Peritonsillar Abscess

Peritonsillar Abscess: Excerpt from The 5-Minute Pediatric Consult

Nicholas Tsarouhas, MD

Peritonsillar Abscess - BASICS

Peritonsillar Abscess - description

Infectious complication of tonsillitis or pharyngitis resulting in an accumulation of purulence in the tonsillar fossa:

• Also referred to as “quinsy.”

Peritonsillar Abscess - general prevention

Abscess formation can often be prevented if appropriate antimicrobial therapy is initiated while the infection is still at the cellulitis stage.

Peritonsillar Abscess - epidemiology

Seen most commonly in adolescents, but occasionally in younger children

Peritonsillar Abscess - risk factors

• Tonsillitis
• Pharyngitis

Peritonsillar Abscess - pathophysiology

• Infectious tonsillopharyngitis progresses from cellulitis to abscess.
• The infection starts in the intratonsillar fossa, which is situated between the upper pole and the body of the tonsil, and eventually extends around the tonsil.
• The abscess is a suppuration outside the tonsillar capsule, in proximity to the upper pole of the tonsil, involving the soft palate.
• Purulence usually collects within one tonsillar fossa, but it may be bilateral.
• Tonsillar and peritonsillar edema may lead to compromise of the upper airway.

Peritonsillar Abscess - etiology

• Most of these true abscesses are polymicrobial
• Group A β-hemolytic streptococci (GABHS)
• α-Hemolytic streptococci
• Staphylococcus aureus
• Haemophilus influenzae
• Anaerobic bacteria play an important role:
  • Prevotella
  • Porphyromonas
  • Fusobacterium
  • Peptostreptococcus
• Possible synergy between anaerobes and GABHS

Peritonsillar Abscess - associated conditions

• Tonsillitis or pharyngitis usually precedes its development.
• Peritonsillar cellulitis is often associated with infectious mononucleosis.

Peritonsillar Abscess - DIAGNOSIS

Peritonsillar Abscess - signs & symptoms

• Fever and sore throat:
  • Most common initial complaints
• Trouble swallowing, pain with opening the mouth (trismus), muffled (“hot potato”) voice:
  • Classic presenting symptoms
• Unilateral neck or ear pain:
  • Other common presenting symptoms

Peritonsillar Abscess - physical exam

• Unilateral peritonsillar fullness, or bulging of the posterior, superior, soft palate:
  • Diagnostic finding
• Uvular deviation:
  • Classic finding
• Palpable fluctuance of palatal swelling:
  • Calls for urgent aspiration
• Erythematous, edematous pharynx, with enlarged and exudative tonsils:
  • Coexisting tonsillopharyngitis is common.
• Cervical adenopathy:
  • Common
• Drooling:
  • Often present
• Torticollis:
  • Sometimes seen

Peritonsillar Abscess - tests

Peritonsillar Abscess - lab

• WBC count:
  • Usually elevated with prominent left shift
• Rapid streptococcal throat antigen studies:
  • Helpful to diagnose GABHS infection
• Gram stain and culture of aspirate specimen:
  • Confirms causative micro-organism

Peritonsillar Abscess - imaging

• Radiographic studies are rarely necessary.
• CT scan or intraoral ultrasound:
  • Differentiation of peritonsillar cellulitis from peritonsillar abscess.
  • CT scan most useful if patient cannot open mouth secondary to trismus.
  • CT scan also important if deep neck extension is suspected.

Peritonsillar Abscess - differencial diagnosis

• Peritonsillar cellulitis:
  • Most common diagnostic consideration
  • Can be distinguished by its lack of peritonsillar space fullness, uvular deviation, dysphonia, and trismus
• Retropharyngeal abscess:
  • Minimal peritonsillar findings, along with a widened prevertebral space on lateral neck radiograph are diagnostic of this airway-compromising disease, which usually occurs in preschool children.
• Epiglottitis:
  • This life-threatening airway emergency presents abruptly with fever, stridor, increased work of breathing, and drooling.
  • Usually occurs in toxic-appearing children 3–7 years old
  • Becoming a rare entity since the advent of the Haemophilus influenzae type B vaccine
• Other infectious causes of severe tonsillopharyngitis:
  • Epstein-Barr virus (infectious mononucleosis), coxsackievirus (herpangina), Corynebacterium diphtheriae, and Neisseria gonorrhoeae

Peritonsillar Abscess - TREATMENT

Peritonsillar Abscess - general measures

Treating a true abscess without incision and drainage is inadequate and can have airway-threatening implications:

• Abscesses should be urgently/emergently drained via either needle aspiration or surgical incision and drainage.
• Antibiotic therapy
• Steroid therapy debatable
• Surgical drainage
• Appropriate analgesia and adequate hydration should be ensured.

Peritonsillar Abscess - medication

Peritonsillar Abscess - first line

• Clindamycin or ampicillin/sulbactam are the most commonly used 1st-line antibiotics due to their efficacy versus GABHS, Staph, and anaerobes.
• Some initiate therapy with high-dose IV penicillin—in the presence of a positive strep antigen or culture study.

Peritonsillar Abscess - second line

• Nafcillin, oxacillin, and cefazolin are acceptable antibiotic alternatives.
• Steroids:
  • Some experts recommend steroids to decrease swelling, pain, and trismus.
  • Methylprednisolone, dexamethasone, and prednisone are all acceptable.

Peritonsillar Abscess - surgery

Surgical drainage with tonsillectomy:

• Consider in children not responding to parenteral antibiotics within 24–48 hours.

Peritonsillar Abscess - FOLLOW UP

• Patients may be discharged on oral antibiotics to complete a 10–14-day course when afebrile and peritonsillar swelling has subsided.
• Tonsillectomy should be considered after severe or recurrent peritonsillar abscesses.

Peritonsillar Abscess - disposition

Peritonsillar Abscess - issues for referral

Peritonsillar abscess:

• Otorhinolaryngology consultation for acute and chronic management

Peritonsillar Abscess - prognosis

• Complete recovery with appropriate therapy.
• Recurrence of the abscess may occur.

Peritonsillar Abscess - complications

• Upper airway obstruction is the most feared complication.
• Abscesses left untreated can rupture spontaneously into the pharynx, leading to aspiration.
• Dehydration from decreased oral intake is the most common complication.

Peritonsillar Abscess - bibliography

1. Blotter JW, Yin L, Glynn M, et al. Otolaryngology consultation for peritonsillar abscess in the pediatric population. Laryngoscope. 2000;110:1698–1701.
2. Brook I. The role of anaerobic bacteria in tonsillitis. International J Pediatr Otorhinolaryngol. 2005;69(1):9–19.
3. Brook I. Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofacial Surg. 2004;62(12):1545–1550.
4. Cherukuri S, Benninger MS. Use of bacteriologic studies in the outpatient management of peritonsillar abscess. Laryngoscope. 2002;112:18–20.
5. Friedman NR, Mitchell RB, Pereira KD, et al. Peritonsillar abscess in early childhood. Presentation and management. Arch Otolaryngol Head Neck Surg. 1997;123:630–632.
6. Hanna BC, McMullan R, Hall SJ. Corticosteroids and peritonsillar abscess formation in infectious mononucleosis. J Laryngol Otol. 2004;118(6):459–461.
7. Herzon FS, Nicklaus P. Pediatric peritonsillar abscess: Management guidelines. Curr Probl Pediatr. 1996;26:270–278.
8. Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003;128:332–343.
9. Scott PMJ, Loftus WK, Kew J, et al. Diagnosis of peritonsillar infections: A prospective study of ultrasound, computerized tomography, and clinical diagnosis. J Laryngol Otol. 1999;113:229–232.
10. Tewfik TL, Al Garni M. Tonsillopharyngitis: Clinical highlights. J Otolaryngol. 2004;34(Suppl 1):S45–S49.

Peritonsillar Abscess - CODES

Peritonsillar Abscess - icd9

475 Peritonsillar abscess

Peritonsillar Abscess - FAQ

• Q: Are radiographs necessary to make the diagnosis of peritonsillar abscess?
• A: No. The physical examination is diagnostic; a lateral neck radiograph is useful only if retropharyngeal abscess or epiglottitis is a diagnostic concern.
• Q: Is surgical consultation necessary in cases of peritonsillar abscess?
• A: Yes. Otorhinolaryngology consultation is indicated for both acute as well as chronic management.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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