- Published on
Emergency and Acute Medicine – Peritonsillar Abscess
Peritonsillar abscess is a suppurative complication of tonsillitis in which infection spreads beyond the tonsillar capsule into the space between the palatine tonsil and the pharyngeal muscles. It is the most common deep infection of the head and neck, with an incidence of approximately 30 per 100,000 people per year and about 45,000 cases annually in the United States. It occurs at any age but is most common in young adults between 20 and 40 years. Incidence peaks during November to December and April to May, corresponding with higher rates of streptococcal pharyngitis. Although uncommon, complications can include airway compromise, sepsis, recurrence in 12–15% of patients, spread to the lateral neck or mediastinum, spontaneous rupture with aspiration pneumonitis, internal jugular vein thrombosis (Lemierre syndrome), poststreptococcal glomerulonephritis or rheumatic fever, carotid sheath erosion with hemorrhage, severe dehydration, and intracranial extension such as meningitis, cavernous sinus thrombosis, cerebral abscess, or dural sinus thrombosis.
Two primary mechanisms are proposed for its development. One theory involves direct bacterial invasion into deeper tissues during acute pharyngitis. The other suggests obstruction and infection of the Weber glands located in the superior tonsillar pole. Smoking may increase risk. Infection is typically polymicrobial. Common pathogens include Group A Streptococcus, Staphylococcus species including MRSA, and anaerobes such as Prevotella, Peptostreptococcus, and Fusobacterium.
Patients commonly present with unilateral sore throat, fever, voice change, odynophagia, drooling, headache, referred ear pain, decreased oral intake, and malaise. Physical examination often reveals fever, trismus, a muffled “hot potato” voice, erythematous tonsils and soft palate, medial and inferior displacement of the superior pole of the affected tonsil, uvular deviation away from the affected side, halitosis, cervical lymphadenitis, and tenderness along the ipsilateral angle of the jaw. Airway assessment is critical, with attention to stridor, tripod positioning, or inability to handle secretions. Clinicians must also consider possible extension into deeper neck spaces when systemic toxicity or atypical findings are present.
Diagnosis is usually clinical based on careful oropharyngeal examination, although severe trismus may limit visualization. Throat culture and monospot testing may be considered, as infectious mononucleosis is present in up to 20% of cases. A complete blood count and abscess culture may be useful in selected patients. A basic metabolic panel may help assess dehydration. Bedside intraoral ultrasound can assist in identifying and localizing the abscess, particularly in cooperative patients, while transcutaneous ultrasound may be useful if trismus prevents intraoral imaging. CT of the neck with contrast is indicated when deep neck infection is suspected, after failed needle aspiration, or when examination is limited. MRI may help detect complications such as internal jugular vein thrombosis or carotid sheath involvement. Needle aspiration is both diagnostic and frequently therapeutic, and incision and drainage is also effective.
Management begins with airway evaluation and stabilization, IV access, cardiac and pulse oximetry monitoring, and supplemental oxygen as needed. Children account for 25–30% of cases and may require sedation or general anesthesia for drainage procedures. In young children with signs of upper airway obstruction, a lateral neck radiograph may be obtained before oral examination. Antibiotics should be started promptly, along with IV fluids for dehydration and appropriate analgesia. A single dose of corticosteroid such as dexamethasone may improve symptoms. Adequate local anesthesia using benzocaine spray and lidocaine with epinephrine is essential before drainage. Needle aspiration has a success rate of 87–94% and should be performed by clinicians experienced in airway management. The internal carotid artery lies approximately 2.5 cm posterolateral to the tonsil, so limiting needle depth to less than 0.5 cm is recommended. The superior pole is the most common site of maximal fluctuance. Incision and drainage has a success rate of 90–92% and should be performed using a guarded blade with no more than 1 cm exposed, avoiding incisions deeper than 0.5 cm. Packing is generally not required. Tonsillectomy may be indicated in cases of airway obstruction, recurrent severe pharyngitis, recurrent abscess, or failure of drainage.
Antibiotic therapy should continue for 14 days, as shorter courses may increase recurrence risk. Intravenous options include ampicillin/sulbactam or penicillin G combined with metronidazole. Clindamycin is appropriate for penicillin-allergic patients. Oral regimens include amoxicillin/clavulanate, penicillin VK with metronidazole, or clindamycin. A single dose of dexamethasone 10 mg (0.6 mg/kg in children, maximum 10 mg) may be administered.
Admission is indicated for airway compromise, sepsis, altered mental status, significant dehydration, or extension beyond the peritonsillar space. Most patients can be discharged after successful drainage if they tolerate oral intake and medications. Referral to otolaryngology is recommended, and interval tonsillectomy is often considered 6–8 weeks after resolution. Close follow-up within 24–48 hours is essential because treatment failure and recurrence are relatively common.
Peritonsillar abscess is a suppurative complication of tonsillitis in which infection spreads beyond the tonsillar capsule into the space between the palatine tonsil and the pharyngeal muscles. It is the most common deep infection of the head and neck, with an incidence of approximately 30 per 100,000 people per year and about 45,000 cases annually in the United States. It occurs at any age but is most common in young adults between 20 and 40 years. Incidence peaks during November to December and April to May, corresponding with higher rates of streptococcal pharyngitis. Although uncommon, complications can include airway compromise, sepsis, recurrence in 12–15% of patients, spread to the lateral neck or mediastinum, spontaneous rupture with aspiration pneumonitis, internal jugular vein thrombosis (Lemierre syndrome), poststreptococcal glomerulonephritis or rheumatic fever, carotid sheath erosion with hemorrhage, severe dehydration, and intracranial extension such as meningitis, cavernous sinus thrombosis, cerebral abscess, or dural sinus thrombosis.
Two primary mechanisms are proposed for its development. One theory involves direct bacterial invasion into deeper tissues during acute pharyngitis. The other suggests obstruction and infection of the Weber glands located in the superior tonsillar pole. Smoking may increase risk. Infection is typically polymicrobial. Common pathogens include Group A Streptococcus, Staphylococcus species including MRSA, and anaerobes such as Prevotella, Peptostreptococcus, and Fusobacterium.
Patients commonly present with unilateral sore throat, fever, voice change, odynophagia, drooling, headache, referred ear pain, decreased oral intake, and malaise. Physical examination often reveals fever, trismus, a muffled “hot potato” voice, erythematous tonsils and soft palate, medial and inferior displacement of the superior pole of the affected tonsil, uvular deviation away from the affected side, halitosis, cervical lymphadenitis, and tenderness along the ipsilateral angle of the jaw. Airway assessment is critical, with attention to stridor, tripod positioning, or inability to handle secretions. Clinicians must also consider possible extension into deeper neck spaces when systemic toxicity or atypical findings are present.
Diagnosis is usually clinical based on careful oropharyngeal examination, although severe trismus may limit visualization. Throat culture and monospot testing may be considered, as infectious mononucleosis is present in up to 20% of cases. A complete blood count and abscess culture may be useful in selected patients. A basic metabolic panel may help assess dehydration. Bedside intraoral ultrasound can assist in identifying and localizing the abscess, particularly in cooperative patients, while transcutaneous ultrasound may be useful if trismus prevents intraoral imaging. CT of the neck with contrast is indicated when deep neck infection is suspected, after failed needle aspiration, or when examination is limited. MRI may help detect complications such as internal jugular vein thrombosis or carotid sheath involvement. Needle aspiration is both diagnostic and frequently therapeutic, and incision and drainage is also effective.
Management begins with airway evaluation and stabilization, IV access, cardiac and pulse oximetry monitoring, and supplemental oxygen as needed. Children account for 25–30% of cases and may require sedation or general anesthesia for drainage procedures. In young children with signs of upper airway obstruction, a lateral neck radiograph may be obtained before oral examination. Antibiotics should be started promptly, along with IV fluids for dehydration and appropriate analgesia. A single dose of corticosteroid such as dexamethasone may improve symptoms. Adequate local anesthesia using benzocaine spray and lidocaine with epinephrine is essential before drainage. Needle aspiration has a success rate of 87–94% and should be performed by clinicians experienced in airway management. The internal carotid artery lies approximately 2.5 cm posterolateral to the tonsil, so limiting needle depth to less than 0.5 cm is recommended. The superior pole is the most common site of maximal fluctuance. Incision and drainage has a success rate of 90–92% and should be performed using a guarded blade with no more than 1 cm exposed, avoiding incisions deeper than 0.5 cm. Packing is generally not required. Tonsillectomy may be indicated in cases of airway obstruction, recurrent severe pharyngitis, recurrent abscess, or failure of drainage.
Antibiotic therapy should continue for 14 days, as shorter courses may increase recurrence risk. Intravenous options include ampicillin/sulbactam or penicillin G combined with metronidazole. Clindamycin is appropriate for penicillin-allergic patients. Oral regimens include amoxicillin/clavulanate, penicillin VK with metronidazole, or clindamycin. A single dose of dexamethasone 10 mg (0.6 mg/kg in children, maximum 10 mg) may be administered.
Admission is indicated for airway compromise, sepsis, altered mental status, significant dehydration, or extension beyond the peritonsillar space. Most patients can be discharged after successful drainage if they tolerate oral intake and medications. Referral to otolaryngology is recommended, and interval tonsillectomy is often considered 6–8 weeks after resolution. Close follow-up within 24–48 hours is essential because treatment failure and recurrence are relatively common.
0 Comments
