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

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

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

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

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

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

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

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

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

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

11. 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

12. Laboratory Aids
Throat Culture
Lateral Neck X-ray
CBC
Monospot

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

14. 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)

15. 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

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

17. 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

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

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

20. 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

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

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

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

24. 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

25. 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