celina martinez msiii april 25 2006
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Peritonsillar Abscess

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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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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
slide4
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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