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DocumentPeritonsillar AbscessNICHOLASJ.GALIOTO,MD,Broadlawns Medical Center, Des Moines, IowaPeritonsillarabscessisthemostcom-mondeepinfectionoftheheadandneckinyoungadults,despitethewidespreaduseofantibioticsfortreatingtonsillitisandpharyngitis.Thisinfectioncanoccurinallagegroups,butthehighestincidenceisinadults20to40yearsofage.1,2PeritonsillarabscessmostcommonlyoccursduringNovembertoDecemberandApriltoMay,whichcoincideswiththehigh-estincidenceratesofstreptococcalpharyn-gitisandexudativetonsillitis.3,4Peritonsillarabscessesarealmostalwaysrstencounteredbythefamilyphysician,andthosewithappro-priatetrainingandexperiencecandiagnoseandtreatmostpatients.Promptrecogni-tionandinitiationoftherapyisimportanttoavoidpotentialseriouscomplications.AnatomyThetwopalatinetonsilslieonthelateralwallsoftheoropharynxinthedepressionbetweentheanteriortonsillarpillar(palatoglossalarch)andtheposteriortonsillarpillar(pala-topharyngealarch).Thetonsilsformduringthelastmonthsofgestationandgrowirregu-larly,reachingtheirlargestsizeatapproxi-matelysixorsevenyearsofage.Thetonsilsbegintograduallyinvoluteatpuberty,andbyolderagelittletonsillartissueremains.5Whenhealthy,thetonsilsdonotprojectbeyondthetonsillarpillarsmedially.Each2tonsilhasanumberofcryptsonitssurfaceandissurroundedbyacapsulethatprovidesapathwayforbloodvesselsandnerves.Peri-tonsillarabscessesformintheareabetweenthepalatinetonsilanditscapsule.1EtiologyPeritonsillarabscesshastraditionallybeenregardedastheendpointofacontinuumthatbeginsasacuteexudativetonsillitis,pro-gressestocellulitis,andeventuallyformsanabscess.ArecentreviewimplicatesWebersglandsasplayingakeyroleintheformationofperitonsillarabscesses.6,7Thisgroupof20to25mucoussalivaryglandsarelocatedinthespacejustsuperiortothetonsilinthesoftpalateandareconnectedtothesurfaceofthetonsilbyaduct.Theglandsclearthe7tonsillarareaofdebrisandassistwiththedigestionoffoodparticlestrappedinthetonsillarcrypts.IfWebersglandsbecomeinamed,localcellulitiscandevelop.Astheinfectionprogresses,theducttothesurfaceofthetonsilbecomesprogressivelymoreobstructedfromsurroundinginam-mation.Theresultingtissuenecrosisandpusformationproducetheclassicsignsandsymp-tomsofperitonsillarabscess.Theseabscesses8generallyformintheareaofthesoftpalate,justabovethesuperiorpoleofthetonsil,inthelocationofWebersglands.Theoccurrenceof7peritonsillarabscessesinpatientswhohaveundergonetonsillectomyfurthersupportsthetheorythatWebersglandshavearoleinthepathogenesis.Otherclinicalvariablesincludesignicantperiodontaldiseaseandsmoking.6 Peritonsillar abscess remains the most common deep infection of the head and neck. The condition occurs primarilyin young adults, most often during November to December and April to May, coinciding with the highest incidence ofstreptococcal pharyngitis and exudative tonsillitis. A peritonsillar abscess is a polymicrobial infection, but Group Astreptococcus is the predominate organism. Symptoms generally include fever, malaise, sore throat, dysphagia, andotalgia. Physical ndings may include trismus and a mufed voice (also called hot potato voice). Drainage of theabscess, antibiotics, and supportive therapy for maintaining hydration and pain control are the foundation of treat-ment. Antibiotics effective against Group A streptococcus and oral anaerobes should be rst-line therapy. Steroidsmay be helpful in reducing symptoms and speeding recovery. To avoid potential serious complications, prompt rec-ognition and initiation of therapy is important. Family physicians with appropriate training and experience can diag-nose and treat most patients with peritonsillar abscess. (Am Fam Physician.2008;77(2):199-202, 209. Copyright 2008American Academy of Family Physicians.) This article exempli-es the AAFP 2008 AnnualClinical Focus on infectiousdisease: prevention, diag-nosis, and management.Patient information:A handout on peritonsillarabscess, written by theauthor of this article, isprovided on page 209.Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2008 American Academy of Family Physicians. For the private, noncommercialuse of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.PeritonsillarAbscess200American Family Physicianwww.aafp.org/afpVolume 77, Number 2January 15, 2008ClinicalManifestationsPatientswithperitonsillarabscessappearillandpresentwithfever,malaise,sorethroat,dysphagia,orotalgia.Thethroatpainismark-edlymoresevereontheaffectedsideandisoftenreferredtotheearonthesameside.Phys-icalexaminationusuallyrevealstrismus,withthepatienthavingdifcultyopeninghisorhermouthbecauseofpainfrominammationandspasmofmasticatormuscles.Swallowing9isalsohighlypainful,resultinginpoolingofsalivaordrooling.Patientsoftenspeakina9mufedvoice(alsocalledhotpotatovoice).Markedlytendercervicallymphadenitismaybepalpatedontheaffectedside.Inspectionoftheoropharynxrevealstenseswellinganderythemaoftheanteriortonsillarpillarandthesoftpalateoverlyingtheinfectedtonsil.Thetonsilisgenerallydisplacedinferiorlyandmediallywithcontralateraldeviationoftheuvula(Figure 1).Themostcommonsymp-tomsandphysicalndingsaresummarizedinTable 1.Potentialcomplicationsofperitonsil-larabscessareoutlinedinTable 2.Deathcanoccurfromairwayobstruction,aspiration,orhemorrhagefromerosionorsepticnecrosisintothecarotidsheath.DiagnosisThediagnosisofperitonsillarabscessisoftenmadeonthebasisofathoroughhis-toryandphysicalexamination.Differentialdiagnosisincludesinfectiousmononucleosis,lymphoma,peritonsillarcellulitis,andret-romolarorretropharyngealabscess.Patientsoftenpresentwithperitonsillarcellulitiswiththepotentialtoprogresstoabscessformation.Inperitonsillarcellulitis,theareabetweenthetonsilanditscapsuleisedematousandery-thematous,butpushasnotyetformed.1Onoccasionswhenthediagnosisofperi-tonsillarabscessisinquestion,thepresenceofpusonneedleaspirationorradiologictest-ingmayhelpconrmthediagnosis.Trans-cutaneousorintraoralultrasonographyalsocanbehelpfulinidentifyinganabscessandindistinguishingperitonsillarabscessfromperitonsillarcellulitis.1,6Ifspreadoftheinfectionbeyondtheperitonsillarspaceorcomplicationsinvolvingthelateralneckspacearesuspected,computedtomography(CT)or SORT:KEYRECOMMENDATIONSFORPRACTICEClinical recommendation Evidencerating ReferencesTreatment for peritonsillar abscess shouldinclude drainage and antibiotic therapy.C1, 3, 6, 12Initial empiric antibiotic therapy forperitonsillar abscess should includeantimicrobials effective against Group Astreptococcus and oral anaerobes.C8, 13, 14Steroids may be useful in reducing symptomsand in speeding recovery in patients withperitonsillar abscess.B17 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usualpractice, expert opinion, or case series. For information about the SORT evidencerating system, see page 131 or http://www.aafp.org/afpsort.xml. Figure1. Patientwithrightperitonsillarabscess. Table1.CommonSymptomsandPhysicalFindingsinPatientswithPeritonsillarAbscessSymptomsFeverMalaiseSevere sore throat(worse on one side)DysphagiaOtalgia (ipsilateral)PhysicalndingsErythematous, swollen soft palatewith uvula deviation to contralateralside and enlarged tonsilTrismusDroolingMufed voice (hot potato voice)Rancid or fetor breathCervical lymphadenitisTonsilSoft palateswelling PeritonsillarAbscessJanuary 15, 2008Volume 77, Number 2www.aafp.org/afpAmerican Family Physician201magneticresonanceimaging(MRI)isindicated.CTcandistinguishbetweenperitonsillarcellulitisandperitonsillarabscess,aswellasdemonstratethespreadoftheinfectiontoanycontiguousspacesinthedeepneckregion(Figure 2).MRIhastheadvantageofimprovedsoft-tissuedenitionoverCTwithoutexposuretoradiation.Additionally,MRIissuperiortoCTindetectingcomplicationsfromdeepneckinfectionssuchasinternaljugularveinthrombosisorerosionoftheabscessintothecarotidsheath.Disadvan-tagesofMRIincludelongerscanningtimes,highercost,lackofavailability,andthepotentialforclaustrophobia.10TreatmentDrainageoftheabscess,antibiotics,andsupportivether-apytomaintainhydrationandpaincontrolarethefoun-dationoftreatmentforperitonsillarabscess.Becauseperitonsillarcellulitisrepresentsatransitionalstageinthedevelopmentofperitonsillarabscess,itstreatmentissimilartothatofaperitonsillarabscess,excludingtheneedforsurgicaldrainage.Themainproceduresforthedrainageofperitonsillarabscessareneedleaspiration,incisionanddrainage,andimmediatetonsillectomy.Drainageusinganyofthesemethodscombinedwithantibiotictherapywillresultinresolutionoftheperitonsillarabscessinmorethan90percentofcases.Theacutesurgicalmanagementof6peritonsillarabscesshasevolvedovertimefromroutineimmediatetonsillectomytoincreaseduseofincisionanddrainageorneedleaspiration.11Immediateabscesstonsil-lectomyhasnotbeenproventobeanymoreeffectivethanneedleaspirationorincisionanddrainage,anditisconsid-eredtobelesscost-effective.12Severalstudiescomparingneedleaspirationwithincisionanddrainagehavefoundnosignicantstatisticaldifferencesinoutcomes.11,12Althoughitisnotroutinelyperformedforthetreat-mentofperitonsillarabscess,immediatetonsillectomyshouldbeconsideredforpatientswhohavestrongindi-cationsfortonsillectomy,includingthosewhohavesymptomsofsleepapnea,ahistoryofrecurrenttonsil-litis(fourormoreinfectionsperyeardespiteadequatemedicaltherapy),orarecurrentornonresolvingperi-tonsillarabscess.6InitialempiricantibiotictherapyshouldincludeantimicrobialseffectiveagainstGroupAstreptococcusandoralanaerobes.13Themostcom-monorganismsassociatedwithperitonsillarabscessarelistedinTable 3.8,14Althoughperitonsillarabscessesarepolymicrobialinfections,severalstudieshaveshownintravenouspenicillinalonetobeasclinicallyeffectiveasbroader-spectrumantibiotics,providedtheabscesshasbeenadequatelydrained.12,14Inthesestudies,inad-equateclinicalresponsefollowing24hoursofantibiotictherapyplayedasignicantroleinthedecisiontousebroad-spectrumantibiotics.Severalotherstudieshavereportedthatmorethan50percentofcultureresultsdemonstratedthepresenceofbeta-lactamaseproduc-inganaerobes,leadingmanyphysicianstousebroader-spectrumantibioticsasrst-linetherapy.8,14,15Table 4showssuggestedantimicrobialregimens.16Althoughsteroidshavebeenusedtotreatedemaandinammationinotherotolaryngologicdiseases,theirroleinthetreatmentofperitonsillarabscesshasnot Table2.ComplicationsofPeritonsillarAbscessAirway obstructionAspiration pneumonitis or lung abscess secondary toperitonsillar abscess ruptureDeath secondary to hemorrhage from erosion or septicnecrosis into carotid sheathExtension of the infection into the tissues of the deep neckor posterior mediastinum Poststreptococcal sequelae (e.g., glomerulonephritis, rheumaticfever) when infection is caused by Group A streptococcus Table3.CommonOrganismsAssociatedwithPeritonsillarAbscessAerobicbacteriaGroup A streptococcusStaphylococcus aureusHaemophilus inuenzae Information from references 8 and 14.AnaerobicbacteriaFusobacteriumPeptostreptococcusPigmented PrevotellaFigure2. Computedtomographyofarightperitonsillarabscess. Area of abscessRight tonsilUvula PeritonsillarAbscess202American Family Physicianwww.aafp.org/afpVolume 77, Number 2January 15, 2008 beenextensivelystudied.Arecentstudyreportedthat32patientswhoreceivedasinglehighdoseofsteroids(methylprednisolone[Depo-Medrol]2to3mgperkgupto250mg)intravenouslyplusantibioticsrespondedmuchmorequicklytotreatmentthan28patientswhoreceivedantibioticsplusplacebo.17Theuseofsteroidsinthetreatmentofperitonsillarabscessappearstohelpspeedrecovery,butadditionalstudiesareneededbeforemakingarecommendationfortheirroutineuse.6,17Whenthefamilyphysicianisinexperiencedintreat-ingperitonsillarabscessorwhencomplicationsorques-tionsariseduringtreatment,anotolaryngologistshouldbeconsulted.Oncethediagnosishasbeenestablished,drainageoraspirationoftheabscessshouldbeper-formedinasettingwherepossibleairwaycomplicationscanbemanaged.Peritonsillaraspirationisatechnique3wellsuitedforthefamilyphysicianwhohashadappro-priatetraining.Thepatientshouldbeobservedforafewhoursafteraspirationtoensureheorshecantolerateoralantibioticsandpainmedications.Outpatientfollow-upshouldoccurin24to36hours.18Oralantibioticsarecon-tinuedfor10days.Mostpatientswithaperitonsillarabscesscanbetreatedinanoutpatientsetting,butasmallpercentage(e.g.,14percentinonestudy)mayrequirehospitaliza-tion.12Hospitalstaysusuallydonotexceedtwodaysandarerequiredforpaincontrolandhydration.Theoverallriskofdevelopingasecondperitonsillarabscessisapproximately10to15percent.11,12Upto30per-centofpatientswithaperitonsillarabscessmeetthecrite-riafortonsillectomy.12Thisoperationmaybeperformedimmediatelyordelayeduntiltheabscesshasresolved.TheAuthorNICHOLAS J. GALIOTO, MD, is associate director of the Family MedicineResidency Program and director of the Transitional Year Residency Pro-gram for Broadlawns Medical Center in Des Moines, Iowa. He also has aclinical teaching appointment in the Department of Family Medicine at the University of Iowa Carver College of Medicine in Iowa City. Dr. Galiotoreceived his medical degree from Creighton University in Omaha, Neb., andcompleted a family medicine residency at Broadlawns Medical Center.Address correspondence to Nicholas J. Galioto, MD, Broadlawns Medi-cal Center, 1801 Hickman Rd., Des Moines, IA 53104 (e-mail: [email protected]). Reprints are not available from the author.Author disclosure: Nothing to disclose.REFERENCES1.Steyer TE. Peritonsillar abscess: diagnosis and treatment [Published cor-rection appears inAm Fam Physician.2002;66(1):30].Am Fam Physi-cian. 2002;65(1):93-96.2.Khayr W, Taepke J. Management of peritonsillar abscess: needle aspi-ration versus incision and drainage versus tonsillectomy.Am J Ther.2005;12(4):344-350.3.Belleza WG, Kalman S. Otolaryngologic emergencies in the outpatientsetting.Med Clin North Am. 2006;90(2):329-353.4.Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH, for theInfectious Diseases Society of America. Practice guidelines for the diag-nosis and management of group A streptococcal pharyngitis. InfectiousDiseases Society of America.Clin Infect Dis. 2002;35(2):113-125.5.Berkovitz BK, ed. Pharynx. In: Standring S, ed. Grays Anatomy. TheAnatomical Basis of Clinical Practice. 39th ed. New York, NY: ChurchillLivingstone, 2005:623-625.6.Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar,retropharyngeal, and parapharyngeal abscesses.Curr Infect Dis Rep.2006;8(3):196-202.7.Passy V. Pathogenesis of peritonsillar abscess.Laryngoscope.1994;104(2):185-190.8.Brook I. Microbiology and management of peritonsillar, retropharyn-geal, and parapharyngeal abscesses.J Oral Maxillofac Surg.2004;62(12):1545-1550.9.Nwe TT, Singh B. Management of pain in peritonsillar abscess.J Laryn-gol Otol. 2000;114(10):765-767.10.Gidley PW, Ghorayeb BY, Stiernberg CM. Contemporary manage-ment of deep neck space infections.Otolaryngol Head Neck Surg.1997;116(1):16-22.11.Johnson RF, Stewart MG, Wright CG. An evidence-based review ofthe treatment of peritonsillar abscess.Otolaryngol Head Neck Surg.2003;128(3):332-343.12.Herzon FS, Harris P. Mosher Award thesis. Peritonsillar abscess: inci-dence, current management practices, and a proposal for treatmentguidelines.Laryngoscope. 1995;105(8 pt 3 suppl 74):1-17.13.Brook I. The role of beta lactamase producing bacteria and bacte-rial interference in streptococcal tonsillitis.Int J Antimicrob Agents.2001;17(6):439-442.14.Kieff DA, Bhattacharyya N, Siegel NS, Salman SD. Selection of antibiot-ics after incision and drainage of peritonsillar abscesses.OtolaryngolHead Neck Surg. 1999;120(1):57-61.15.Ozbek C, Aygenc E, Unsal E, Ozdem C. Peritonsillar abscess: a compari-son of outpatient IM clindamycin and inpatient IV ampicillin/sulbactamfollowing needle aspiration.Ear Nose Throat J. 2005;84(6):366-368.16.Fairbanks DN, ed. Pocket Guide to Antimicrobial Therapy in Otolaryn-gologyHead and Neck Surgery. 12th ed. Alexandria, Va.: AmericanAcademy of OtolaryngologyHead and Neck Surgery Foundation, Inc.,2005:40, 86-90.17.Ozbek C, Aygenc E, Tuna EU, Selcuk A, Ozdem C. Use of ste-roids in the treatment of peritonsillar abscess.J Laryngol Otol.2004;118(6):439-442.18.Roberts, JR. ED considerations in the diagnosis and treatment of peri-tonsillar abscess.Emerg Med News.2001;23(3):6,9-10. Table4.AntimicrobialRegimensforPeritonsillarAbscessIntravenoustherapyAmpicillin/sulbactam (Unasyn) 3 g every six hoursPenicillin G 10 million units every six hours plusmetronidazole (Flagyl) 500 mg every six hoursIf allergic to penicillin, clindamycin (Cleocin) 900 mgevery eight hoursOraltherapyAmoxicillin/clavulanic acid (Augmentin) 875 mg twice dailyPenicillin VK 500 mg four times daily plus metronidazole500 mg four times dailyClindamycin 600 mg twice daily or 300 mg four times daily Information from reference 16.