and chest wall. Int J Clin Pract. 2005 Dec;59(12):1476-8. • NSTI from peritonsillar abscess is rapidly spreading and life threatening. • High index of suspicion, early diagnosis, broad-spectrum antibiotics and aggressive surgical management are essential. • Fasano CJ, Chudnofsky C, Vanderbeek P. Bilateral peritonsillar abscesses: not your usual sore throat. Emerg Med. 2005 Jul;29(1):45-7. • Bilateral tonsil swelling, midline uvula

  16. References • Johnson RF, Stewart MG. The contemporary approach to diagnosis and management of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005 Jun;13(3):157-60. • Thomas GR, et al. Managing Common Otolaryngologic Emergencies. Emerg Med 37(5):18-47, 2005. • Bisno AL. Acute Pharyngitis. N Engl J Med. 2001 Jan 18;344(3):205-11 • Steyer TE. Peritonsillar Abscess: Diagnosis and Treatment. Am Fam Physician. 2002 Jan 1;65(1):93-6.

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