peritonsillar abscess celina martinez, msiii april 25, 2006

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 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

Labs

9.0 6.9 0.6 17

3.8 11

Alk Phos – 69

144 105 11

3.1 29 0.6

Glucose – 98

11.813,460 264

35.2

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


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•Neoplasm•Dental infection•Salivary gland tumor•Aneurysm of internal carotid artery

•Peritonsillar cellulitis•Tonsillar abscess•Mononucleosis•FB aspiration•Cervical adenitis

Peritonsillar AbscessPathophysiology - 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


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


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


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


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


• 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. 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

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.

peritonsillar abscess celina martinez, msiii april 25, 2006

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