II. Epidemiology

  1. Highest Incidence ages 20-40 years old

III. Pathophysiology

  1. Sequelae of acute Tonsillitis or Tonsillopharyngitis
  2. Progression from exudative Tonsillitis to Peritonsillar Cellulitis to Peritonsillar Abscess
    1. Weber's Glands (mucous Salivary Glands within Soft Palate)
      1. Reside in Soft Palate, superior to Tonsil
      2. Duct between Weber Gland and Tonsil
    2. Cellulitis develops within the Weber Gland
    3. Weber Gland duct obstructs and abscess forms

IV. Risk Factors

V. Etiology

  1. Group A Streptococcal Pharyngitis complication
    1. Streptococcus Pyogenes (most common aerobic organism)
  2. Mixed oropharyngeal flora
    1. Staphylococcus aureus
    2. Corynebacterium
    3. Streptococcus milleri (S. intermedius, S. anginosus, S. constellatus)
    4. HaemophilusInfluenzae
    5. Neisseria
    6. Anaerobic Bacteria
      1. Fusobacterium
      2. Peptostreptococcus
      3. Prevotella
      4. Bacteroides

VI. Symptoms

  1. Fever
    1. Temp over 39.4 F suggests more serious infection (parapharyngeal space infection, Sepsis)
  2. Severe, unilateral throat pain
  3. Dysphagia and Odynophagia (difficult and painful swallowing)
  4. Malaise
  5. Otalgia (ipsilateral to abscess)

VII. Signs

  1. General
    1. Ill appearance
    2. Muffled ("hot potato") voice
    3. Trismus
    4. Drooling
  2. Oropharynx
    1. Uvula deviates to the opposite side
    2. Localized swelling of Soft Palate over affected Tonsil
  3. Swollen Tonsil (usually superior pole)
    1. Indurated, fluctuant mass
    2. Exudate may be present
    3. Erythematous peritonsillar area
    4. Usually unilateral

IX. Imaging

  1. Indications
    1. Confirm Peritonsillar Abscess where the diagnosis is uncertain, such as in failed aspiration (Ultrasound)
    2. Evaluate contiguous soft tissues and vessels (CT or MRI)
  2. Neck Ultrasound
    1. Preferred imaging modality for diagnosis and aspiration guidance
    2. Endocavitary probe transducer intraoral (preferred)
      1. Alternatively, may attempt visualization over Submandibular Gland
    3. Abscess is echo-free with irregular border
  3. CT Neck with contrast
    1. Abscess appears with low attenuation
    2. Shows contiguous spread of infection to deep neck tissue
  4. MRI neck
    1. Evaluate for deep neck infections (better than CT)
    2. Evaluate internal Jugular Vein thrombosis and Carotid Artery sheath erosion

X. Differential Diagnosis

  1. Peritonsillar Cellulitis (no pus in capsule)
  2. Retropharygeal abscess
  3. Dental Infection (e.g abscessed tooth, Retromolar abscess)
  4. Epiglottitis
  5. Mononucleosis (up to 6% coinfection, esp. in teens and young adults)
  6. Cervical adenitis
  7. Sialolithiasis or Sialadenitis
  8. Mastoiditis
  9. Internal cartoid artery aneurysm
  10. Malignancy (e.g. Lymphoma)

XI. Management

  1. Needle aspiration
    1. See Needle Aspiration technique below
    2. Be prepared for airway emergency
    3. Observe patient for several hours after observation and confirm able to tolerate liquids
    4. Failed aspiration of pus
      1. May be consistent with Peritonsillar Cellulitis
      2. Consider imaging soft tissue for deep space infection
      3. If no serious findings, may discharge home with close follow-up on oral medications
  2. Disposition: Indications for inpatient management (typically 2-4 day stays)
    1. Children
    2. Dehydration
    3. Toxic appearance
    4. Persistent significant Trismus or Dysphagia (refractory to aspiration)
    5. Airway compromise risk (e.g. kissing Tonsils)
  3. Disposition: Outpatient Management
    1. Observe after aspiration for several hours before discharge (confirm tolerating liquids)
    2. Prescribe antibiotics, Corticosteroids (typically) and Analgesics
    3. Close interval follow-up at 24-36 hours
  4. Antibiotics for 10-14 days
    1. Broad spectrum antibiotics are typically needed (polymicrobial infections, often with resistance)
      1. May adjust antibiotic based 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. Piperacillin/Tazobactam (Zosyn) 3.375 mg every 6 hours
      3. Ampicillin with Sulbactam (Unasyn) 3 grams every 6 hours
      4. Ceftriaxone 1 g every 12 hours AND Metronidazole
      5. Clindamycin 900 mg IV every 8 hours (if Penicillin allergic)
      6. Consider Vancomycin AND Flagyl if MRSA concern
    3. Oral agents
      1. Clindamycin 300 to 450 mg orally every 8 hours
      2. Cefdinir (Omnicef) 300 mg every 12 hours AND Metronidazole
      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
  5. Corticosteroids as adjunct to antibiotics
    1. Dexamethasone 10 mg orally for 1 dose
      1. O'Brien (1993) Ann Emerg Med 22(2): 212-5 [PubMed]
    2. Depo Medrol 2-3 mg/kg up to 250 mg IV for 1 dose
      1. Patients improved faster when adjunctive steroids were used
      2. Ozbek (2004) J Laryngol Otol 118:439-42 [PubMed]
    3. Efficacy
      1. Decreased pain and improved oral intake within 12-24 hours
      2. Faster recovery and shorter hospital stays
      3. Lee (2016) Clin Exp Otorhinolaryngol 9(2): 89-97 [PubMed]

XII. Procedure: Needle Aspiration

  1. Precautions
    1. Carotid Artery runs 2 cm posterolateral to Tonsillar Pillar
    2. Do not insert aspiration needle more than 8 mm
  2. Primary anesthetic
    1. Step 1: Spray with topical anesthetic
      1. Benzalkonium 0.5% spray (Cetacaine)
    2. Step 2: Gargle 2% Lidocaine with Epinephrine
    3. Alternative anesthetic
      1. Sphenopalatine block
        1. Lidocaine or Cocaine soaked pledget
        2. Place under posterior aspect of middle turbinate
      2. Local anesthetic injection
        1. Inject into mucosa overlying region of fluctuance using 25 g 1.5 inch needle OR
        2. Inject Lidocaine into mucosa with aspiration needle and then aspirate
  3. Preparation
    1. Be prepared for airway emergency (e.g. bleeding)
    2. Suction with Yanker tip
    3. 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
    4. 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
    5. Patient positioning
      1. Patients sits forward, at eye level to examiner
    6. Ultrasound with endocavitary probe
      1. Helps to guide needle towards largest abscess pocket
      2. Trismus may limit use
    7. References
      1. Lin in Herbert (2014) EM:Rap 14(4): 5-7
  4. Needle Aspiration Technique
    1. Retract Tongue
      1. Tongue blade or
      2. Laryngoscope Blade (consider having patient hold this, see above)
    2. Spinal needle 18 gauge on 3 cc syringe
      1. Longer spinal needle obstructs view less
      2. Smaller syringe requires less force to withdraw plunger
    3. 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 syringe to secure
    4. Avoid lateral margin of Tonsil
      1. Carotid Artery is 2 to 2.5 cm posterolateral to Tonsil
      2. Keep needle in sagittal plane
    5. 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
    6. Failed aspiration
      1. Move the needle inferolaterally along the Soft Palate and reattempt aspiration up to twice more
      2. Exercise caution, as carotid puncture increases in risk with inferior needle placement
  5. Complications
    1. Patient aspiration of pus or blood
    2. Hemorrhage from puncture of Carotid Artery

XIII. 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 or mediastinal infection from contiguous spread

XIV. Follow-up

  1. Consider Tonsillectomy 3-6 months after Peritonsillar Abscess (40% recurrence rate)

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

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
Russian ABSTSESS PERITONZILLIARNYI, PERITONZILLIARNYI ABSTSESS, АБСЦЕСС ПЕРИТОНЗИЛЛЯРНЫЙ, ПЕРИТОНЗИЛЛЯРНЫЙ АБСЦЕСС
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