Celina martinez msiii april 25 2006
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Celina Martinez, MSIII April 25, 2006. Peritonsillar Abscess. Clinical Presentation of A.E. 47 y.o. AAF c/o “sore throat” and difficulty swallowing for 4 days PMH None Meds None SH Current cigarette use with 20 pack-year history Moderate EtOH use, current heroin use ROS

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Peritonsillar Abscess

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Celina martinez msiii april 25 2006

Celina Martinez, MSIII

April 25, 2006

Peritonsillar Abscess


Clinical presentation of a e

Clinical Presentation of A.E.

  • 47 y.o. AAF c/o “sore throat” and difficulty swallowing for 4 days

  • PMH

    • None

  • Meds

    • None

  • SH

    • Current cigarette use with 20 pack-year history

    • Moderate EtOH use, current heroin use

  • ROS

    • + fever, throat pain, cough, wheezing, dysphagia

    • Throat pain is 7/10


Physical exam

Physical Exam

VS: 137/86 HR 103 T 100.8 98-100% RA

HEENT:

  • + lymphadenopathy bilaterally

  • Unable to visualize oropharynx, patient cannot fully open mouth

    Repeat exam of oropharynx

  • L tonsil swollen, with exudate

  • Uvula midline


Peritonsillar abscess

Labs

9.0 6.9 0.6 17

3.8 11

Alk Phos – 69

144 105 11

3.1 29 0.6

Glucose – 98

  • 11.8

  • 13,460264

  • 35.2

    • P =82%

    • L =14%

    • M = 4%


Differential diagnosis

Anatomically related conditions

Epiglottitis

Peritonsillar abscess

Retropharyngeal abscess

Candidal pharyngitis

Apthous stomatitis

Thyroiditis

Bullous erythema multiforme

Differential Diagnosis

  • Viral

    • Rhinovirus, coronavirus, adenovirus

    • Influenza

    • Parainfluenza

    • Coxsackie virus

    • HSV

    • CMV

    • HIV

  • Bacterial

    • GAβS

    • Gonococci

    • Chlamydia

    • Diphtheria

    • Legionella

    • Mycoplasma


Imaging

Imaging

  • Neck CT with Contrast

    • L tonsillar enlargement with 2 rim-enhancing peritonsillar hypodensities

    • Oropharyngeal narrowing at level of tonsillar enlargement

    • Swelling of adjacent soft palate with hypodensity compatible with fluid that crosses the midline

  • Impression

    • Enlargement of the left palatine tonsil with cystic/necrotic change and marked swelling of adjacent structures


Peritonsillar abscess

  • Peritonsillar cellulitis

  • Tonsillar abscess

  • Mononucleosis

  • FB aspiration

  • Cervical adenitis

  • Neoplasm

  • Dental infection

  • Salivary gland tumor

  • Aneurysm of internal carotid artery

Peritonsillar Abscess

Background

  • 30 cases per 100,000 people per year

    • 45,000 US cases annually

  • Highest incidence in 3rd and 4th decades of life

    Differential Diagnosis


Peritonsillar abscess1

Peritonsillar Abscess

Pathophysiology - Progression of tonsillitis

Tonsillitis  Peritonsilar Inflammation  Abscess

  • Inflammation of supratonsillar soft palate and surrounding muscle

  • Pus collects between fibrous capsule and superior constrictor muscle of the pharynx

  • Common infectious agents

    • Common aerobes

      • Streptococcus pyogenes in 30%

      • H. influenzae, S. aureus, neisseria species

    • Common anaerobes

      • Fusobacterium, peptostreptococcus, prevotella, bacteroides


  • Peritonsillar abscess2

    Signs

    Fever

    Trismus

    Drooling, salivation

    Lymphadenopathy

    Dehydration

    Signs of airway compromise (rare)

    Oropharyngeal exam

    Peritonsillar Abscess

    Symptoms

    • Sore throat

    • Dysphagia

    • Difficulty opening mouth

    • “Hot potato voice”

    • Headache

    • Neck pain

    • Referred ear pain

    • General malaise


    Oropharyngeal exam

    Oropharyngeal Exam

    • Edema of tissues lateral and superior to the involved tonsil

    • Medial and/or anterior displacement of the involved tonsil

    • Displacement of the uvula to the contralateral side of the pharynx

    • Possibly erythematous, enlarged, or exudate-covered tonsil


    Peritonsillar abscess3

    Peritonsillar Abscess

    Diagnosis is usually clinical!

    Other Tests

    • Intraoral ultrasound

      • Rule out retropharyngeal abscess and peritonsillar cellulitis

    • CT scan

      • Trismus, suspicion of invasion into deep neck tissue


    Peritonsillar abscess4

    Peritonsillar Abscess

    Treatment

    • IV hydration

    • IV steroids

    • IV pain control

    • Antibiotics

      • Penicillin V 500 mg TID for 10-14 days

      • Metronidazole 500 mg BID for 10-14 days

        OR

      • Clindamycin 300 mg QID for 10 days


    Peritonsillar abscess5

    Peritonsillar Abscess

    Treatment

    • Needle aspiration

      • Anesthetic spray, 2-4 cc of lidocaine w/epi

      • 19-gauge needle; keep proximal half covered w/cap

      • Point needle medially, keep medial to molars to avoid vessels!

      • Needle can be inserted 1-2 cm safely

      • Culture aspirate and gram stain aspirate


    Peritonsillar abscess6

    Peritonsillar Abscess

    • When to defer to otolaryngology

      • Marked trismus

      • Unsuccessful aspiration

      • Deep neck invasion


    Current literature

    Current Literature

    • Losanoff JE, Missavage AE. Neglected peritonsillar abscess resulting in necrotizing soft tissue infection of the neck and chest wall. Int J Clin Pract. 2005 Dec;59(12):1476-8.

      • NSTI from peritonsillar abscess is rapidly spreading and life threatening.

      • High index of suspicion, early diagnosis, broad-spectrum antibiotics and aggressive surgical management are essential.

    • Fasano CJ, Chudnofsky C, Vanderbeek P. Bilateral peritonsillar abscesses: not your usual sore throat. Emerg Med. 2005 Jul;29(1):45-7.

      • Bilateral tonsil swelling, midline uvula


    References

    References

    • Johnson RF, Stewart MG. The contemporary approach to diagnosis and management of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005 Jun;13(3):157-60.

    • Thomas GR, et al. Managing Common Otolaryngologic Emergencies. Emerg Med 37(5):18-47, 2005.

    • Bisno AL. Acute Pharyngitis. N Engl J Med. 2001 Jan 18;344(3):205-11

    • Steyer TE. Peritonsillar Abscess: Diagnosis and Treatment. Am Fam Physician. 2002 Jan 1;65(1):93-6.


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