Approach to Sore Throat & Peritonsillar Abscess MR 8/3/09 J.Chen

General Approach R/O Life Threatening causes R/O non-infectious causes Determine whether or not treatment is required

Life Threatening Causes Airway Compromise Sitting in sniffing position Toxic appearing Drooling Voice change Fever

Life Threatening Causes Epiglottitis Retropharyngeal abscess Peritonsillar abscess Significant tonsillar hypertrophy Diphtheria

Management NPO Supplemental O2 Consider airway adjunct (NP airway) IV access (if pt can tolerate) Anesthesia

Non-infectious Causes Environmental Irritative pharyngitis Smoke Dry air Chemicals Trauma Burns Foreign Body Retained Laceration to posterior pharynx

Non-infectious Causes Allergic/Inflammatory Allergens causing chronic postnasal drip Eosinophilic esophagitis Tumors Rare in pediatric population

Infectious Causes Bacterial: Group A Beta Hemolytic Streptococcus Group C Strep Group G Strep Neisseria Gonorrhoeae Tularemia Chlamydia Mycoplasma Diptheria

Infectious Causes Viral Causes Stomatitis Adenovirus Influenza Parainfluenza Epstein-Barr Virus Cytomegalovirus HIV Stomatitis HSV Coxsackievirus

History Drooling? Voice Change? Fever? Exposure? Foreign Body? Headache? Abdominal Pain? URI symptoms? Immunization status? Sexual activity?

Physical Exam General Appearance Drooling Stridor LAD Pharyngeal erythema/exudate Asymmetric Enlargement of tonsillar pillar Deviation of uvula Cobblestoning of posterior pharyngeal mucosa Vesicular or ulcerative lesions in oropharynx

Laboratory Aids Throat Culture Lateral Neck X-ray CBC Monospot

Peritonsillar Abscess Suppurative infection of the tissues adjacent to the palatine tonsil Most common abscess of the head and neck

Background Gradual onset Progression from peritonsillar cellulitis 2 mechanisms Direct spread of inadequately treated bacterial tonsillitis Abscess formed in a group of salivary glands (Weber glands) in the supratonsillar fossa 30 per 100,000 person/year (25-30% Pediatric)

Cause Bacterial Growth often polymicrobial Aerobic organisms Group A beta-hemolytic streptococcus pyogenes Staphlococcus aureus Alpha-hemolytic strep Coag-negative staph Streptococcus pneumoniae Anaerobic organisms Gram neg bacilli Provetella Bacteroides Peptostreptococcus Fusobacterium

History Sore Throat/Dysphagia 5-7 days Trismus (2nd to inflammation of internal pterygoid muscle) Fever Drooling Muffled Voice Referred Ear Pain

Physical Exam Asymettric swelling of the soft tissue lateral and superior aspect of tonsil Fluctuant area palpable Uvula displaced to contral Lateral side Soft palate red/swollen

Physical Exam Moderately uncomfortable appearing Febrile Potential resp distress Trismus Halitosis Cervical adenopathy

Laboratory Tests CBC with diff-leukocytosis with neutrophil predominance Needle aspiration for culture and sensativity

Imaging CT scan US Sensitivity 100%, Specificity 75% Abscess appears as low attenuation mass with ring- enhancing wall US Sensitivity 89%, Specificity 100% Intraoral approach prefered

Complications Airway Compromise Aspiration of abscess contents Parapharyngeal abscess Sepsis Hemorrhage Contiguous spread to pterygomaxillary space

Treatment Hydration Analgesia Antibiotics Admit patients for: Airway Compromise Dehydration, inability to take PO Poor Compliance Systemic complication Toxic Appearing Unclear diagnosis

Antibiotics Augmentin (amox+clavulanate) is DOC Unasyn (amp+sulbactan) for inpatient Ceftriaxone and clindamycin or imipenem for severe or complicated cases

Surgical Drainage Needle Aspiration 90% success rate after one aspiration Another 5-10% after second Complications: resp distress, aspiration, hemorrhage Contraindications: uncertain diagnosis, uncooperative, very young, airway management problem

I&D Tonsillectomy Wider Drainage More Painful Containdications: same as needle aspiration Tonsillectomy Definitive Therapy May decrease overall duration of stay Requires OR and intubation