Peritonsillar Abscess Celina Martinez, MSIII April 25, 2006

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

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

Labs Alk Phos – Glucose – , P = 82% L = 14% M = 4%

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

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

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

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

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

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

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

Peritonsillar Abscess Treatment –IV hydration –IV steroids –IV pain control –Antibiotics Penicillin V 500 mg TID for days Metronidazole 500 mg BID for days OR Clindamycin 300 mg QID for 10 days

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

Peritonsillar Abscess When to defer to otolaryngology –Marked trismus –Unsuccessful aspiration –Deep neck invasion

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 Dec;59(12): –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 Jul;29(1):45-7. –Bilateral tonsil swelling, midline uvula

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