II. Pathophysiology

  1. Sequelae of acute Tonsillitis or tonsillopharyngitis
  2. Progression from exudative Tonsillitis to Peritonsillar Cellulitis to Peritonsillar Abscess
    1. Abscess develops within the Weber's Glands (mucous Salivary Glands within Soft Palate)

III. Risk Factors

IV. Etiology

  1. Group A Streptococcal Pharyngitis complication
    1. Streptococcus Pyogenes (most common aerobic organism)
  2. Mixed oropharyngeal flora
    1. Staphylococcus aureus
    2. HaemophilusInfluenzae
    3. Neisseria
    4. Anaerobic Bacteria
      1. Fusobacterium
      2. Peptostreptococcus
      3. Prevotella
      4. Bacteroides

V. Symptoms

  1. Fever over 39.4 suggests more serious infection
    1. Parapharyngeal space infection
    2. Sepsis
  2. Severe, unilateral throat pain
  3. Dysphagia
  4. Trismus
  5. Muffled ("hot potato") voice
  6. Drooling

VI. Signs

  1. Ill appearance
  2. Uvula deviates to the opposite side
  3. Localized swelling of Soft Palate over affected tonsil
  4. Swollen tonsil (usually superior pole)
    1. Indurated, fluctuant mass
    2. Exudate may be present
    3. Erythematous peritonsillar area
    4. Usually unilateral

VIII. Imaging

  1. Indications
    1. Confirm Peritonsillar Abscess where the diagnosis is uncertain (Ultrasound)
    2. Evaluate contiguous soft tissues and vessels (CT or MRI)
  2. Neck Ultrasound (preferred imaging modality for diagnosis)
    1. Transducer intraoral or over Submandibular Gland
    2. Abscess is echo-free with irregular border
  3. CT Neck with contrast
    1. Abscess shows low attenuation
    2. Shows contiguous spread of infection to deep neck tissue
  4. MRI neck
    1. Evaluate for deep neck infections
    2. Evaluate jugular and carotid vessels

IX. Differential Diagnosis

  1. Peritonsillar Cellulitis (no pus in capsule)
  2. Tonsillar abscess
  3. Mononucleosis
  4. Cervical adenitis
  5. Dental Infection (e.g abscessed tooth)
  6. Sialolithiasis or Sialadenitis
  7. Mastoiditis
  8. Internal cartoid artery aneurysm
  9. Malignancy (e.g. Lymphoma)

X. Management

  1. Appropriate Healthcare
    1. Children: Hospitalize for IV antibiotics
    2. Adults: Outpatient unless dehydrated or toxic
  2. Antibiotics for 10-14 days
    1. Base antibiotic choice on needle aspiration sample
    2. Parenteral
      1. Combination
        1. Penicillin G 10 MU IV every 6 hours and
        2. Metronidazole 1.0 g load, and then 500 mg IV every 6 hours
      2. Cefoxitin 2 g IV q8h
      3. Clindamycin 900 mg IV every 8 hours
      4. Timentin
      5. Piperacillin
      6. Ampicillin with Sulbactam (Unasyn) 3 grams every 6 hours
    3. Oral agents
      1. Clindamycin 500 mg PO bid
      2. Second and Third Generation Cephalosporins
      3. Augmentin 875 mg orally twice daily
      4. Combination
        1. Penicillin VK 500 mg orally every 6 hours and
        2. Metronidazole 500 mg orally every 6 hours
  3. Experimental: Corticosteroids as adjunct to antibiotics
    1. Do not use routinely until larger studies are completed
    2. Patients improved faster when adjunctive steroids were used
      1. Protocol used Depo Medrol 2-3 mg/kg up to 250 mg IV for 1 dose
    3. Reference
      1. Ozbek (2004) J Laryngol Otol 118:439-42 [PubMed]

XI. Procedure: Needle Aspiration

  1. Primary anesthetic
    1. Step 1: Spray with topical anesthetic
      1. Benzalkonium 0.5% spray (Cetacaine)
    2. Step 2: Gargle 2% Lidocaine with Epinephrine
  2. Alternative anesthetic: Sphenopalatine block
    1. Lidocaine or Cocaine soaked pledget
    2. Place under posterior aspect of middle turbinate
  3. Preparation
    1. Suction
    2. Light source: Direct Laryngoscope with curved blade
      1. Position overlying the Tongue, lighting the posterior pharynx, but not so deep as to trigger a Gag Reflex
    3. Patient as assistant (if sufficiently calm)
      1. Patient may hold shallowly placed Laryngoscope Blade in place with one of their hands
      2. Patient may hold the suction catheter with their opposite hand
    4. Ultrasound with endocavitary probe
      1. Helps to guide needle towards largest abscess pocket
      2. Trismus may limit use
    5. References
      1. Lin in Herbert (2014) EM:Rap 14(4): 5-7
  4. Needle Aspiration Technique
    1. Spinal needle 18 gauge on 3 cc syringe
      1. Longer spinal needle obstructs view less
      2. Smaller syringe requires less force to withdraw plunger
    2. Consider needle guard
      1. Prevents entrance into Carotid Artery
      2. Needle should protrude only 0.5 cm beyond guard
      3. Cut off distal 0.5 cm of plastic needle cover
      4. Tape needle cover to syring to secure
    3. Avoid lateral margin of tonsil
      1. Carotid Artery is 2.5 cm posterolateral to tonsil
      2. Keep needle in sagittal plane
    4. Aspirate most fluctuant area
      1. Superior pole of tonsil most commonly affected
      2. Aspirate peritonsillar space (medial Soft Palate)
        1. Tonsil itself is not aspirated
  5. Complications
    1. Patient aspiration of pus or blood
    2. Hemorrhage from puncture of Carotid Artery

XII. Complications

  1. Airway obstruction
  2. Lung infection (Aspiration Pneumonia or Lung Abscess) from Peritonsillar Abscess rupture
  3. Erosion into Carotid Artery sheath (uniformly fatal)
  4. Deep neck infection from contiguous spread

XIII. Follow-up

  1. Tonsillectomy 3-6 months after Peritonsillar Abscess

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Ontology: Peritonsillar Abscess (C0031157)

Definition (MSH) An accumulation of purulent material in the area between the PALATINE TONSIL and its capsule.
Definition (MSHCZE) Paratonzilární absces, flegmona – absces, resp. flegmona v přilehlých tkáních kolem patrové tonzily. Podle lokalizace abscesu se rozlišuje supratonzilární horní absces (maximum zánětu je ve stejnostranné polovině měkkého patra), zevní laterální absces (prosáknutí předního patrového oblouku a vysunutí tonzily mediálně), a dolní infratonzilární absces (zánět se šíří na dolní část patrového oblouku, na laterální stěnu hypofaryngu a do vchodu hrtanu, srov. parafaryngeální absces). P. a. se rozvíjí nejč. ve druhém týdnu průběhu angíny nebo po akutní exacerbaci chronické tonzilitidy. Jednostranná bolestivá dysfagie může být doprovázena zvýšenou salivací, regurgitací tekutin nosem, trismem a huhňavou řečí spolu s bolestivým zduřením regionálních uzlin. Léčba je chirurgická (incize, tonzilektomie) a antibiotická. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Concepts Disease or Syndrome (T047)
MSH D000039
ICD9 475
ICD10 J36
SnomedCT 155534002, 15033003
English Abscess, Peritonsillar, Abscesses, Peritonsillar, Peritonsillar Abscesses, Peritonsillar Abscess, peritonsillar abscess (physical finding), peritonsillar abscess, tonsils peritonsillar abscess, peritonsillar abscess (diagnosis), quinsy peritonsillar abscess (diagnosis), quinsy peritonsillar abscess, Abscess peritonsillar, Peritonsillar abscess NOS, quinsy, Peritonsillar Abscess [Disease/Finding], quinsies, Abscess;peritonsillar, tonsillaris angina, angina tonsillary, Peritonsillar abscess, Quinsy, Angina tonsillaris, Peritonsillar abscess (disorder), abscess; peritonsillar, peritonsillar; abscess
Dutch abces peritonsillair, angina tonsillaris, peritonsillair abces NAO, keelontsteking, abces; peritonsillair, peritonsillair; abces, peritonsillair abces, Abces, peritonsillair, Peritonsillair abces
French Abcès péri-amygdalien SAI, Angine amygdalienne, Abcès péri-amygdalien, Abcès périamygdalien, Abcès péritonsillaire, Phlegmon amygdalien
German Angina tonsillaris, peritonsillaerer Abszess NNB, peritonsillaerer Abszess, Peritonsillarabszess, Abszeß, peritonsillärer, Abszeß, Peritonsillar-, Peritonsillarabszeß, Peritonsillärer Abszeß
Italian Ascesso peritonsillare NAS, Angina tonsillare, Ascessi peritonsillari, Ascesso peritonsillare
Portuguese Abcesso periamigdalino NE, Amigdalite, Angina tonsilar, Abcesso periamigdalino, Abscesso Periamigdaliano, Abscesso Peritonsilar
Spanish Quinsy, Angina tonsillaris, Absceso periamigdalar NEOM, absceso periamigdalino (trastorno), absceso periamigdalino, angina amigdalina, angina tonsillaris, Absceso periamigdalar, Absceso Periamigdalino, Absceso Peritonsilar
Japanese 扁桃性アンギナ, 扁桃周囲膿瘍NOS, ヘントウシュウイノウヨウ, ヘントウセイアンギナ, ヘントウシュウイノウヨウNOS, 膿瘍-扁桃周囲, 扁桃周囲膿瘍
Swedish Halsböld
Czech peritonzilární absces, Zánět patrových mandlí, Peritonzilární absces, Peritonzilární absces NOS, paratonzilární absces
Finnish Kurkkupaise
Korean 편도주위 고름집(농양)
Polish Ropień okołomigdałkowy
Hungarian peritonsillaris abscessus, peritonsillaris tályog k.m.n., angina tonsillaris, Peritonsillaris tályog, Abscessus peritonsillaris
Norwegian Peritonsillær abscess, Halsbyll

Ontology: Peritonsillar cellulitis (C0553656)

Concepts Disease or Syndrome (T047)
ICD10 J36
SnomedCT 102453009, 15033003
English peritonsillar cellulitis, cellulitis of peritonsillar region (diagnosis), cellulitis of peritonsillar region, Peritonsillar cellulitis, Acute peritonsillitis, Peritonsillar cellulitis (disorder), cellulitis; peritonsillar, peritonsillar; cellulitis
Dutch cellulitis; peritonsillair, peritonsillair; cellulitis
Spanish celulitis periamigdalina (trastorno), celulitis periamigdalina, periamigdalitis aguda