ENT

Peritonsillar Abscess

PeritonsilarAbsess.jpg
Right sided peritonsillar abscess
https://en.wikipedia.org/wiki/Peritonsillar_abscess

Peritonsillar abscess is the most common deep neck infection in children and adolescents. It is a bacterial infection that often follows an acute pharyngitis or tonsillits. The infection forms in the “peritonsillar space”, a potential space between the palatine tonsils and the surrounding capsule. Peritonsillar abscesses can also occur without infection. These abscess are attributed to inflammation of the Weber’s glands, which are salivary glands superior to the tonsil in the soft palate.

Epidemiology

  1. In the US, there are 30 per 100,000 persons years (45,000 cases annually).
  2. Most infections occur during November to December and April to May, coinciding with the highest incidence of streptococcus pharyngitis and exudative tonsilitis.
  3. Most prevalent in young adults. Younger children diagnosed with this condition are usually immunocompromised.
  4. Risk Factors include: dental infection (periodontitis, gingivitis), chronic tonsilitis, infectious mononucleosis, smoking, chronic lymphocytic leukemia, tonsilloliths

Clinical Presentation

  1. Unilateral sore throat
    1. occasionally accompanied by ipsilateral ear pain
    2. Fever
  2. Muffled "hot potato" voice
  3. Dysphagia with pooling of saliva and drooling
  4. Trismus: inability to open the mouth due to muscle inflammation and spasm of the masticator muscle
    1. Caused by irritation and reflex spasm of the Internal Pterygoid muscle
  5. Torticollis

Physical Findings

  1. Patient may appear toxic and very uncomfortable
  2. Localized erythema of the soft palate and uvula pushed to the contralateral side
  3. Erythematous, exudative tonsillar tissue with possible “pointing" of abscess
  4. Inferior and medial displacement of the tonsil
  5. Cervical adenopathy
  6. Rancid or fetor breath

Causative Organisms

  1. Streptococcus Pyogenes (Group A Streptococcus)
  2. Staphylococcus Aureus, including MRSA
  3. Respiratory Anaerobes - Fusobacterium, Prevotella and Veillonella

Differential Diagnosis

  1. Dental infections
  2. Epiglottitis
  3. Peritonsillar Cellulitis
  4. Retropharyngeal Abscess
  5. Pharyngitis
  6. Mononucleosis
  7. Cervical Adenitis
  8. Salivary gland infections
  9. Leukemia or Lymphoma

Complications

  1. Airway obstruction
  2. Cellulitis of the jaw, neck, or chest
  3. Necrotizing Fascitis
  4. Endocarditis, Pericarditis, Mediastinitis
  5. Pleural effusion
  6. Aspiration Pneumonia
  7. Internal Jugular Vein thrombosis and thrombophlebitis
  8. Carotid Artery pseudoaneurysm and rupture
  9. Septicemia

Diagnosis

  1. Clinical diagnosis based on symptoms
  2. Labs - used for establishing therapy
    1. CBC with differential and electrolytes - increased WBCs with predominant PMN Leukocytes
    2. Gram stain, culture and susceptibility test
    3. Throat culture to rule out GAS

Imaging

 Used to differentiate PTA from peritonsilar cellulitis

  1. Lateral neck radiograph - distortion of soft tissue
    1. Rules out epiglottis and retropharyngeal abscess
  2. CT scan with IV contrast - hypodense fluid collection with rim enhancement seen on affected tonsil
    1. Distinguishes from cellulitis, which shows a loss of fat planes and lack of enhancement
    2. Demonstrates spread to contiguous deep neck spaces
    3. Used for children younger than 5 yrs old due to physical limitations from a small oropharynx
  3. c.     Ultrasonography - echogenic cavity with irregular borders
    1. Distinguishes from cellulitis which presents as a homogenous or striated area with no distinct fluid collection

Treatment

    1. Antimicrobial Therapy - begin with Penicillin
    2. Drainage
      1. Needle aspiration should be attempted and will alleviate the symptoms.
      2. Incision and Drainage - out patient procedure with topical analgesia. More painful and involves more bleeding than aspiration. Send specimens for culture.
    3. Supportive Care
      1. Analgesics
      2. Antipyretics
      3. Fluid resuscitation
    4. Tonsillectomy
      1. Indications - significant upper airway obstruction or other complications
        1. Patient uncooperative
        2. Previous episodes of severe recurrent pharyngitis or peritonsillar abscess
        3. Failure of abscess resolution with other drainage techniques
      2. Timing
        1. Quinsy Tonsillectomy or  “tonsillectomy a chaud” - performed immediately
        2. Interval Tonsillectomy - performed after resolution of infection
    5. Fasano Charles J, Chudnofsky Carl, Vanderbeek Paul. Bilateral peritonsillar abscesses: not your usual sore throat. Journal of Emergency Medicine 2005; 29(1):45–47.
    6. Friedman Norman R, Mitchell Ron B. Peritonsillar abscess in early childhood. Presentation and management. Archives of Otolaryngology Head and Neck Surgery 1997;123(6):630-632.
    7. Galioto Nicholas. Peritonsillar Abscess. Journal of American Academy of Family Physicians 2008 Jan 15;77(2):199-202
    8. Schraff Scott, McGinn Johnathan. Peritonsillar Abscess in children: a 10 year review of diagnosis and management. International Journal of Pediatric Otolaryngology 2001;57 (3):313-318
    9. Steyer Terrence. Peritonsillar Abscess: Diagnosis and Treatment. American Family Physician Vol. 65 Number 1 January 1, 2002.