Mastering Minor Care: Peritonsillar Abscess

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Background

Image 1: Right pTA with uvular deviation

Image 1: Right pTA with uvular deviation courtesy of Dr. Heilman by CC-SA 3.0 AT https://en.wikipedia.org/wiki/Peritonsillar_abscess#/media/File:PeritonsilarAbsess.jpg

A peritonsillar abscess (PTA) is a collection of fluid located between the capsule of the palatine tonsil and the pharyngeal muscles (1). The diagnosis of a PTA is typically based on history and exam. Patients might initially experience symptoms of pharyngitis (sore throat or discomfort) that progresses to a severe sore throat (usually unilateral), fever, and a "hot potato" or muffled voice. Some patients might develop a PTA from obstruction of a group of salivary glands, and thus might not experience any preceding symptoms. Pooling of saliva or drooling may be present. Trismus, or limited mouth opening related to irritation and reflex spasm of the internal pterygoid muscle, occurs in nearly two-thirds of patients (2-3).

Evaluation

On physical exam, patients may present with an extremely swollen and/or fluctuant tonsil or show a fluctuant area of the soft palate with deviation of the uvula to the opposite side (Image 1).

PTA is a clinical diagnosis. However, if a PTA is suspected but the patient is experiencing neck stiffness, respiratory obstruction, significant trismus, and/or has a toxic appearance, consider the possibility of a deep space infection. In this case, CT with IV contrast would be the imaging of choice (4).

Image 2: ultrasound of a 2.26 cm x 1.80 cm PTA using the endocavitary probe

Image 2: ultrasound of a 2.26 cm x 1.80 cm PTA using the endocavitary probe

If there is diagnostic uncertainty based on exam, ultrasonography might prove useful.  Ultrasound possesses great specificity for PTA and may be more diagnostically accurate than previously thought. Ultrasound is particularly well tolerated, avoids radiation exposure, as well as minimizes false-positive aspirations. Ultrasound can be used when there is a lower suspicion for deeper neck infection but questionable pocket for drainage (which could point towards peritonsillar cellulitis vs abscess) (5-6). Ultrasound can also be useful in localizing important vascular structures that exist close to the area of a PTA, although laceration of the carotid artery has not been shown to be a frequent complication of this procedure (11). An endoluminal or endocavitary probe should be utilized for this scan (Image 2).

Management

Drainage of a PTA along with use of antimicrobial therapy and proper hydration result in resolution of symptoms in approximately 90% of patients (9). Although there is no strong data that indicates a higher rate of recurrence with antibiotic treatment alone, it is important to consider likelihood of failure of follow up and/or failure of finishing medical treatment in certain populations (10). Most of the data testing antibiotic treatment alone, also requires an observation period to prove improvement prior to discharge, which may lead to longer ED stays (18). The data shows that needle aspiration and incision and drainage have similar rates of success (13-14). Incision and drainage is typically preferred and performed by ENTs.

Equipment:

  • Laryngoscope with a Mac blade or speculum for visualization

  • Suction

  • Local anesthesia:

    • Qtip covered in 2 or 4% viscous lidocaine up to the area of planned aspiration

    • 4% atomized lidocaine

    • Syringe with 1% lidocaine with 25G needle

  • 18G needle (can use spinal if more length is needed) for drainage with partially cut needle sheath that exposes only 1cm to prevent inserting the needle deeper OR 11-blade scalpel

  • +/- Glycopyrrolate to decrease secretions

  • +/- Methylprednisolone 125mg IV x1 OR dexamethasone 10mg PO/IM pre-procedure*

*Although it lacks supporting data, some otolaryngologists use a dose of steroids to improve trismus prior to the procedure.

IMAGE 3: ALiEM shows the use of a video macintosh blade, as well as the use of a speculum with the top removed (12)

IMAGE 3: ALiEM shows the use of a video macintosh blade, as well as the use of a speculum with the top removed (12)

Steps:

  • Gather your equipment as noted above

  • Pre-anesthetize

  • Have the patient sit up with the back of the bed up

  • Give the laryngoscope to the patient and have them hold the blade in a way that depresses the tongue (Image 3)

  • Hand them the suction to hold in their other hand so it is readily available for use

  • Locate the superior pole of the PTA, as this is where fluid is most likely to collect. Can subsequently try middle and then inferior poles if unsuccessful

  • Perform your aspiration or I&D

Post-drainage:

Patients should prove that they can tolerate oral intake prior to discharge, as they will need to take antibiotics and keep themselves hydrated. Some patients with severe disease, those who are immunosuppressed, or fail to improve symptomatically, might require ENT consult and/or admission and IV antibiotics.

Treatment

Antibiotics

  • Cover group A strep, staph aureus, and respiratory anaerobes.

  • Oral options:

    • Clindamycin 450mg TID 10-14 days OR

    • Amoxicillin/Clavulanate 875mg BID 10-14 days

  • IV options:

    • Ampicillin/Sulbactam 3gm q6H

    • Piperacillin/Tazobactam 4.5gm TID

    • Clindamycin 600mg TID

Steroids

Evidence regarding use of steroids is controversial but some studies have shown steroids lead to faster recovery. If not already given pre-procedure, methylprednisolone 125mg IV x 1 OR dexamethasone 10mg PO/IM x1 is sufficient for treatment (18).

Follow-up

If discharged, patients should be referred to ENT and be seen 24-36 hours after drainage to ensure appropriate improvement. Patients should be cautioned to seek immediate care if they experience dyspnea, worsening neck pain/sore throat/ or trismus, or significant bleeding.

Post by Martina Diaz, MD

Dr. Diaz is a PGY-2 in Emergency Medicine at the University of Cincinnati

Editing by Bronwyn Finney, MD and James Li, MD

Dr. Finney is a PGY-2 in Emergency Medicine at the University of Cincinnati
Dr. Li is an EMS Fellow in Emergency Medicine at the University of Cincinnati

References

  1. Passy V. Pathogenesis of peritonsillar abscess. Laryngoscope. 1994;104(2):185-190. doi:10.1288/00005537-199402000-00011

  2. Galioto NJ. Peritonsillar abscess. Am Fam Physician. 2008;77(2):199-202.

  3. Szuhay G, Tewfik TL. Peritonsillar abscess or cellulitis? A clinical comparative paediatric study. J Otolaryngol. 1998;27(4):206-212.

  4. Hurley MC, Heran MKS. Imaging studies for head and neck infections. Infect Dis Clin North Am. 2007;21(2):305-353, v-vi. doi:10.1016/j.idc.2007.04.001

  5. Gibbons RC, Costantino TG. Evidence-Based Medicine Improves the Emergent Management of Peritonsillar Abscesses Using Point-of-Care Ultrasound. J Emerg Med. 2020;59(5):693-698. doi:10.1016/j.jemermed.2020.06.030

  6. Costantino TG, Satz WA, Dehnkamp W, Goett H. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg Med. 2012;19(6):626-631. doi:10.1111/j.1553-2712.2012.01380.x

  7. Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope. 1995;105(8 Pt 3 Suppl 74):1-17. doi:10.1288/00005537-199508002-00001

  8. Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003;128(3):332-343. doi:10.1067/mhn.2003.93

  9. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses - PubMed. Accessed August 31, 2021. https://pubmed.ncbi.nlm.nih.gov/16643771/

  10. Forner D, Curry DE, Hancock K, et al. Medical Intervention Alone vs Surgical Drainage for Treatment of Peritonsillar Abscess: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2020;163(5):915-922. doi:10.1177/0194599820927328

  11. Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep. 2006;8(3):196-202. doi:10.1007/s11908-006-0059-8

  12. Trick: Peritonsillar abscess drainage 3.0 | All the steps with added variations. Accessed August 31, 2021. https://www.aliem.com/tricks-peritonsillar-abscess-drainage-all-steps-variations/

  13. A randomized trial for outpatient management of peritonsillar abscess - PubMed. Accessed August 31, 2021. https://pubmed.ncbi.nlm.nih.gov/3422562/

  14. Maharaj D, Rajah V, Hemsley S. Management of peritonsillar abscess. J Laryngol Otol. 1991;105(9):743-745. doi:10.1017/s0022215100117189

  15. Apostolopoulos NJ, Nikolopoulos TP, Bairamis TN. Peritonsillar abscess in children. Is incision and drainage an effective management? Int J Pediatr Otorhinolaryngol. 1995;31(2-3):129-135. doi:10.1016/0165-5876(94)01077-b

  16. Apostolopoulos NJ, Nikolopoulos TP, Bairamis TN. Peritonsillar abscess in children. Is incision and drainage an effective management? Int J Pediatr Otorhinolaryngol. 1995;31(2-3):129-135. doi:10.1016/0165-5876(94)01077-b

  17. Adjunct steroids in the treatment of peritonsillar abscess: A systematic review - Hur - 2018 - The Laryngoscope - Wiley Online Library. Accessed August 31, 2021. https://onlinelibrary.wiley.com/doi/10.1002/lary.26672

  18. Battaglia A, Burchette R, Hussman J, Silver MA, Martin P, Bernstein P. Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2018;158(2):280-286. doi:10.1177/0194599817739277