Peritonsillar Abscess

Background

• A peritonsillar abscess is a collection of purulent material that forms between the palatine tonsillar capsule (pharyngobasilar fascia) and superior constrictor and palatopharyngeus muscles.
• If left untreated, peritonsillar abscess can lead to:
  • extension of infection into tissues of the deep neck or posterior mediastinum
  • abscess rupture leading to aspiration pneumonia, pneumonitis, or lung abscess
  • airway obstruction
  • internal jugular vein thrombosis
  • hemorrhage from erosion or septic necrosis into carotid sheath
• Risk factors for development of peritonsillar abscess include smoking, oropharyngeal or dental infection, male sex, and age 20-40 years.

Evaluation

• Diagnosis is usually made by the history and physical exam in patients with typical presentation, which may include:
  • severe sore throat (usually unilateral), odynophagia, dysphagia, poor oral intake due to odynophagia and dysphagia, fever, malaise, otalgia, and voice changes
  • tense edema and erythema of the affected tonsil and overlying soft palate, uvular deviation to contralateral side, trismus, and lymphadenopathy
• Consider blood tests to help confirm diagnosis, rule out other infections, and evaluate hydration status, including complete blood count, C-reactive protein, and basic metabolic panel.
• If there is diagnostic uncertainty, further testing may include:
  • intraoral or transcutaneous ultrasound, which may help confirm diagnosis and differentiate between peritonsillar abscess and peritonsillar cellulitis
  • needle aspiration or intraoral incision and drainage (peritonsillar abscess confirmed by presence of purulent material)
• Computed tomography (CT) or magnetic resonance imaging (MRI) of oropharyngeal and neck tissues typically reserved for patients with infection suspected to have spread outside peritonsillar space.

Management

• Adequate fluid hydration, pain management, antibiotics, and drainage of the abscess are the mainstays of treatment.
• Consider IV fluid resuscitation for patients with limited oral intake and those with signs of dehydration.
• Titrate analgesia to symptomatic relief using oral or parenteral analgesics.
• Antibiotics:
  • Consider a trial period of IV antibiotics as initial management for small abscesses in children, which may help prevent need for surgical drainage.
  • Use antibiotics to clear remaining and disseminated infection following surgical intervention, but optimal type and route not determined.
    • Consider combination of penicillin and metronidazole in adults (clindamycin and cefotaxime in children) due to the high rate of penicillin resistance (reported in up to 58% of cases).
    • Consider oral therapy for 10-14 days after surgical drainage or after resolution with initial IV antibiotic therapy.
• Corticosteroids may help speed recovery by reducing edema and inflammation, and reducing pain in the acute phase.
• Consider surgical drainage for peritonsillar abscess, which is reported to resolve the abscess in > 90% of patients when combined with antibiotic therapy.
  • Intraoral needle aspiration is often used as the initial treatment in both adults and children. Benefits include the option of outpatient management, more prompt pain relief compared to incision and drainage, and avoidance of general anesthesia.
  • Incision and drainage is often performed secondarily when needle aspiration is unsuccessful at draining purulent material or in patients with a nonresolving peritonsillar abscess. It can also be used as the primary drainage technique depending on physician and patient preference. Younger children may require general anesthesia during this procedure.
  • Abscess tonsillectomy (quinsy tonsillectomy) is not recommended for routine use but may be indicated in certain circumstances.