12/7/2016

PeritonsillarAbscessinEmergencyMedicine:PracticeEssentials,Background,Pathophysiology

Thissiteisintendedforhealthcareprofessionals

PeritonsillarAbscessinEmergencyMedicine
Updated:May25,2016
Author:JorgeFlores,MDChiefEditor:Jeter(Jay)PritchardTaylor,III,MDmore...

OVERVIEW

PracticeEssentials
Peritonsillarabscesses(PTAs)arecommoninfectionsoftheheadandneckregion,accountingfor
approximately30%ofsofttissueheadandneckabscesses.Withanincidenceofabout1in10,000,
PTA(seetheimagebelow)isthemostcommondeepspaceinfectionoftheheadandneckthat
presentstotheemergencydepartment.

Rightperitonsillarabscess.Thesoftpalate,whichiserythematousandedematous,isdisplacedanteriorly.The
patienthasa"hotpotatosounding"voice.

ViewMediaGallery

Signsandsymptoms
SymptomsofPTAusuallybegin35daysbeforeevaluationandmayincludethefollowing:
Fever
Malaise
Headache
Neckpain
Throatpain(moresevereontheaffectedsideoccasionallyreferredtotheipsilateralear)
Dysphagia
Changeinvoice
Otalgia
Odynophagia
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PeritonsillarAbscessinEmergencyMedicine:PracticeEssentials,Background,Pathophysiology

Physicalfindingsmayincludethefollowing:
Mildtomoderatedistress
Fever
Tachycardia
Dehydration
Drooling,salivation,ortroublehandlingoralsecretions
Trismus
Hotpotatoormuffledvoice
Rancidorfetidbreath
Cervicallymphadenitisintheanteriorchain
Asymmetrictonsillarhypertrophy
Localizedfluctuance
Inferiorandmedialdisplacementofthetonsil
Contralateraldeviationoftheuvula
Erythemaofthetonsil
Exudatesonthetonsil
SeePresentationformoredetail.

Diagnosis
NodefinitivestudiesarerequiredtodiagnosePTA.Thefollowinglaboratorytestsmaybeconsidered:
Basicstudies,suchascompletebloodcount,electrolytes,andCreactiveprotein(ifthepatient
hassignificantcomorbidities)
Monospottest/heterophileantibodytest(toruleoutinfectiousmononucleosisiftheetiologyis
unclear)
Cultureoffluidfromneedleaspiration(toguideantibioticselectionorchanges)
Bloodcultures(iftheclinicalpresentationissevere)
Thefollowingimagingstudiesmaybeconsidered:
Lateralsofttissueneckradiography(tohelpruleoutothercauses)
Intraoralultrasonography
Computedtomography(CT)oftheheadandneckwithintravenous(IV)contrast(ifincisionand
drainagefails,ifthepatientcannotopenhisorhermouth,orifthepatientisyoungand
uncooperative)
SeeWorkupformoredetail.

Management
InitialmanagementofPTAmayincludethefollowing:
Transportwithsupplementaloxygen.
AttentiontotheABCs(airway,breathing,andcirculation)
Ifthepatientsairwayiscompromised,immediateendotrachealintubationor,ifthiscannotbe
accomplished,cricothyroidotomyortracheostomyalternatively,awakefiberopticbronchoscopy
Fluidresuscitationasnecessary
Antipyreticsforelevatedtemperature
Adequateanalgesiaforpain
IfacutesurgicalmanagementofPTAisindicated,thefollowing3optionsareavailable:
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PeritonsillarAbscessinEmergencyMedicine:PracticeEssentials,Background,Pathophysiology

Needleaspiration
Incisionanddrainage
Quinsytonsillectomy(eg,simultaneoustonsillectomywithopenabscessdrainage)
Additionalpharmacologictherapymayincludethefollowing:
Empiricantibiotics
Adjunctivesteroids
SeeTreatmentandMedicationformoredetail.
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PeritonsillarAbscessinEmergencyMedicine:PracticeEssentials,Background,Pathophysiology

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